PICTORIAL ESSAY

CME ARTICLE

The Fetal Cerebellar Vermis

Assessment for Abnormal Development by Ultrasonography
and Magnetic Resonance Imaging
Ashley J. Robinson, MB, ChB,*Þ Susan Blaser, MD,Þ Ants Toi, MD,þ David Chitayat, MD,§
William Halliday, MD,|| Sophie Pantazi, MD,þ Munire Gundogan, MD,Þ¶
Suzanne Laughlin, MD,Þ and Greg Ryan, MBL

Abstract: Fetal magnetic resonance provides a new tool in the

imaging of the posterior fossa and is proving useful in cases that are
difficult to assess sonographically by allowing further assessment
of the fourth ventricle, cisterna magna, and vermian growth and
development. We describe various criteria with which to evaluate
vermian growth, including vermian biometry and the relationship
between the superior and inferior lobes. We demonstrate 2 markers
of normal vermian development: the primary fissure and fastigial
point. We illustrate the tegmento-vermian angle, Bclosure^ of the
fourth ventricle, and communication of the fourth ventricle with
the basal cisterns during development and in several disorders. We
correlate those features with the expected embryological course of
development and illustrate identification of these features and as-
sociated abnormalities of the posterior fossa, brain stem, and central
nervous system in mid-trimester scans of fetuses with abnormal
development. Correlation with contemporaneous ultrasound exam-
inations is demonstrated.
Key Words: ultrasound, magnetic resonance, fetus, prenatal,
antenatal cerebellum, vermis, posterior fossa, cisterna magna, fouth
ventricle, Dandy-Walker, Blake pouch, mega cisterna magna
(Ultrasound Quarterly 2007;23:211Y223)
Received for publication February 12, 2007; accepted June 20, 2007.
*Staff Radiologist, Department of Radiology, Children’s & Women’s
Hospital of British Columbia, Vancouver, British Columbia; †Staff
Radiologists (Robinson and Gundogan), Associate Professor (Blaser),
Assistant Professor (Laughlin), Department of Neuroradiology, Hospital
for Sick Children; ‡Associate Professor (Toi), Assistant Professor
(Pantazi), Department of Medical Imaging, §Professor, Department of
Prenatal Diagnosis & Medical Genetics, Mt. Sinai Hospital; ||Professor,
Department of Neuropathology, Hospital for Sick Children, Toronto,
Ontario; ¶Staff Radiologist, Department of Diagnostic Imaging,
Dalhousie University, Halifax, Nova Scotia; #Professor, Department of
Obstetrics and Gynecology, Mt. Sinai Hospital, Toronto, Ontario, Canada.
The authors have disclosed that they have no financial interests in or
relationships with any commercial companies pertaining to this educa-
tional activity.
Lippincott Continuing Medical Education Institute, Inc. has identified and
resolved all faculty conflicts of interest regarding this educational activity.
Reprints: Ashley J. Robinson, MB, ChB, Department of Radiology, Chil-
dren’s Hospital of British Columbia, 4480 Oak St, Vancouver, V6H 3V4,
Canada (e-mail: ash@radiologist.net).
Copyright * 2007 by Lippincott Williams & Wilkins
LEARNING OBJECTIVES
1. Distinguish the normal and abnormal embryology of the
cerebellum, fourth ventricle, and cisterna magna.
2. Identify the presence or absence of the key vermian
landmarks and be able to apply biometric criteria, to de-
termine if the vermis is morphologically normal.
3. Identify the serious vermian pathologies and establish
how to differentiate them from those with a potentially
good prognosis.
E valuation of the posterior fossa is an essential part of
routine fetal sonography, as defined by guidelines from the
American College of Radiology, American Institute of
Ultrasound in Medicine, American College of Obstetricians
and Gynecologists, the Society of Obstetricians and Gynae-
cologists of Canada, and Canadian Association of Radiolo-
gists, which state that views of the cerebellum and cisterna
magna should be specifically included.1Y3 Normal measure-
ments of the cisterna magna (between 2 and 11 mm) and
ventricular atrium (G10 mm) confer a very high negative
predictive value (P G 0.005%) for abnormal central nervous
system (CNS) and spinal cord development.4
When an abnormality is found, however, there are a
variety of pathologies that can look similar and even iden-
tical by standard axial ultrasonography, including Dandy-
Walker continuum (DWC) and other vermian hypoplasia
syndromes, mega cisterna magna and posterior fossa arach-
noid cyst. Differentiation is difficult because there are tech-
nicalities often preventing access to sagittal and coronal views
of the posterior fossa. Although strived for, sagittal fetal CNS
sonography obtained via transabdominal and transvaginal
approaches5Y8 still remains an optional view in most centers
and is not required by the aforementioned guidelines.
Considerable attention has been paid to the more readily
obtained axial sonographic views, and although most of the
aforementioned disorders can be demonstrated, so can
a variety of false-positive vermian pathologies.9Y11 For ex-
ample, imaging the posterior fossa in the semicoronal plane
can give a false appearance of an enlarged cisterna magna
or even partial vermian agenesis.12 Additionally there is nor-
mal physiological variation in time of completion of vermian
development, which may therefore be incomplete at the time
of initial mid-trimester assessment.13
The advent of fetal magnetic resonance (MR) has pro-
vided a new tool in the imaging armamentarium that is proving

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Robinson et al Ultrasound Quarterly & Volume 23, Number 3, September 2007

FIGURE 1. Diagrammatic representation of early vermian development as seen by MR imaging of fetal specimens.19Y21 Eleven
to 12 weeksVdeveloping vermis (A, single arrow) and position of fourth ventricle roof which is nonresoluble by MR (double arrow).
Thirteen to 14 weeksVdeveloping fastigial point (B, single arrow) and fourth ventricle roof now visible. The brain stem develops
a kinkVthe dorsal pontine flexure (double arrow). Sixteen weeksVvermis now covers fourth ventricle roof (C, double arrow).
Eighteen weeksVvermis usually complete (D, double arrow).

to be extremely useful in difficult cases, often because those fetal skull ossification, and oligohydramnios can frequently
orthogonal views are more readily obtainable and because be overcome. Therefore, fetal MR allows additional assess-
other limitations of ultrasonography such as maternal obesity, ment of the fourth ventricle, cisterna magna, and vermian

FIGURE 2. Early development as seen on MR imaging in vivo. Approximately 17.5 weeksVthe primary fissure (A, single arrow)
is the first major vermian fissure to appear and marks the boundary between the anterior and posterior vermis. By MR, it is seen
as a high signal indentation on the posterosuperior aspect of the vermis. The fastigial point (double arrow) is the posterosuperior recess
of the fourth ventricle and should form an acute angle, giving it a diamond shape. Twenty-one weeksVprepyramidal fissure (B,
arrow). Twenty-one to 22 weeksVpreculminate fissure (C, arrow). Twenty-four weeksVsecondary (postpyramidal) fissure (D, arrow).
Twenty-seven weeksVall lobules visible (E). Detail of E (F). Detail of gross specimen for comparison (G) (adapted from 62).

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Ultrasound Quarterly & Volume 23, Number 3, September 2007 The Fetal Cerebellar Vermis

growth and development not as readily achieved by
ultrasonography.
EARLY DEVELOPMENT OF THE
CEREBELLAR VERMIS
Genetics
There is emerging experimental evidence on the mech-
anisms of cerebellar and vermian development that occurs
under the influence of various factors.14,15 Several genes,
including Gbx2, homeobox, Otx2, and Zic3, play a signifi-
cant role in the formation and function of the isthmic orga-
nizer14,16 which, in turn, regulates cerebellar development
through release of hormonal factors.14 Two distinct germinal
matrices form the cerebellum, one periventricular and the
other derived from the rhombic lip.14,15 A change in the axis
of alignment of the cells from rostrocaudal to mediolateral
produces the winglike expansion of the cerebellar hemi-
spheres from the germinal matrix of the rhombic lips, which
then undergo transverse (medial) migration during subse-
quent foliation.17
As Seen Histologically
The cerebellar vermis per se starts development as a
thickening of the alar plate of the rhombencephalon during
the fifth week of gestation.18 This thickening occurs in the
anterior membranous area of the roof of the rhomben-
cephalic vesicle. Whereas the hemispheres grow on each
side, the vermis forms in the midline through proliferation
of the median primordium17 (not by fusion of the hemi-
spheres), starting in the ninth week of gestation. By 10 to
11 weeks, the vermis enlarges rostrally, and the hemi-
spheres enlarge laterally. By 12 to 13 weeks, the lobules
and folia of the cerebellum proliferate, and the central of
the vermis develops further.
As Seen on MR Imaging of Fetal Specimens
This same pattern of development can be demonstrated
on MR imaging of fetal specimens in vitro, although the
gestational age at which the respective features are seen is
later than that by histology19Y21 because of a drop in reso-
lution by MR scanning.
At around 11 to 12 weeks, the cerebellum and early
vermis can be seen along the rostral aspect of the fourth
ventricle (Fig. 1). By 13 to 14 weeks, the early fastigial point
(Fig. 2G) can be seen developing as a crease along the ven-
tral surface of the cerebellar plate, and the roof of the fourth
ventricle is just able to be resolved.21,22 The hemispheres
enlarge first dorsolaterally and then later caudolaterally.
By 14 to 16 weeks, the primary fissure of the vermis is
visible.19,21 By 16 weeks, the roof of the fourth ventricle is
visible throughout, and the vermis enlarges caudally, Bfolds^
along the fastigial point, and begins to cover the roof of the
fourth ventricle. This is commonly referred to as Bclosure^ of
the fourth ventricle. By 16 to 17 weeks, the secondary,
prepyramidal, preculminate, and precentral vermian fissures
are visible on MR images of these specimens.19,21
By 18 to 19 weeks, the craniocaudal length of the vermis
is equal to that of the cerebellar hemispheres, and the fourth
ventricle is usually completely covered,13,22 although cover-
age of the fourth ventricle as seen in the normal newborn
relationship should always occur by 22 to 24 weeks,19,21 a
feature also demonstrated by fetal ultrasonography.23,24
It should be remembered that in fetal specimen studies,
the age of the embryo or fetus is defined as the age from
conception (gestational age), whereas in clinical studies, it is
the age from the first day of the last menstrual period
(menstrual age), typically accounting for a 2-week difference.
Therefore, when comparing fetal specimen studies and
clinical studies, an adjustment has to be made to allow for

FIGURE 3. In this fetus at 20 weeks’ gestation, axial sonography (A) shows an enlarged cisterna magna measuring 15 mm in
the standard anteroposterior direction. There is an abnormally shaped fourth ventricle (arrow) that is rounded rather than the
normal diamond shape. Some vermian tissue is seen to separate the fourth ventricle and cisterna magna, but in real time, more
tissue was seen inferiorly rather than superiorly. Conversely, in DWC, the vermian tissue is seen superiorly rather than inferiorly;
therefore, this appearance is atypical, and the sonographic diagnosis is uncertain. On sagittal MR (B), we see a small amount
of midline tissue between the cerebellar hemispheres consistent with vermian tissue. On this view, some of what looks to be midline
vermis are actually partial volume averaging of adjacent cerebellar hemisphere. There is no fastigial point (double arrow), and
the roof of the fourth ventricle has a squared-off shape rather than being triangular. There is no primary fissure (single arrow).
On the axial MR (C), there is a ‘‘molar tooth’’ shape to the brain stem (double arrow), and the fourth ventricle has an abnormal
‘‘batwing’’ shape (outlined).

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Robinson et al Ultrasound Quarterly & Volume 23, Number 3, September 2007

FIGURE 4. In this fetus case at 30 weeks’ gestation, sonography showed several abnormalities including schizencephaly and
polymicrogyria. Axial sonography demonstrates an abnormal cerebellum with transverse folia that are seen to be continuous
between the hemispheres across the midline (A, arrow). The transcerebellar diameter was 3.02 cm, which would be normal for
26 weeks of gestational age. On sagittal MR, the fastigial point is rounded off (B, double arrow) rather than triangular. There is no
primary fissure (single arrow). The craniocaudal diameter (square calipers) of the ‘‘vermis’’ is much larger than expected because
it is actually the fused cerebellar hemispheres that are being measured (see below for vermian craniocaudal diameter
measurement). This could lead to false reassurance that the vermis is present. A large left-sided cerebrospinal fluid collection is
also present and included on the slightly off-axis sagittal image. C, On axial MR views, the cerebellar folia are again seen to be
continuous across the midline (arrow). Additionally, the transverse cerebellar diameter is too small. This is an example of
rhombencephalosynapsis, a fusion anomaly where the vermis does not form as it should, starting at around 9 weeks’ gestation.

this pseudodifference in the age of the fetus. By convention,
we use menstrual age for the remainder of this paper.
A SYSTEMATIC APPROACH TO ANALYSIS
OF VERMIAN DEVELOPMENT
Assessment for Presence of the Vermis Using
Its Major Landmarks
On fetal in vivo MR, development follows the same
pattern as seen with in vitro MR19Y21 and in vivo ultra-
sound studies13,22Y24 (Fig. 2). However, because of the drop
in resolution incurred by imaging in vivo (motion, larger
field of view, lower signal-noise ratio), there is a pseu-
dodelay of up to 3 weeks between identification of the
vermian fissures in vivo compared with in vitro.
By 17.5 weeks, one should be able to identify whether
the vermis is present by assessing for the major landmarks
that we know should be present by this gestation as deter-
mined by in vitro MR. This includes whether the fastigial
point is present and has a normal acute angle (Fig. 2G), or
whether it is deficient (ie, absent or obtuse angle), and
whether the primary fissure is identifiable.
In Joubert syndrome (Fig. 3) and Joubert-like-related-
disorders, for example, the vermis is incomplete, the fastigial

FIGURE 5. In this fetus at 28 weeks’ gestation, the axial sonography shows a deficient vermis (A, arrow) apparently consistent
with a Dandy-Walker variant. There was also asymmetric ventricular size (not shown). On sagittal MR, we see that the vermis is
abnormally shaped with no fastigial point (B, short arrow) or primary fissure (large arrow). The fourth ventricle appears abnormally
large, and an occipital cephalocele is seen (small arrow). The brain stem has a primitive configuration, retaining the dorsal
pontine flexure, giving it a ‘‘Z’’ shape (Fig. 1B).63 On axial MR , the fourth ventricle has lost its normal diamond shape (C, arrow),
and one of the fetal eyes is small and distorted (small arrow). This is an example of congenital muscular dystrophy. The brain
stem has a primitive Z-shaped configuration. The additional findings of occipital cephalocele and microphthalmia are consistent
with Walker-Warburg phenotype; however, interestingly, this patient actually had a Fukutin gene mutation on postnatal
genetic studies, a known but exceedingly rare variant cause of this condition.

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Ultrasound Quarterly & Volume 23, Number 3, September 2007 The Fetal Cerebellar Vermis

FIGURE 6. In this fetus at 20 weeks’ gestation, the axial sonogram shows a large posterior fossa cystic space, and 2 tiny
cerebellar hemispheres either side of the midline (A, arrows). Biometric measurements were abnormally small. On sagittal MR,
we see that the vermis is incomplete, and there is no fastigial point (B, double arrow) or primary fissure (single arrow). The fourth
ventricle is uncovered (small arrow). There is a thin cerebral cortex with a prominent subarachnoid space, and the brain stem
has a primitive Z-shaped configuration. There is complete agenesis of the corpus callosum that cannot be seen at all on this midline
section. On axial MR, there are shell-like cerebellar hemispheres (C, arrow) and a hypoplastic brain stem (small arrow). This is
an example of microlissencephaly. Again, the brain stem has maintained its primitive Z-shaped configuration with a dorsal kink
at the pontomesencephalic junction.63 This pregnancy was terminated. Karyotype was normal with no genetic abnormality
compatible with congenital muscular dystrophy or LIS1 deletion.

point is distorted, and the primary fissure is not identifi-
able. Additionally, there is a Bmolar tooth^ configuration
of the mesencephalon. The vermis is either aplastic, hypo-
plastic, or cleft, and the superior medullary velum is absent.
There are specific associated clinical features, typically tran-
sient neonatal hyperpnea, abnormal eye movements, rhyth-
mic tongue protrusion, motor delays, and mild-to-moderate
mental retardation.
Rhombencephalosynapsis (Fig. 4) is another disorder in
which the vermis is absent and in which the cerebellar
hemispheric folia are continuous across the midline. A wide
range of clinical features have been reported,18 and pre-
sentation correlates with the presence and degree of sup-
ratentorial abnormalities, most commonly in the spectrum
of holoprosencephaly.
Other causes of severe pontocerebellar and vermian hy-
poplasia include the congenital muscular dystrophies (Fig. 5)
and similar-appearing abnormalities such as microlissence-
phaly with pontocerebellar hypoplasia (Fig. 6). It is difficult
to differentiate microlissencephaly from congenital muscu-
lar dystrophy antenatally without genetic studies; however,
in the latter, one would expect a normal head size and other
features such as asymmetric orbits and ventricular dilatation.
In either case, the outcome is dismal. Clinically, patients
with congenital muscular dystrophies have generalized hy-
potonia and muscle weakness, mental retardation, and ad-
ditional structural eye and CNS abnormalities, typically
cobblestone lissencephaly and microphthalmia.18
Assessment of Vermian Maturity
Having assessed for whether the vermis is present, one
can evaluate its developmental maturity. In addition to the
fastigial point and the primary fissure, we can assess for
vermian lobulation, the tegmento-vermian angle, the cranio-
caudal diameter of the vermis, and the ratio of vermian
tissue above and below the fastigial point to gauge the rela-
tive growth of the superior (anterior) versus inferior (poste-
rior) lobes.
Assessment of Vermian Lobulation
Degree of vermian lobulation has been demonstrated
to correlate with prognosis.25 By 21 weeks, the prepyramidal

FIGURE 7. Construction of lines used to assess the

tegmento-vermian angle: normal tegmento-vermian
angle (A) and abnormal tegmento-vermian angle (B).

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Robinson et al Ultrasound Quarterly & Volume 23, Number 3, September 2007

FIGURE 8. In this 22-week fetus, a large cystic posterior fossa is seen on axial sonography with small cerebellar hemispheres on
either side of the midline (A, arrows). No midline vermian tissue is identified. On sagittal MR, the tegmento-vermian angle is
increased (B, lines) with the fourth ventricle uncovered (arrow). The vermis is very small; there is no primary fissure or fastigial point,
again in keeping with a primitive configuration.63 Diagrammatic representation (C) of DWC (adapted from Robinson and
Goldstein31). There is variable vermian hypoplasia (small arrow) and elevation by a dilated rhombencephalic vesicle (double arrow)
and a variable degree of fenestration of the foramina of Luschka and Magendie. On axial MR, the cerebellar hemispheres are small
(D, arrows). The ventricular system is dilated, resulting in large temporal horns (small arrows).

fissure can be seen between the tuber and pyramis, and by
21 to 22 weeks, the preculminate fissure can be seen
between the central lobule and culmen. By 24 weeks, the
secondary fissure can be seen between the pyramis and
uvula, and from 27 weeks, all the vermian lobules and
fissures become visible15,26Y28 (Fig. 2). Therefore, before
24 weeks’ gestation, a critical time in many jurisdictions
with respect to considering termination of pregnancy, we
cannot currently determine if vermian lobulation is com-
plete, although improvement in MR resolution may make
this possible in the future.
The Tegmento-Vermian Angle
The superior-to-inferior growth of the vermis to cover
the fourth ventricle is frequently referred to as Bclosure^ of
the fourth ventricle, although this is really a misconception
because the vermis actually grows exophytically from the
roof of the rhombencephalic vesicle to cover the roof. The
roof itself is nonresoluble by in vivo imaging, thus giving
the false impression that the fourth ventricle is initially
open and is closed by growth of the vermis caudally.
In our study of 131 consecutive fetal MR examina-
tions, we described the tegmento-vermian angle as a way of
measuring this Bclosure.^26,29 This angle is measured by
drawing a line along the dorsal surface of the brain stem
parallel to the tegmentum and which should transect the
nucleus gracilis at the obex (see Fig. 2 for anatomy). A second
line is drawn along the ventral surface of the vermis. The
angle between them is the tegmento-vermian angle (Fig. 7).
The normal fetal tegmento-vermian angle is usually close to
0 degree, and a significantly elevated tegmento-vermian
angle (approximately 940 degrees) is often associated with
vermian and cerebellar hypoplasia.26,30 Measurements in
between are less clearly pathological.
This method of measuring Bclosure^ avoids a false-
positive diagnosis of inferior vermian hypoplasia when a

FIGURE 9. In this next example, in a 22-week fetus, axial sonographic findings are similar to those in Figures 8 and 9 except
that the cerebellar hemispheres are seen to be larger (A, arrows), and a small amount of vermian tissue is seen in the
midline. On sagittal MR, the tegmento-vermian angle is increased (B, lines), and the fourth ventricle is uncovered. The vermis
is small but not as small as that in the previous case. There is no primary fissure, and the fastigial point is visible but relatively
flattened compared with what is expected at this gestation. On axial MR, the cerebellar hemispheres are hypoplastic (C, arrows)
but larger than those in the previous case. Again, the configuration is primitive.63

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Ultrasound Quarterly & Volume 23, Number 3, September 2007 The Fetal Cerebellar Vermis

FIGURE 10. In this fetus at 34 weeks, by axial sonography, the cerebellar hemispheres are approaching normal size (A, arrows),
and proportionally, more midline vermian tissue is seen in the midline than those in Figures 8 and 9. Nuchal thickening is noted.
On sagittal MR, the tegmento-vermian angle is increased (B, lines), with the fourth ventricle uncovered (small arrow). The vermis
is less hypoplastic than in the previous examples, and the primary fissure is seen (single arrow). The fastigial point is less flattened.
On axial MR (slightly oblique), the cerebellar hemispheres are proportionally larger than those in Figures 8 and 9 (C, arrows).
Postnatal MR (D) at 8 months of age shows good vermian lobulation. Petrous CT (E) demonstrates bilateral cochlear dysplasia. The
central part of the cochlea should normally contain a box-shaped piece of bone, which is the modiolus, but in this case, the
modiolus is deficient (long arrow), with a simple septum forming part of the basal cochlear turn (small arrow).

normal vermis is merely angulated away from the tegmen-
tum, leaving a gap (ie, the gap can be due to angulation
not deficiency). The vermis per se should be assessed for
deficiency using morphological and biometric criteria as
described elsewhere in this paper. When we see failure of
Bclosure^ with normal vermian morphology and biometry,
and without any associated fetal abnormalities, this prob-
ably represents isolated elevation or rotation of the vermis
due to a persistent Blake pouch31 and does not necessarily
indicate an adverse outcome.25,26,32Y36 Failure of Bclosure^
therefore seems to result from 2 potential processes: either
arrest of vermian development so it does not cover the fourth
ventricle at its inferior extent or failure of adequate fen-
estration of the fourth ventricular outflow foramina, leading to
a secondary elevation of an otherwise normal vermis. Often,
these 2 processes are seen together as in DWC, presumably

FIGURE 11. Construction of lines used to measure

the craniocaudal diameter of the vermis: fastigial
point-declive line (A)Vthe declive is the first lobule
posterior to the primary fissure, seen as a low-signal
focus (see also Fig. 2); craniocaudal diameter (B)
(perpendicular to fastigial point-declive line).

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Robinson et al Ultrasound Quarterly & Volume 23, Number 3, September 2007

Dandy-Walker Continuum
TABLE 1. Predicted Cerebellar Vermian Craniocaudal
Diameter26,29 The DWC includes classic Dandy-Walker malforma-
Menstrual Age, wk Mean Diameter, mm
tion (DWM), Dandy-Walker variant, and possibly also mega
cisterna magna and persistent Blake pouch cyst,31,37
14 4.6 although, for the purposes of this paper, the latter two are
15 5.3 considered separately in the final section. Fetuses with dis-
16 6.1 orders in this continuum can have normal outcomes or
17 6.8 can be syndromic with poor outcomes. The outcomes are
18 7.5 based on the degree of vermian hypoplasia/dysplasia, plus
19 8.3 the presence of associated abnormalities, which can be
20 9.0 structural, chromosomal, or genetic, making counseling ex-
21 9.7 tremely difficult. Thus, there is a spectrum of abnormalities,
22 10.4 and the term continuum is now a preferred nomenclature.18
23 11.2
Classic DWM comprises complete or partial vermian
24 11.9
agenesis, cystic dilatation of the fourth ventricle, and en-
25 12.6
largement of the posterior fossa with elevation of transverse
26 13.4
sinus, tentorium, and torcula (Btorcula-lambdoid inver-
27 14.1
sion^).38 Some authors also include hydrocephalus.39 How-
28 14.8
ever, hydrocephalus is a frequent complication of, but not
29 15.6
actually a part of, the malformation 38,40 and is not
30 16.3
usually present at birth.41 Classic DWM was initially de-
31 17.0
scribed in infants with hydrocephalus and was thought to
32 17.7
be the sequelae of atresia of foramina of Luschka and
33 18.5
Magendie.42Y44 However, current theories suggest that it is a
34 19.2
more global developmental defect affecting the area mem-
35 19.9
branacea of the roof of the rhombencephalon,18,31 leading to
36 20.7
variable degrees of vermian hypoplasia, variable fenestration
37 21.4
of the fourth ventricular outlet foramina, and variable asso-
38 22.1
ciated anomalies.
39 22.9
Patients with vermian hypoplasia syndromes as an
40 23.6
isolated abnormality may have normal intelligence.45,46
However, DWC is often associated with agenesis of the
corpus callosum,41,47,48 neural tube defects,49Y51 heart
because of a more global insult to developing rhombence- defects,41,48,49,52 polydactyly and syndactyly,41,48,53 and facial
phalic roof structures, but they can be seen separately (vide anomalies.48,49 Dandy-Walker continuum with additional
infra, Figs. 13, 14). findings have an associated poorer outcome.40,54 There is

FIGURE 12. In this 24-week fetus, axial sonography (A) shows a fully formed vermis, but the transcerebellar diameter (calipers)
measures too small for the gestational age (2.25 cm = 20w5d), and the other cranial biometric parameters were also too small
(biparietal diameter, 4.98 cm = 21w1d; head circumference, 17.26 cm = 19w6d). On sagittal MR (B) at 28 weeks, the vermis is fully
formed, the fourth ventricle is ‘‘closed,’’ and the fastigial point is present. The expected craniocaudal diameter of the vermis
(lines) is 14.8 mm, but it actually measures 10.9 mm (equivalent of 22 weeks). Additionally, on the sagittal view, there is a sloping
forehead in keeping with microcephaly and an abnormal lack of sulcation, and the cerebrospinal fluid spaces are prominent.
On axial MR (C), the transcerebellar diameter is small (double-ended arrow), in keeping with cerebellar hypoplasia. At autopsy,
this fetus had severe microencephaly with dysmorphic features, proptosis, and mild hypotelorism.

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Ultrasound Quarterly & Volume 23, Number 3, September 2007 The Fetal Cerebellar Vermis

FIGURE 13. In this 25-week fetus, the axial sonogram demonstrates a defect in the vermis with a communication between
the fourth ventricle and cisterna magna (A, arrow). Notice that the cavum septi pellucidum is included in this axial plane
(double arrow), thereby suggesting that this finding is not an artifact that is caused by imaging the posterior fossa in too coronal
a plane.12 On sagittal MR (B), the tegmento-vermian angle is normal (fourth ventricle is closed); the vermis is small overall,
especially inferiorly (arrow). The cisterna magna seems large because of an ex vacuo effect. Note an occipital cephalocele
(small arrow). On postnatal MR (C), it can be seen that the inferior vermis is deficient (there is some partial volume artifact from
the adjacent cerebellar hemisphere). The fourth ventricle is not dilated, and its roof can be seen in almost its expected position
(arrows). There were additional cortical heterotopias.

also a recurrence risk when DWC is associated with single
gene disorders as in Warburg and Meckel-Gruber syndromes
and with chromosomal abnormalities.49
The fetus in Figure 8 falls into the classification of
DWC; however, it is more severe than classic DWM be-
cause of additional hypoplasia of the brain stem and pons.
Although this pregnancy continued, a poor outcome was
predicted. The infant died shortly after birth because of
respiratory failure.
The fetus in Figure 9 demonstrates features of classic
DWM. Although not accurately predictable, a better outcome
might be expected than in the previous case because of
the lack of brain stem hypoplasia and relatively larger cere-
bellar hemispheres.25,55 This pregnancy was terminated with-
out autopsy.
Coexistence of Cerebellar and Labyrinthine Anomalies
Cerebellar and labyrinthine anomalies often coexist be-
cause the rhombic lip forms the cerebellum and also the co-
chlear nucleus,56 and the rhombencephalon induces the otocyst.
The fetus in Figure 10 has less severe changes with-
in DWC than those in the previous cases. Postnatally, this

FIGURE 14. This 23-week fetus was small for gestational age. On axial sonography, there is a cystic space between relatively
well-formed cerebellar hemispheres (A, arrow). On sagittal MR (B), there is an increased tegmento-vermian angle. The fastigial
point is present (large arrow), and there is apparently normal lobulation and primary fissure (small arrow). At first glance, the
appearances are suggestive of DWC; however, the craniocaudal diameter of the vermis was 10.7 mm, within normal limits for
gestational age. Additionally, the ratio of tissue above and below the fastigial point is equal. Therefore, there is no indication of
vermian hypoplasia. There were no other fetal abnormalities. The mother had sickle cell anemia, and ultimately, there was fetal
demise because of placental insufficiency. Autopsy (C) demonstrated a normal fetal karyotype and apparently normal cerebellar
and vermian morphology. This was a case thought to represent a persistent Blake pouch cyst that had collapsed by the time
of autopsy. It is recognized that posterior fossa cysts easily can be missed at autopsy unless the specimen is examined under
water.32 The other possibility would be that there was physiological delay in ‘‘closure’’ of the fourth ventricle. This is unlikely
at this gestation; however, it should be borne in mind that abnormalities within the DWC cannot be reliably ruled out at earlier
gestations.13,24 Diagrammatic representation (D) of persistent Blake pouch (adapted from Robinson and Goldstein31). The
cerebellar vermis forms normally. Nonfenestration of the foramina of Luschka and Magendie leads to dilatation of the
rhombencephalic vesicle (double arrow) and elevation of the vermis (small arrow) away from the brain stem.

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Robinson et al Ultrasound Quarterly & Volume 23, Number 3, September 2007

FIGURE 15. In this example, a fetus at 36 weeks, on sonography (A), the cisterna magna measures too large (‘‘x’’ calipers = 15 mm;
abnormal is 910 mm), although the transcerebellar diameter was normal (‘‘+’’ calipers). Fetal sagittal MR also confirms a large
cisterna magna (B, arrow). Also seen on axial MR (C, arrow), however, the vermis is fully formed, with normal tegmento-vermian
angle, fastigial point, and fissuration. This is a case of mega cisterna magna, and this fetus had normal postnatal follow-up.
Diagrammatic representation (D) of mega cisterna magna (adapted from Robinson and Goldstein31). The foramina of Luschka
and Magendie probably fenestrate late, leading to dilatation of the rhombencephalic vesicle and enlargement of the posterior
fossa (double arrow). The vermis itself develops normally. Once fenestration occurs, an enlarged cisterna magna results.

child has deafness with keratitis and ichthyosis (KID
syndrome), but allowing for deafness has otherwise normal
development.
The Craniocaudal Diameter of the Vermis
Magnetic resonance scans for CNS anatomy are usually
performed after 18 weeks, and by that stage, the fastigial
point and primary fissure should always be visible. The
declive is seen as a focal punctate of low intensity imme-
diately below the primary fissure. Therefore, a line can
usually be drawn through the fastigial point and declive (the
fastigium-declive line), even if the primary fissure is only
visible as an indentation in the posterosuperior aspect of
the vermis. The craniocaudal diameter of the vermis can be
measured perpendicular to this line (Fig. 11), and this mea-
surement is therefore independent of whether there is
tegmento-vermian angulation. According to this method of
measurement,26,29 excluding abnormals, growth of the
craniocaudal diameter is linear (Table 1), and this has been
confirmed both ultrasonographically7,8,57,58 and by MR.59,60
From this, we can predict expected craniocaudal diameter
at any gestational age (Fig. 12).
The Ratio of Vermian Tissue Above and Below
the Fastigial Point
A second measurement that can be made from the same
fastigium-declive line is the relative growth of the superior
and inferior lobes. Instead of measuring the entire vermis, it is
measured above and below this line, and the values were
compared. This is useful in cases of suspected inferior
vermian hypoplasia where the relative growth of the inferior
vermis would be reduced.
There should be linear and symmetrical growth of the
vermis throughout gestation. The average height above and
below the fastigial point should increase linearly, with
average percentages above and below of 47% and 53%,

FIGURE 16. In this fetus at 29 weeks, the cisterna magna is extremely large on axial sonography (A, arrows), and the cerebellar
hemispheres seem pushed forward and the folia effaced. On sagittal MR (B), the vermis is the correct craniocaudal diameter,
with a minimally elevated tegmento-vermian angle, and a fastigial point is seen. Lobulation is not clearly seen (arrows), and
the cisterna magna is too big. Additionally, as seen on the axial MR views, the cerebellar hemispheres are displaced ventrally
(C, arrows). This was thought to represent a posterior fossa arachnoid cyst, with ventral displacement and compression of the
cerebellum and vermis. Postnatal MR imaging (D) at 5 months of age demonstrates a posterior fossa arachnoid cyst. The baby
had ventriculomegaly as a secondary mechanical complication. Neurodevelopmental follow-up was normal.

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Ultrasound Quarterly & Volume 23, Number 3, September 2007 The Fetal Cerebellar Vermis

FIGURE 17. An example of scanning in too coronal a plane. The patient was referred because, on sonography at 19 weeks, an
apparently normal vermis was seen superiorly (A, arrow), and a small defect was seen in the vermis inferiorly (B, arrow). The
MR study at 21 weeks shows normal morphology of the vermis except that there is a minimally increased tegmento-vermian angle,
leaving a gap between the inferior vermis and brain stem (C, arrow). Follow-up sonography (D) at 26 weeks shows normal
appearances of the posterior fossa with an intact vermis. Postnatal sagittal sonography (E) on day 1 of life demonstrates an
apparently complete vermis on the sagittal views, with no evidence of an increased tegmento-vermian angle. Postnatal axial
sonography demonstrates a normal vermis (F) and normal cerebellar vallecula (G). The baby had normal development at 2 years.

respectively, and no significant change in this ratio with
gestational age.26,29 An example of an abnormal ratio is given
(Fig. 13). This case is important because it demonstrates that
cystic dilatation of the fourth ventricle is not necessarily sec-
ondary to a deficiency of the vermis (or vice versa) but is
probably due to a failure of fenestration of the fourth ven-
tricle outflow foramina. Conversely, cystic dilatation of the
fourth ventricle can be seen with an increased tegmento-
vermian angle and normal vermian morphology (Fig. 14).
POTENTIAL PITFALLS IN THE DIAGNOSIS
OF VERMIAN PATHOLOGY
Other causes of a cystic appearance of the posterior
fossa are often confused with the more severe entities
within DWC, particularly on axial sonographic images.
Such appearances can be seen with persistent Blake pouch
(Fig. 14), mega cisterna magna (Fig. 15), and posterior
fossa arachnoid cyst (Fig. 16).31 These can have normal
outcomes; therefore, differentiation from true vermian
pathology is imperative. Also, imaging the posterior fossa
in the semicoronal plane can give a false appearance of an
enlarged cisterna magna or even partial vermian agenesis
(Fig. 17).12 This error can be avoided by making sure that
the cavum septum pellucidum is included in the image, thus
ensuring that the scan plane is truly axial or modified axial.
The small Bdefect^ seen in the inferior vermis in this
semicoronal plane most likely corresponds to Blake metapore,31
the predecessor to the foramen of Magendie. This appearance
has been demonstrated to be normal.23,31,61
CONCLUSIONS
In summary, we describe several anatomical criteria
for normal and abnormal vermian development. These
include identification of the fastigial point and primary fis-
sure. We illustrate Bclosure^ of the fourth ventricle assessed
using the tegmento-vermian angle and provide vermian
biometry including craniocaudal diameter and relative sizes
of the superior and inferior vermian lobes as indicators of
satisfactory vermian growth. We illustrate specific abnor-
malities of vermian and cerebellar development and show
potential pitfalls in the diagnosis of disorders such as DWC.
ACKNOWLEDGMENTS
The authors thank Dr Phyllis Glanc, Women’s College
Campus, Sunnybrook, and Women’s College Hospital,
Toronto, Canada, for the ultrasound image in Figure 3A
and Dr A. Michelle Fink, Department of Medical Imaging,
The Royal Children’s Hospital, Melbourne, Australia, for all
the images in Figure 4.
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