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CASE REPORT
Year : 2009  |  Volume : 4  |  Issue : 2  |  Page : 131-132
 

Dandy-Walker variant associated with bipolar affective disorder


1 Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, A Unit of Sri Balaji Vidyapeeth University, Pondy-Cuddalore Main Road, Pillayarkuppam, Pondicherry - 607 402, India
2 Department of Radiology and Neuroimaging, Mahatma Gandhi Medical College and Research Institute, A Unit of Sri Balaji Vidyapeeth University, Pondy-Cuddalore Main Road, Pillayarkuppam, Pondicherry - 607 402, India

Date of Web Publication29-Oct-2009

Correspondence Address:
Anand Lingeswaran
61/5, V. V. P. Nagar, C-lane, Thattanchavady Post, Pondicherry - 605 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.57341

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   Abstract 

The Dandy-Walker malformation is a congenital brain malformation, typically involving the fourth ventricle and the cerebellum. To date, the Dandy-Walker syndrome has not been described in association with bipolar disorder type I mania, and therefore we briefly report the case of a Dandy-Walker variant associated with acute mania. A 10-year-old boy was brought by his mother to the outpatient clinic of the Department of Psychiatry of a tertiary care hospital, with symptoms of mania. The MRI brain of the patient showed a posterior fossa cystic lesion, a giant cisterna magna communicating with the fourth ventricle and mild hypoplasia of the cerebellar vermis, with the rest of the structures being normal and no signs of hydrocephalus. These findings showed that the patient had a Dandy-Walker variant. He responded partially to valproate and olanzepine, which controlled the acute manic symptoms in the ward.


Keywords: Bipolar affective disorder, Dandy-Walker, syndrome


How to cite this article:
Lingeswaran A, Barathi D, Sharma G. Dandy-Walker variant associated with bipolar affective disorder. J Pediatr Neurosci 2009;4:131-2

How to cite this URL:
Lingeswaran A, Barathi D, Sharma G. Dandy-Walker variant associated with bipolar affective disorder. J Pediatr Neurosci [serial online] 2009 [cited 2017 Apr 29];4:131-2. Available from: http://www.pediatricneurosciences.com/text.asp?2009/4/2/131/57341



   Introduction Top


The Dandy-Walker malformation is a congenital brain malformation, typically involving the fourth ventricle and the cerebellum. This syndrome has been described in association with schizophrenia, [1] obsessive-compulsive disorder, [1] and bipolar II disorder. [2] However, to date, the Dandy-Walker syndrome has not been described in association with bipolar disorder type I mania, and therefore we briefly report a case of a Dandy-Walker variant associated with acute mania.


   Case Report Top


A 10-year-old boy, was brought by his mother to the outpatient clinic of the Department of Psychiatry of a tertiary care hospital, with excessive cheerfulness. He was disinhibited in speech and behavior, restless, talking fast and loudly, singing songs at times, disobeying parents and doctors, had poor sleep and appetite, and was difficult to manage at home. His mental status examination revealed psychomotor agitation and elated mood, but no delusional ideas or hallucinations. His manner was friendly but uncooperative and he had no insight. A complete physical examination revealed malformed teeth, pallor, poor nutritional status, and the neurological examination was unremarkable. Exploration of the patient's developmental history from the mother revealed an uneventful antenatal history, a full-term vaginal delivery, history of birth asphyxia, and all milestones were delayed. He had received all his immunizations appropriately. He had stopped going to school after the third grade, due to poor academic abilities.

There was no family history of any neurological or psychiatric illness.

Upon consent and request from his mother, he was admitted into the child psychiatry unit with his mother. He was reviewed by senior psychiatrists and a diagnosis of bipolar affective disorder, mania without psychotic symptoms, first episode, was confirmed along with possible mental subnormality, pending IQ assessment. After obtaining informed consent from his mother, routine blood tests was done. His blood hemoglobin levels were 8.0g/dl, liver and renal functions, electrocardiogram, an echocardiograph, and an abdominal ultrasound was normal. Interestingly, the MRI brain scan [Figure 1] of the patient showed a posterior fossa cystic lesion, a giant cisterna magna communicating with the fourth ventricle and mild hypoplasia of the cerebellar vermis, with the rest of the structures being normal and no signs of hydrocephalus. These findings showed that the patient had a Dandy-Walker variant.

He was prescribed valproate and olanzepine to control his acute manic symptoms. After two weeks of admission, the psychomotor agitation had reduced and he was less friendly than before. His sleep improved, but his appetite was still poor. In subsequent reviews, he was more manageable, however, the symptoms still persisted. He continues to receive the above medications now. Even though the incidence of associated malformations range between 50 and 70%, our case had only malformed teeth with overriding. His low hemoglobin levels were due to poor nutrition and he was prescribed iron supplements. A clinical diagnosis of mild mental retardation was made, but could not be confirmed by proper neuropsychological assessment, as the patient was highly uncooperative.


   Discussion Top


Dandy-Walker malformation may occur as part of Mendelian disorders and chromosomal aberrations. Environmental factors including viral infections, alcohol, and diabetes have also been suggested to play a role in the genesis of Dandy-Walker malformation, but the evidence is uncertain. Clinically this syndrome can present with mental retardation, cerebellar ataxia, and symptoms of hydrocephalus. This patient had none of the direct complications as described above, except for mental retardation, which could also be explained by the history of birth asphyxia. Morphometric [3],[4] and functional [5] neuroimaging studies have demonstrated a link between the cerebellum and mood symptoms in bipolar patients. All this suggests a possible direct causal relationship between the pathophysiology of bipolar disorder and the Dandy-Walker variant with cerebellar vermian hypoplasia. It can even be speculated that this syndrome could influence the poor response of the bipolar illness to treatment, as seen in this case.


   Acknowledgments Top


As the primary author of this report, I am grateful to Professor Gyaneshwar Sharma, the Head of the Department of Psychiatry, who is also my current supervisor, for his support and advice that encouraged me to write up this report. I also thank the patient and his parents who have given me this opportunity to share the knowledge with my peers purely for the purpose of scientific improvement. I owe my gratitude to them for signing the consent form as per the journal requirements, helping me to submit the clinical information. I wish to thank Dr. Vinayak and Dr. John Dinesh for showing keen interest in treating the patient while in the ward.

 
   References Top

1.Papazisis G, Mastrogianni A, Karastergiou A. Early-onset schizophrenia and obsessivecompulsive disorder in a young man with Dandy-Walker variant. Schizophr Res 2007;93:403-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Huichun Li, Chen Q, Liu W. Adult asymptomatic case of Dandy-Walker syndrome associated with bipolar disorder . Acta Neuropsychiatr 2008: 20:170-1.  Back to cited text no. 2      
3.Delbello MP, Strakowski SM, Zimmerman ME, Hawkins JM, Sax KW. MRI analysis of the cerebellum in bipolar disorder: A pilot study. Neuropsychopharmacology 1999;21:63-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Mills NP, Delbello MP, Adler CM, Strakowski SM. MRI analysis of cerebellar vernal abnormalities in bipolar disorder. Am J Psychiatry 2005;162:1530-2.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Cecil KM, Delbello MP, Sellars MC, Strakowski SM. Proton magnetic resonance spectroscopy of the frontal lobe and cerebellar vermis in children with a mood disorder and a familial risk for bipolar disorders. J Child Adolesc Psychopharmacol 2003;13:545-55.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1]


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    Abstract
    Introduction
    Case Report
    Discussion
    Acknowledgments
    References
    Article Figures

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