Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 16, Number 9, September 2025, pages 337-344

Anesthesiologist’s Concerns About Dandy-Walker Syndrome: Airway Management, Muscle Relaxants, and Train-of-Four Monitoring of Neuromuscular Blockade

Figures

↓  Figure 1. Preoperative head MRI demonstrating agenesis of the cerebellar vermis, dilatation of the fourth ventricle, and hydrocephalus (arrows). MRI: magnetic resonance imaging.
Figure 1.
↓  Figure 2. Preoperative head MRI demonstrating significant hydrocephaly (arrow). MRI: magnetic resonance imaging.
Figure 2.
↓  Figure 3. Preoperative head MRI demonstrating agenesis of the cerebellar vermis, significant hydrocephaly (arrows). MRI: magnetic resonance imaging.
Figure 3.
↓  Figure 4. Eye deviation.
Figure 4.
↓  Figure 5. Mild micrognathia.
Figure 5.
↓  Figure 6. Mallampati class II-III.
Figure 6.
↓  Figure 7. ICP monitoring (ICP was 15 mm Hg, in arrow). ICP: increased intracranial pressure.
Figure 7.
↓  Figure 8. Standard monitoring.
Figure 8.
↓  Figure 9. Video laryngoscopy intubation.
Figure 9.
↓  Figure 10. Postoperative MRI indicating shunt catheter in arrow. MRI: magnetic resonance imaging.
Figure 10.
↓  Figure 11. Postoperative MRI indicating reduced hydrocephaly in arrows. MRI: magnetic resonance imaging.
Figure 11.

Table

↓  Table 1. Key Considerations and Recommended Actions in Pediatric Neuroanesthesia for Patients With Dandy-Walker Syndrome [7-9]
 
Situation Management considerations Recommended actions
Pediatric neuroanesthesia expertise Requires specialized pediatric and neuroanesthetic skills Fellowship or extended training programs for advanced experience
Airway management 1) Macrocephaly, micrognathia, macroglossia;
2) Cervical spine anomalies;
3) Limited cooperation in pediatric patients.		 1) Thorough preoperative airway assessment;
2) Difficult airway protocol in place;
3) Consider laryngeal mask airway or video laryngoscope if conventional intubation fails.
Intubation High risk of failed conventional intubation 1) Prepare alternative devices; 2) Ensure rapid, atraumatic intubation
Anesthetic technique 1) Risk of postoperative respiratory complications;
2) Brainstem dysfunction.		 1) Total intravenous anesthesia with short-acting agents;
2) Avoid muscle relaxants if train-of-four monitoring unavailable;
3) Ensure rapid emergence.
Postoperative respiratory care Risk of apnea, aspiration, atelectasis, prolonged ventilation 1) Close monitoring in postanesthesia care unit;
2) Respiratory exercises as indicated;
3) Train-of-four monitoring if muscle relaxants used.
Pain management Limitations due to respiratory depression and bleeding risk 1) Multimodal analgesia (nonsteroidal anti-inflammatory drugs, paracetamol, ketamine, dexmedetomidine, regional techniques);
2) Reserve opioids for insufficient pain control.
Cardiac and other congenital anomalies Possible coexisting defects Comprehensive preoperative evaluation including electrocardiography and echocardiography