The Cisterna Magna Septa

The Cisterna Magna Septa
Vestigial Remnants of Blakes Pouch and a Potential

New Marker for Normal Development of the
Rhombencephalon
Ashley J. Robinson, MB, ChB, Ruth Goldstein, MD
Objective. The purpose of this study was to show the normal sonographic embryologic anatomy of
the cisterna magna septa, fourth ventricle, and cerebellar vallecula at various stages of development
and our experience with their variable appearance in multiple planes and to discuss the probable rela-
tionship between the cisterna magna septa, Dandy-Walker continuum, mega cisterna magna, and per-
sistent Blakes pouch. Methods. Retrospective and prospective selection of examples of cisterna
magna septa was performed over approximately a 12-month period. Standard and nonstandard imag-
ing planes were adopted as necessary. Results. The septa are typically seen inferoposterior to the cere-
bellar vermis, usually straight and parallel, arising at the cerebellovermian angle and coursing
posteriorly to the occipital bone. The cisterna magna septa become contiguous with the roof of the
fourth ventricle inferior to the cerebellar vermis. The cerebrospinal fluid space enclosed between the
cisterna magna septa is in direct contiguity with the fourth ventricle via the vallecula and is always com-
pletely anechoic because it develops intra- and not extra-axially. Conclusions. We propose that the cis-
terna magna septa represent the walls of Blakes pouch, a phylogenetic vestigial structure observed
during ontogeny. Additionally, our observations support current opinion that a persistent Blakes pouch
and mega cisterna magna represent (less severe) abnormalities within the Dandy-Walker continuum.
The cisterna magna septa therefore are a marker of normal development of the roof of the rhomben-
cephalon. Deviation from their normal appearances should prompt a closer assessment for associated
abnormalities of the cerebellum, vermis, and brain stem by additional imaging in orthogonal planes
with either sonography or magnetic resonance imaging. Key words: Blakes pouch; cisterna magna;
Dandy-Walker continuum; mega cisterna magna; septa.
Received June 7, 2006, from the Department of
Radiology, Childrens Hospital of British Columbia,
Vancouver, British Columbia, Canada (A.J.R.); and
Department of Radiology, University of California,
San Francisco, San Francisco, California USA (R.G.).
Revision requested June 28, 2006. Revised manuscript
accepted for publication August 24, 2006.
Address correspondence to Ashley J. Robinson,
MB, ChB, Department of Radiology, Childrens
Hospital of British Columbia, 4480 Oak St, Vancouver
BC V6H 3V4, Canada.
E-mail: ash@radiologist.net
Abbreviations
CSF, cerebrospinal fluid; MRI, magnetic resonance imaging
inear echoes are often seen in the fetal and
neonatal cisterna magna by sonography. These
septa have been variously described as the
straight sinus,
1
the torular Herophili,
2
dural folds
of the inferior attachments of the falx cerebelli,
3
or bridg-
ing arachnoid septations.
4
Clearly there is disagreement
about what they represent. Even in previous studies,
which attempted pathologic correlation between the
sonographic appearances and the gross and histologic
appearances in fetal specimens,
3,4
there was disagree-
ment in what these septations appeared to represent, one
finding dense connective tissue containing small blood
vessels but no arachnoid cells thought to be consistent
with dura and the other finding concentrations of arach-
noid septations; therefore, it seems unlikely that further
pathologic studies will be of assistance. It is, however, rec-
2007 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2007; 26:8395 0278-4297/07/$3.50
L
Image Presentation
26.1.jum.online.q 12/12/06 9:10 AM Page 83
ognized that there is great difficulty in seeing
membranes within the posterior fossa at autopsy
unless the specimen is examined under water
5
and also because of specimen degeneration due
to autolysis.
6
Characteristics of the Cisterna Magna
Septa
Previous studies have shown that the cisterna
magna septa are seen in 84% to 92% of fetuses in
the second and third trimesters.
3,4
The fact that
they are seen in such a high number of fetuses is
probably because they are normal structures.
4
Their visualization is not dependent on gesta-
tional age after 15 weeks
3
and is dependent on
the size of the cisterna magna, being most often
observed when the cisterna magna is greater
than 3 mm in anteroposterior diameter.
3
If they
are not seen, it is often because of technical or
positional issues or skull ossification.
4
These same previous studies showed that the
cisterna magna septa are typically seen infero-
posterior to the cerebellar vermis. They are usu-
ally straight and parallel to the anteroposterior
diameter of the cisterna magna
3
arising at the
cerebellovermian junction
4
and coursing posteri-
orly to the occipital bone (Figure 1). Serial follow-
up imaging of the septa show them to be more
difficult to discern later in gestation, and they
may even disappear altogether, but the posterior
fossa structures can be seen to develop normally
(Figure 2).
Additional observations not previously described
are that the cisterna magna septa become con-
tiguous with the roof of the fourth ventricle inferi-
or to the cerebellar vermis, as shown on fetal
(Figure 3) and neonatal (Figure 4) sonography. The
cerebrospinal fluid (CSF) space enclosed between
the cisterna magna septa is therefore in direct con-
tiguity with the CSF space in the fourth ventricle,
via the vallecula. Also, the fluid between the septa
is always completely anechoic, whereas the fluid
outside the septa is always slightly echogenic
(Figures 13 and 5), although this effect is reduced
throughout gestation.
Often, an additional midline septum is visible
in the posterior fossa on fetal and neonatal
sonography, which represents the falx cerebelli
(Figure 5). Therefore, 1, 2, or 3 septa can be
observed depending on the scan plane: some-
times only the midline septum (falx cerebelli)
straight to the occiput, sometimes only the 2 par-
allel septa originating at the cerebellovermian
junction, and sometimes all 3 septa.
4
This triple-
septa appearance relates not only to the scan
plane but also to the apparent variable inferior
extent of the falx cerebelli.
84
J Ultrasound Med 2007; 26:8395
Figure 1. Typical appearance of the cisterna magna septa (arrows) at 20 weeks gestation. Cb indicates cerebellum; and Cp, choroid
plexus in the lateral ventricle. A, Semiaxial view. B, Coronal view.
A B
Embryology
The Dura
At every site in the brain where the dural leaves
are separated, a venous sinus exists in the space
between them. This is because embryologically
the sinuses develop from rich vascular plexuses
within the epidural conjunctive tissue (Figure
6).
7,8
Therefore, the cisterna magna septa cannot
represent dural leaves because we would expect
there to be vascular spaces between them, but
no vascular flow is ever shown.
3,4
Although there
85
Robinson and Goldstein
Figure 3. Typical appearances of the cisterna magna septa (large arrows) at 13 weeks gestation. There was normal follow-up at 18
weeks. A, Above the level of the vallecula, the fourth ventricle (asterisk) is separated from the septa by developing cerebellar tonsils
(small arrows). B, Slightly more inferiorly, the walls of the fourth ventricle are contiguous with the cisterna magna septa via the val-
lecula (arrowhead).
A B
Figure 2. Typical appearance of the cisterna magna septa (arrows). Cb indicates cerebellum. A, At 22 weeks. B, Same fetus with nor-
mal follow-up at 35 weeks.
A B
are dural folds in the region of the cisterna
magna, they cover tributary veins of the inferior
sagittal sinus.
9
Additionally, they meet in the
midline at the falx cerebelli and diverge around
the foramen magnum, whereas the cisterna
magna septa are parallel and do no meet in the
midline. For similar reasons, the septa do not
represent the walls of the straight sinus, torcular
Herophili, or any other vascular structure. Also,
the vein of Galen and straight sinus are located
above the cisterna magna.
10
The Roof of the Rhombencephalon
Early in development, there is focal dilatation of
the central canal of the neural tube in the hind-
brain. This can be shown by sonography as a
cystic structure at the dorsal aspect of the fetal
head (Figure 7). This is the rhombencephalic
vesicle, and it eventually develops into the
fourth ventricle. Normal development of the
cerebellar vermis in the superior roof of the
rhombencephalic vesicle has been shown on
fetal sonographic
11,12
and specimen magnetic
resonance imaging (MRI) studies,
1316
and,
allowing for some physiologic variation in tim-
ing, a closed (covered) fourth ventricle should
usually be present by 17.5 to 18 weeks
17
but may
be as late as 22 to 24 weeks.
11,12
The inferior roof of the rhombencephalic vesi-
cle evaginates caudal to the developing cerebel-
lar vermis into the meninx primitiva as an
ependyma-lined diverticulum,
18
which expands
86
Figure 4. Typical appearances of the cisterna magna septa (arrows) at 28 weeks on neonatal head sonography. Asterisk indicates fourth
ventricle; and Cb, cerebellum. A, Above the vallecula, the fourth ventricle and septa (large arrows) are separated by the inferior vermis
(small arrow). B, At the level of the vallecula, the septa (arrows) are contiguous with the walls of the fourth ventricle (arrowheads).
A B
Figure 5. Triple appearance of the cisterna magna septa on
neonatal head sonography at 27 weeks gestation. The falx cere-
belli is separate from the midline cerebellar structures. It becomes
progressively smaller in anteroposterior diameter toward the infe-
rior aspect of the posterior fossa until it disappears, owing to its
sickle shape. The visible downside cisterna magna septum
meets the brain at the cerebellovermian junction. Arrow indicates
falx cerebelli; Cb, cerebellum; and Vm, cerebellar vermis.
dorsally to form Blakes pouch.
19
The walls of
Blakes pouch are composed of an inner layer of
ependyma, an intermediate layer of attenuated
neuroglial tissue, and an outer layer of pia-arach-
noid.
18
Blakes pouch fenestrates to a variable
degree down to the obex (the inferior recess of the
fourth ventricle), depending on whether the walls
of the pouch are supported from adjacent neural
and pial structures.
19,20
This fenestration leaves
Blakes metapore.
20,21
The metapore, otherwise
known as the foramen of Magendie, represents
the neck of Blakes pouch, and the cisterna magna
septa represent the remnants of its walls.
This explains why the fluid between the septa
is always anechoic, whereas the fluid lateral to
the septa is usually slightly echogenic; the
fluid between the septa is intra-axial, whereas
the fluid outside the septa is in the subarach-
noid space of the cisterna magna. The sub-
arachnoid space is trabeculated in multiple
planes by pia-arachnoid septations, a result of
its embryologic development,
4
which give rise
to the relative echogenicity compared with the
intra-axial CSF spaces. The relative echogenic-
ity diminishes throughout gestation as cavita-
tion progresses.
87
Figure 6. Embryologic features of the dura. A, The brain (large
arrow) is covered by a layer of meninx primitiva (small arrow) and
vascular mesenchyme (double arrow). B, As the cerebral and
cerebellar hemispheres expand and overgrow the developing
midline structures (arrows), there is eventual apposition and
fusion of the two reflected dural layers from adjacent hemi-
spheres. The meninx primitiva starts to cavitate to form the sub-
arachnoid space, delimited by an inner condensation of pia
mater and an outer condensation of arachnoid mater. The vas-
cular mesenchyme persists as a wedge of tissue trapped in the
dural folds (double arrow). C, The reflected dural layers fuse,
thus forming the falx cerebri, falx cerebelli, and tentorium. The
meninx primitiva cavities coalesce to form the subarachnoid
space, which is traversed by multiple pia-arachnoid septations
(small arrow). Where no dural fusion takes place, the vascular
mesenchyme cavitates to form venous sinuses, for example, the
superior and inferior sagittal sinuses (double arrows). D, Color
Doppler examination at 21 weeks showing flow in the occipital
sinus (double arrow) between the diverging dural leaves of the
falx cerebelli but none between or within the cisterna magna
septa (arrows).
C
D
A
B
The process of dorsal expansion also explains
why the tela choroidea has been shown to extend
outward beneath the vermis into the cisterna
magna
19,20
as it is carried in the walls of Blakes
pouch as it expands dorsally. Once fenestration
of the pouch occurs, it would then appear as if
the tela choroidea would be within the cisterna
magna and contiguous with the pia mater over
the brain stem.
Lateral Displacement of the
Cisterna Magna Septa
The fenestration of Blakes pouch and therefore
communication of the pouch with the sub-
arachnoid space are variable in timing but
should occur by 4 months.
18,20,21
The foramen
of Luschka normally opens later than the fora-
men of Magendie; however, in 1% to 2% of
healthy individuals, the foramen of Magendie
is absent.
20
This is understandable inasmuch as
ontogeny recapitulates phylogeny, and in lower
species, the pouch never fenestrates, and
Blakes metapore is therefore absent.
19
In these
healthy individuals (and in lower species), it is
the opening of the foramen of Luschka that
leads to equilibrium of CSF between ventricles
and subarachnoid cisterns.
22
We speculate that before fenestration of the
foramen, there is transient increased intra-axial
CSF pressure, and this explains the enlargement
of the fourth ventricle, which is seen around 14
to 16 weeks gestation, resolving completely by
22 to 23 weeks gestation.
12,18,22
It also probably
explains the outward bowing of the cisterna
magna septa often observed sonographically,
giving the impression of a posterior fossa cyst
(Figure 8).
4
Intraventricular Hemorrhage
Sometimes the septa are bowed laterally by the
presence of intraventricular hemorrhage extend-
ing posterior to the vallecula (Figure 9). Blood in
the cisterna magna has previously been shown to
have a high positive predictive value for develop-
ment of posthemorrhagic hydrocephalus.
23
The
likely explanation is that in the premature
neonatal population, blood seen inferoposterior
to the cerebellar vermis is actually not in the cis-
terna magna but is contained within Blakes
pouch and is therefore intra-axial, not extra-
axial. Therefore, it has the potential to cause
hydrocephalus because its intra-axial location
allows it to block the foramina of Luschka and
Magendie.
88
Figure 7 (opposite page). Embryologic features of the develop-
ing hindbrain. A, Sagittal view of an embryo at approximately 7
weeks gestation showing the typical appearances of the
rhombencephalic vesicle (arrow). The primitive dorsal pontine
flexure is also clearly shown (dotted line). B, During formation of
the dorsal pontine flexure of the rhombencephalon (small
arrow), a transverse crease forms in the roof of the rhomben-
cephalic vesicle (large arrow), sandwiching a layer of the meninx
primitiva. The crease divides the roof of the fourth ventricle
(asterisk) into the anterior (superiorly) and posterior (inferiorly)
membranous areas. C, The transverse crease and its wedge of
vascular meninx primitiva develop into the choroid plexus (large
arrow) of the roof of the fourth ventricle. The anterior membra-
nous area thickens and proliferates posteroinferiorly, giving rise
to the cerebellar vermis (arrowhead), which covers the posterior
membranous area. The meninx primitiva (double arrow) cavi-
tates to form the subarachnoid space. D, As a result of growth
of overlying and surrounding structures, the posterior mem-
branous area is left effectively evaginating posteriorly into
the meninx primitiva between the inferior vermis superiorly
(large arrow) and the nucleus gracilis inferiorly (small arrow),
forming Blakes pouch, and carries the developing choroid
plexus in its roof. The cavitations in the meninx primitiva coales-
cence to form the subarachnoid space trabeculated by multiple
pia-arachnoid septations. The fluid contained by Blakes pouch
is intra-axial, even though the pouch itself lies within the devel-
oping cisterna magna (double arrow). The pia mater (gray out-
line) develops as a condensation of the meninx primitiva overly-
ing the developing neural structures. The ependyma lining the
neural tube (black outline) also lines Blakes pouch. As the pouch
expands, its walls and the associated tela choroidea become
apposed to the medial surfaces of the adjacent cerebellar hemi-
spheres and the undersurface of the superjacent inferior vermis.
Because these also have pia mater over their outer surfaces, the
two outer layers of pia mater become apposed and indistin-
guishable. E, Blakes pouch fenestrates, leaving an opening at its
neck called Blakes metapore (dashed oval). The choroid plexus
(arrow) is now in direct contiguity with the pia mater over the
inferior surface of the cerebellar vermis and lies in the (extra-
axial) subarachnoid space, although it developed intra-axially.
The remnants of Blakes pouch probably persist to a variable
degree. F, In the axial plane, Blakes pouch extends dorsal to the
fourth ventricle (asterisk) into the developing subarachnoid
space below the vermis and between the cerebellar hemi-
spheres. The developing choroid plexus (double arrows) in the
roof of the rhombencephalic vesicle has normal caudal exten-
sions on either side of the midline, which, once Blakes pouch
fenestrates, will appear to lie on the extra-axial surface of the
cerebellum. The lateral recesses of the rhombencephalic vesicle
(small arrows) are also in contact with the developing subarach-
noid space and fenestrate to form the foramen of Luschka. The
walls of Blakes pouch (large arrows) are visible sonographically
as the cisterna magna septa.
Mega Cisterna Magna
A mega cisterna magna (cisterna magna 10 mm;
Figure 10) is known to result from a defect of the
posterior membranous area during embryogene-
sis.
21
We speculate that in this condition, Blakes
pouch probably persists and expands posterior to
a normally formed cerebellum and vermis, but
unlike a persistent Blakes pouch (see below), fen-
estration occurs late, leaving behind an expanded
posterior fossa, thus explaining the free communi-
cation between the cyst, fourth ventricle, and
subarachnoid space that is seen in this condition.
21
89
F
D A
B
E
C
Dandy-Walker Continuum
The observation that the cisterna magna septa
were not seen in 16 of 18 fetuses with Dandy-
Walker malformation
3
is most likely due to the
fact that the cisterna magna septa (the walls of
Blakes pouch) and the walls of the Dandy-
Walker cyst are identical anatomic structures,
and during expansion of the pouch within the
cisterna magna, its walls become apposed to
and indistinguishable from the sides of the pos-
terior fossa (Figure 11). In those 2 of 18 cases in
which the septa were seen, the size of the
Dandy-Walker cyst may simply have been small-
er, allowing them to be seen separately,
3
or the
diagnosis was erroneous, perhaps representing
a persistent Blakes pouch (see below).
Persistent Blakes Pouch
In a persistent Blakes pouch (Figure 12), there is
thought to be failure of fenestration of both
Blakes pouch and the foramen of Luschka,
leading to dilatation of the fourth ventricle.
21
Although the pouch communicates freely with
the fourth ventricle, there is a failure of commu-
nication between the pouch and the per-
imedullary subarachnoid spaces.
20,24
After
ventricular shunting, subtotal or total reexpan-
sion of the cerebellar hemispheres and vermis
can be seen
22
; that is, although these structures
appear to be hypoplastic, there is actually no
intrinsic hypoplasia but just the mass effect of
the cyst.
90
Figure 8. Septa appear bowed out (arrows), giving a cystic
appearance in this neonate at 24 weeks gestation. Asterisk indi-
cates fourth ventricle; and Cb, cerebellum. This appearance was
seen in 18% of cases in a previous study.
4
Figure 9. Dilatation of the space between the cisterna magna septa on neonatal head sonography at 31 weeks gestation, secondary to
intraventricular hemorrhage. A, Semiaxial view showing a dilated space between the cisterna magna septa with blood layering on the
head-down (dependent) side septum (double arrow) but not reaching the subarachnoid space over the cerebellar hemisphere (small
arrow). Asterisk indicates fourth ventricle; and Cb, cerebellum. B, Axial computed tomography (different patient) showing blood in the
cisterna magna but on closer observation can be seen to be limited in its lateral extent by invisible walls (arrows) corresponding to
the cisterna magna septa and indirectly indicating the existence of Blakes pouch, which itself cannot be resolved.
A B
91
Figure 10. Suspected mega cisterna magna at 19 weeks gestation.
A, Axial scan below the level of the vallecula showing the cisterna
magna septa (arrows) bowed outward. B, Axial scan at level of the
vallecula showing the fourth ventricle (asterisk) to be contiguous with
space between septa via the vallecula. Arrows indicate cerebellar ton-
sils. C, Slightly oblique midline image showing evagination of the roof
of the rhombencephalic vesicle forming a pouch (large arrow) con-
taining anechoic fluid (CSF). The inferior border of the tentorium and
falx cerebelli is visible (double arrow), with a slightly echogenic sub-
arachnoid space directly inferior to it. The vermis (small arrow) is
slightly compressed superoanteriorly. D, Sagittal MRI from the same
fetus showing a mega cisterna magna (double arrow). The walls of
the pouch are not detectable by MRI. The vermian size and morpho-
logic characteristics are normal for gestation with a normal primary
fissure (large arrow) and fastigial point (small arrow) but an impres-
sion of slight compression inferiorly. E, In a mega cisterna magna, the
foramina of Luschka and Magendie fenestrate late, leading to dilata-
tion of the pouch and enlargement of the posterior fossa (double
arrow). Once fenestration occurs, the vermis, which has developed
normally but which may have been elevated, returns to a more nor-
mal position. An enlarged subarachnoid space results, but actual-
ly this enlarged space initially was intra-axial, not extra-axial.
B
D E
A
C
It has been shown that an increased angle
between the vermis and tegmentum without
any other abnormality of growth or structure
of the vermis or abnormality elsewhere in the
fetus may simply represent elevation of the ver-
mis and does not necessarily indicate an adverse
outcome,
5,2528
which could be explained by a
persistent Blakes pouch. Unfortunately, this
elevation of the vermis often leads to the false-
positive diagnosis of a Dandy-Walker continu-
um on axial sonography
25
and inferior vermian
hypoplasia on sagittal sonography or MRI. This
would explain why there has historically been
a poor correlation between sonographic and
autopsy findings in apparent cystic malforma-
tions of the posterior fossa.
6
Dandy-Walker Continuum, Persistent
Blakes Pouch, and Mega Cisterna Magna:
A Single Spectrum
We speculate that the spectrum of findings with
respect to the posterior fossa cyst in the Dandy-
Walker continuum, persistent Blakes pouch,
and mega cisterna magna might depend on the
degree of dilatation of Blakes pouch, which in
turn depends on the relative timing of fenestra-
tion of the fourth ventricle outlet foramina. It
would appear that in a persistent Blakes pouch,
the vermis is fully formed, but neither the
pouch nor the foramina of Luschka fenestrate,
leading to elevation of an otherwise normal ver-
mis. In the Dandy-Walker continuum, there is
92
Figure 11. Dandy-Walker continuum at 22 weeks gestation
(case courtesy of Ants Toi, MD, and Susan Blaser, MD,
Department of Medical Imaging, University of Toronto, Toronto,
Ontario, Canada). The pregnancy was terminated. A, Axial view
showing dilatation of space between the cisterna magna septa
(arrows), which are effaced to adjacent structures and almost
imperceptible. The fourth ventricle (asterisk) is contiguous with
this space via the dilated vallecula. Cb indicates cerebellum; and
Cp, cerebral peduncles. B, Sagittal MRI showing a hypoplastic
cerebellar vermis (double arrow) and superior roof of the
expanded Blakes pouch (small arrow). Adapted with permission
from Imaging the Central Nervous System of the Fetus and
Neonate.
27
C, In the Dandy-Walker continuum, there is variable
vermian hypoplasia (small arrow), elevation by the dilated
Blakes pouch (double arrow), and variable degrees of fenestra-
tion of the foramina of Luschka and Magendie.
A
B
C
93
Figure 12. Persistent Blakes pouch at 23 weeks (case courtesy of Ants Toi, MD, and Susan Blaser, MD, Department of Medical
Imaging, University of Toronto, Toronto, Ontario, Canada). The fetus was stillborn at 28 weeks because of placental insufficiency in a
mother with sickle cell disease. The karyotype and pathologic findings were both normal. A, Axial view with an expanded fourth ven-
tricle (asterisk) and neck of Blakes pouch causing a mass effect with concavity of the adjacent cerebellar hemispheres (Cb), which
appear normal in size. Cp indicates cerebral peduncles. B, Sagittal MRI showing a cerebellar vermis (double arrow) with normal land-
marks that has normal biometric characteristics, but it is angled away from the tegmentum (small arrow), with a large gap between
the inferior vermis and brain stem (arrowhead). Because the vermian structure is normal, this gap should not be confused with infe-
rior vermian hypoplasia. Adapted with permission from Imaging the Central Nervous System of the Fetus and Neonate.
27
C, Sagittal
histopathologic specimen showing that the vermis has returned to a normal position as Blakes pouch has collapsed. The fourth ven-
tricle is now normal in size (asterisk). The vermian structure is normal, with normal primary (long arrow) and prepyramidal (short arrow)
fissures. It is important to note that in the fully mature vermis, there will be 3 lobules between these 2 landmarks (declive, folium, and
tuber), but unlike the other vermian lobules, their white matter cores unite before reaching the fastigium (circle). On fetal MRI, this
can lead to underestimation of the number of visible vermian lobules. Reproduced with permission from Imaging the Central Nervous
System of the Fetus and Neonate.
27
D, In a persistent Blakes pouch, the cerebellar vermis forms normally. Nonfenestration of the
foramina of Luschka and Magendie leads to dilatation of the fourth ventricle and Blakes pouch and elevation of the vermis (small
arrow) away from the brain stem. There is no demonstrable communication between the cyst (double arrow) and the subarachnoid
space by contrast cisternography.
C D
A B
variable vermian hypoplasia and elevation and
variable fenestration.
29
In a mega cisterna
magna, the vermis is fully formed, but fenestra-
tion of Blakes pouch and the foramen of Luschka
is delayed, thus allowing sufficient CSF equilibra-
tion for the vermis not to be elevated but only
after it has already caused expansion of the cis-
terna magna.
Conclusions
We propose that the cisterna magna septa repre-
sent the walls of Blakes pouch, a phylogenetic
vestigial structure observed during ontogeny, the
remnants of which are probably present in the
neonatal period and possibly even into adult-
hood. Additionally, our observations support
current opinion that a persistent Blakes pouch
and mega cisterna magna may represent (less
severe) abnormalities within the Dandy-Walker
continuum.
The cisterna magna septa are therefore a
potential new marker of normal development of
the roof of the rhombencephalon. Deviation
from their normal appearances should prompt a
closer assessment for associated abnormalities
of the cerebellum, vermis, and brain stem by
additional imaging in orthogonal planes with
either sonography or MRI.
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