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Table of Contents    
Year : 2016  |  Volume : 64  |  Issue : 4  |  Page : 830-831

Prenatal Blake pouch cyst with hydrocephalus

1 Department of Radiology and Imaging Sciences, Sri Ramachandra Medical College and Research Institute, Chennai, India
2 Department of Sonography, Abirami Scans, Puducherry, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Dr. Udaya Bhaskarini Vakakmudi
Department of Radiology and Imaging Sciences, Sri Ramachandra Medical College and Research Institute, Chennai - 600 116, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.185399

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How to cite this article:
Vakakmudi UB, Rangasami R, Gopinath VN. Prenatal Blake pouch cyst with hydrocephalus. Neurol India 2016;64:830-1

How to cite this URL:
Vakakmudi UB, Rangasami R, Gopinath VN. Prenatal Blake pouch cyst with hydrocephalus. Neurol India [serial online] 2016 [cited 2020 Jun 6];64:830-1. Available from:

A 38-year-old female patient with 38 weeks of gestation was referred for fetal magnetic resonance imaging (MRI) for the evaluation of her fetus who showed bilateral ventriculomegaly on antenatal sonography. Her 26 -week scan done in a rural hospital was reported as showing a prominent cisterna magna. The fetal MRI performed using the half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence revealed dilatation of all the ventricles. The fourth ventricle was continuous with a cystic area that extended into the cisterna magna [Figure 1]a, [Figure 1]b, [Figure 1]c. The vermis, though visualized, was mildly displaced cranially along with the cerebellum [Figure 1]a. A radiological diagnosis of Blake pouch cyst (BPC) with hydrocephalus was made, and a postnatal follow-up MRI was advised. The postnatal MRI confirmed the findings of BPC with hydrocephalus [Figure 1]d, [Figure 1]e, [Figure 1]f. Before discharge, the parents were counseled and ventricular decompression procedure was advised.
Figure 1: Sagittal T2-weighted magnetic resonance images (a) of the fetus show a dilated IV ventricle continuous with a retrocerebellar cyst (arrow). The vermis is visualized but mildly rotated anticlockwise (arrowhead). The inferior aspect of the membrane is visualized (broken arrow). Axial sections (b and c) show inferior communication of the IV ventricle withthe retrocerebellar fluid collection (open arrow) and dilatation of all the ventricles. Sagittal (d) and axial (e and f) T2-weighted magnetic resonance images of the neonate confirming the antenatal findings

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Embryologically, the choroid plexus divides the roof of the fourth ventricle into an anterior membranous area and a posterior membranous area. Blake's pouch appears as a protrusion of the posterior membranous area of the fourth ventricular roof. Normally, Blake's pouch communicates with the subarachnoid space through the foramen of Magendie by 8 weeks and through the foramen of Luschka by 4–5 months.[1] When the foramen of Magendie fails to perforate, there is dilatation of the Blake's pouch till the foramen of Luschka establishes equilibrium with the subarachnoid space leading to the development of BPC.[2] Persistent BPC represents an embryonic midline outpouching of a portion of the primitive fourth ventricle, which extends inferiorly and posteriorly from the vermis into the cisterna magna and may push the developing tentorium into an abnormal, relatively high position.[3] One-third to one-half of the cases show its spontaneous resolution [4] before birth due to late fenestration of the foramen of Magendie. In the remainder of cases, fenestration of the foramen of Magendie does not occur leading to features such as cystic dilation of the fourth ventricle without cisternal communication, tetraventricular hydrocephalus, a well-developed cerebellar vermis, with mild anticlockwise rotation [Figure 2]b.[2]
Figure 2: Diagrammatic representation of conditions with prominent retrocerebellar space. (a) Mega cistern magna—The vermis is not rotated, the cerebellum and vermis are developed. (b) Blake pouch cyst—The vermis is mildly rotated, the cerebellum and vermis are developed. (c) Dandy–Walker variant—The vermis is moderately rotated, the cerebellum and vermis are hypoplastic. (d) Dandy–Walker malformation—The vermis is severely rotated, the cerebellum and vermis are poorly developed

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Persistent BPC needs to be differentiated from other conditions such as (a) mega cisterna magna, (b) Dandy–Walker variant, (c) Dandy–Walker malformation, and (d) posterior fossa arachnoid cyst. In the mega cisterna magna, cerebellum and fourth ventricle are normal, and there is no anticlockwise rotation of the vermis [Figure 2]a. In the Dandy–Walker variant, there is partial vermian and cerebellar hypoplasia with a moderate anti-clockwise rotation of the vermis [Figure 2]c. In Dandy–Walker malformation, there is abnormal development of the vermis, cerebellar hemispheres, severe anti-clockwise rotation of the vermis and enlarged posterior fossa with elevation of the tentorium and torcula herophili [Figure 2]d.[2]

The clinical significance of persistent Blake pouch cyst is that it is a benign condition that resolves spontaneously; even when it presents with hydrocephalus, the condition gesnerally carries a good prognosis. On the other hand, in Dandy–Walker malformation, the prognosis is guarded. Hence, a precise diagnosis is important for patient counseling and management. Endoscopic third ventriculostomy is the treatment of choice in BPC associated with hydrocephalus.[2]

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 » References Top

Azab WA, Shohoud SA, Elmansoury TM, Salaheddin W, Nasim K, Parwez A. Blake's pouch cyst. Surg Neurol Int 2014;5:112.  Back to cited text no. 1
Cornips EM, Overvliet GM, Weber JW, Postma AA, Hoeberigs CM, Baldewijns MM, et al. The clinical spectrum of Blake's pouch cyst: Report of six illustrative cases. Childs Nerv Syst 2010;26:1057-64.  Back to cited text no. 2
Calabrò F, Arcuri T, Jinkins JR. Blake's pouch cyst: An entity within the Dandy–Walker continuum. Neuroradiology 2000;42:290-5.  Back to cited text no. 3
Subhashree R, Rajeswaran R, Suresh S, Indrani S. Spontaneous resolution of Blake's pouch cyst. Radiol Case Rep (Online) 2013;8:77  Back to cited text no. 4


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