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Original Investigation
January 2019

Sequential Neuroimaging of the Fetus and Newborn With In Utero Zika Virus Exposure

Author Affiliations
  • 1Division of Fetal and Transitional Medicine, Children’s National Health System, Washington, DC
  • 2Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC
  • 3Department of Neurology, School of Medicine and Health Sciences, The George Washington University, Washington, DC
  • 4Division of Radiology, Children’s National Health System, Washington, DC
  • 5Sabbag Radiologos, Barranquilla, Colombia
  • 6Allied Research Society, Miami, Florida
  • 7Bacteriologa, Bio-Nep, Barranquilla, Colombia
  • 8Division of Neurology, Children’s National Health System, Washington, DC
  • 9Arbovirus Diseases Branch, Centers for Disease Control and Prevention, Fort Collins, Colorado
  • 10BIOMELAB, Barranquilla, Colombia
  • 11Division of Infectious Diseases, Children’s National Health System, Washington, DC
  • 12Department of Microbiology, Immunology and Tropical Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC
JAMA Pediatr. 2019;173(1):52-59. doi:10.1001/jamapediatrics.2018.4138
Key Points

Question  What does magnetic resonance imaging add to ultrasonography for detecting Zika–virus related brain lesions?

Findings  In this cohort study of 82 pregnant women with Zika virus infection, 3 cases of severe fetal brain abnormalities were detected by magnetic resonance imaging; in 2 of these, ultrasonography results were abnormal. In neonates, cranial ultrasonography and brain magnetic resonance imaging revealed new relatively mild findings in 23 of 61 infants; most abnormalities were seen on ultrasonography.

Meaning  Although the combination of prenatal and postnatal ultrasonography and magnetic resonance imaging is needed to capture the full spectrum of Zika–virus related brain injury, ultrasonography detected most abnormal cases.


Importance  The evolution of fetal brain injury by Zika virus (ZIKV) infection is not well described.

Objectives  To perform longitudinal neuroimaging of fetuses and infants exposed to in utero maternal ZIKV infection using concomitant magnetic resonance imaging (MRI) and ultrasonography (US), as well as to determine the duration of viremia in pregnant women with ZIKV infection and whether the duration of viremia correlated with fetal and/or infant brain abnormalities.

Design, Setting, and Participants  A cohort of 82 pregnant women with clinical criteria for probable ZIKV infection in Barranquilla, Colombia, and Washington, DC, were enrolled from June 15, 2016, through June 27, 2017, with Colombian women identified by community recruitment and physician referral and travel-related cases of American women recruited from a Congenital Zika Program.

Interventions and Exposures  Women received 1 or more MRI and US examinations during the second and/or third trimesters. Postnatally, infants underwent brain MRI and cranial US. Blood samples were tested for ZIKV.

Main Outcomes and Measures  The neuroimaging studies were evaluated for brain injury and cerebral biometry.

Results  Of the 82 women, 80 were from Colombia and 2 were from the United States. In 3 of 82 cases (4%), fetal MRI demonstrated abnormalities consistent with congenital ZIKV infection. Two cases had heterotopias and malformations in cortical development and 1 case had a parietal encephalocele, Chiari II malformation, and microcephaly. In 1 case, US results remained normal despite fetal abnormalities detected on MRI. Prolonged maternal polymerase chain reaction positivity was present in 1 case. Of the remaining 79 cases with normal results of prenatal imaging, postnatal brain MRI was acquired in 53 infants and demonstrated mild abnormalities in 7 (13%). Fifty-seven infants underwent postnatal cranial US, which detected changes of lenticulostriate vasculopathy, choroid plexus cysts, germinolytic/subependymal cysts, and/or calcification in 21 infants (37%).

Conclusions and Relevance  In a cohort of pregnant women with ZIKV infection, prenatal US examination appeared to detect all but 1 abnormal fetal case. Postnatal neuroimaging in infants who had normal prenatal imaging revealed new mild abnormalities. For most patients, prenatal and postnatal US may identify ZIKV-related brain injury.