SHH
‐activated medulloblastomas (
SHH
‐
MB
) account for 25–30% of all medulloblastomas (
MB
) and occur with a bimodal age distribution, encompassing many infant and adult, but fewer childhood cases. Different age groups are characterized by distinct survival outcomes and age‐specific alterations of regulatory pathways. Here, we review
SHH
‐specific genetic aberrations and signaling pathways. Over 95% of
SHH
‐
MB
s contain at least one driver event – the activating mutations frequently affect sonic hedgehog signaling (
PTCH
1,
SMO
,
SUFU
), genome maintenance (
TP
53), and chromatin modulation (
KMT
2D,
KMT
2C,
HAT
complexes), while genes responsible for transcriptional regulation (
MYCN
) are recurrently amplified.
SHH
‐
MB
s have the highest prevalence of damaging germline mutations among all
MB
s.
TP
53‐mutant
MB
s are enriched among older children and have the worst prognosis among all
SHH
‐
MB
s. Numerous genetic aberrations, including mutations of
TERT
,
DDX
3X, and the
PI
3K/
AKT
/
mTOR
pathway are almost exclusive to adult patients. We elaborate on the newest development within the evolution of molecular subclassification, and compare proposed risk categories across emerging classification systems. We discuss discoveries based on preclinical models and elaborate on the applicability of potential new therapies, including
BET
bromodomain inhibitors, statins, inhibitors of
SMO
,
AURK
,
PLK
,
cMET
, targeting stem‐like cells, and emerging immunotherapeutic strategies. An enormous amount of data on the genetic background of
SHH
‐
MB
have accumulated, nevertheless, subgroup affiliation does not provide reliable prediction about response to therapy. Emerging subtypes within
SHH
‐
MB
offer more layered risk stratifications. Rational clinical trial designs with the incorporation of available molecular knowledge are inevitable. Improved collaboration across the scientific community will be imperative for therapeutic breakthroughs.