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Fla. Dept. of Health investigating non-travel related case of Zika virus in Pinellas County WFTS Webteam, Jacqueline Ingles 10:51 AM, Aug 23, 2016 15 mins ago Autoplay: X First-Non Travel Related Zika Case In Pinellas County WFTS SHOW CAPTION CLEARWATER, Fla. - The Florida Department of Health is now investigating five new non-travel related cases of Zika in the State of Florida. One of the five cases is in Pinellas County and the other four are in the impacted area of Wynwood. Governor Scott held a roundtable discussion on Tuesday morning in Clearwater. During the discussion, he announced that the Department of Health has begun door-to-door outreach and sampling in Pinellas County. Mosquito abatement and reduction activities are also underway. Governor Rick Scott said, “Today, we learned that the Florida Department of Health is investigating one new individual with non-travel related Zika in Pinellas County. While this investigation is ongoing, DOH still believes that ongoing active transmissions are only occurring in the two previously identified areas in Wynwood and Miami Beach. As we’ve seen in Wynwood, our aggressive mosquito control and public education efforts are working which is why DOH was able to clear a significant area in Wynwood today, bringing the total cleared area to 76 blocks. This means that we have now cleared half of the area in Wynwood where we believe ongoing active transmission of Zika is occurring. This is great news and we hope to continue reducing this area. Zika Virus Disease Overview | HealthGrove “In Pinellas County, the Department of Health and Pinellas County Mosquito Control are already working together and have begun aggressive spraying and mosquito abatement efforts. Any pregnant woman who would like to receive a free Zika test or a Zika prevention kit should contact the Florida Department of Health in Pinellas County. We remain fully committed to ensuring that every county has all of the resources they need to combat this virus and stand ready to assist residents and visitors in the impacted communities.” According to the DOH, a travel-related case means the person acquired the Zika Virus outside of Florida. A non-travel related case means the person acquired the virus somewhere in Florida. It is not clear when, where or how the person became infected. Health officials did say the individuals has traveled to multi Bay area counties for work and family activities. "Unfortunately ,there is no magic formula to determining or predicting when exposure may occur," said Dr. Celeste Philip, Florida's Surgeon General. As of right now, health officials have no evidence proving this was locally transmitted. And, they do not believe area mosquitoes are infected with the virus and transmitting it to people. We can say that there has not been on going transmission around the places where that person most frequently visits," Philip added. http://www.abcactionnews.com/news/local-news/fla-dept-of-health-investigating-non-travel-related-case-of-zika-virus-in-pinellas-county

Zika Spreads in Florida With New Case in St. Petersburg Area Sarah Begley @SCBegley 5:06 PM ET So far, 42 people have been found to be infected with Zika in Florida Five new cases of Zika have been reported in Florida, including one in theSt. Petersburg area. At least one person has contracted the disease in Pinellas County, Gov. Rick Scott said Tuesday according to NBC News. Outbreaks have previously been found in Miami Beach and Wynwood, where four more people were reported infected on Tuesday. So far, 42 people have been found to be infected with Zika in Florida, all of them seemingly contracting the virus through non-travel-related incidents. These cases indicate that local mosquitos are now carrying the disease in the region; Zika can also be sexually transmitted. Gov. Scott said, “In Pinellas County, the Department of Health and Pinellas County Mosquito Control are already working together and have begun aggressive spraying and mosquito abatement efforts.” He added that pregnant women can contact local officials for free Zika testing and prevention kits. [NBC News] http://time.com/4463577/zika-florida-st-petersburg/

Florida: 5 new Zika cases including 1 in the Tampa Bay area By TAMARA LUSH Associated Press ST. PETERSBURG, Fla. (AP) - Florida Gov. Rick Scott on Tuesday announced a non-travel-related case of Zika in the Tampa Bay region. It's the first in the state outside the Miami area, but Scott said there wasn't enough evidence to date to declare a new zone of local transmission. If Department of Health officials conclude mosquitoes have transmitted the disease to people in the Tampa Bay area of Pinellas County, it would the third such area in the continental U.S. following clusters of cases traced to downtown Miami's Wynwood arts district and a touristy area of Miami Beach. "While this investigation is ongoing, DOH still believes that ongoing active transmissions are only occurring in the two previously identified areas in Wynwood and Miami Beach," Scott said in a statement. Scott spoke during a Zika roundtable in the Pinellas County city of Clearwater, near Tampa. He also said four new cases were connected to mosquitoes in Miami's Wynwood arts district. A fifth new case was diagnosed in a Pinellas County resident who hasn't traveled internationally. Officials are looking into the possibility that the Pinellas County resident was infected with the virus in a neighboring county. Health officials wouldn't say where the Pinellas resident lives. Zika can cause severe brain-related birth defects, including a dangerously small head, if women are infected during pregnancy. Dr. Charles Lockwood, the dean of the Morsani College of Medicine at the University of South Florida and the senior vice president of USF Health, said that "out of an abundance of caution," all pregnant women in the Tampa Bay area should use condoms with their partners until health officials determine if certain neighborhoods are affected by Zika. "Until we can narrow down with great precision the neighborhoods infected, we have to assume every pregnant woman is at risk in Pinellas and Hillsborough until you can say it's a specific neighborhood," he said. "I believe that it's also time for physicians in this area to start testing pregnant women in this area for the virus." Tampa Mayor Bob Buckhorn, whose city sits across the bay from Pinellas County, said Tuesday that he isn't waiting for federal, state or county officials to act. Buckhorn said he's authorized city officials to buy 4,000 mosquito "dunks," or small, doughnut-shaped pellets. Code enforcement officers will comb the city, looking for abandoned or foreclosed homes with pools and drop the dunks into the water. The pellets kill mosquito larvae for up to 30 days. "We're aware of the impact Zika could have on restaurants and tourism in the city and the state," the mayor said. "I'm not going to wait for either Congress to reconvene or any other agency to dictate the health and safety and welfare of my citizens." ___ Follow Tamara Lush on Twitter at http://twitter.com/tamaralush http://www.koaa.com/story/32825041/florida-5-new-zika-cases-including-1-in-the-tampa-bay-area

Florida politicians respond to Zika's spread in Tampa Bay Michael AuslenMichael Auslen, Times/Herald Tallahassee Bureau Tuesday, August 23, 2016 4:04pm 23 August 1 Comments After Gov. Rick Scott confirmed Tuesday morning that someone became infected by Zika in Pinellas County, Florida politicians weighed in, largely calling on Congress to pass additional emergency money to fight the virus. "For this virus endangering Floridians to now spread unabated to Pinellas County is inexcusable. Lives are in danger, particularly expectant mothers, children, and women planning to have children. We need clear solutions to this serious problem. First, Speaker Ryan must bring Congress back to Washington to do their job and pass a clean funding bill. Then, Florida must expand Medicaid to cover the 200,000 women in the coverage gap without access to affordable healthcare and who are at risk." --Former Gov. Charlie Crist "Florida is at risk and Washington is tone deaf. Today’s news of a locally transmitted case of Zika in Pinellas County is another alarm that should prompt leadership to call members back to DC to address this public health issue. As a representative of a frontline state dealing with the Zika outbreak, I fully understand the serious public health risk this virus presents. But we must address this issue now, responsibly and without playing politics. This is a public health issue, not a political issue." --U.S. Rep. David Jolly, R-Indian Shores “The time for warnings and discussions about a potential public health crisis due to Zika is long past – the Congress must act. President Obama called on Congress six months ago to pass an emergency response package. Instead, House Republicans blocked meaningful action and then adjourned for the summer. My neighbors in Pinellas County and all Floridians need every tool to keep them safe as the Zika virus spreads. I urge House Republicans and Speaker Paul Ryan to reconvene the Congress immediately to pass an emergency Zika response package that can expedite necessary vaccines, diagnostic tests and development of the registry to track pregnant women who contract the Zika virus." --U.S. Rep. Kathy Castor, D-Tampa “Every day Congress remains in recess is a day wasted in the fight to protect Florida families from Zika. I have consistently fought for President Obama’s $1.9 billion emergency funding request and have demanded that Congress immediately return from recess to pass this funding. But on this global health crisis that directly impacts our state, Marco Rubio didn’t care until it was too late, and it’s not clear that he cares now." --U.S. Rep. Patrick Murphy, D-Jupiter "Marco has supported every single Zika funding proposal that has come up in the Senate and has called on Congress to return to Washington immediately to address this public health and economic emergency. Patrick Murphy owes Floridians an explanation for why he's the only candidate in this race who has repeatedly voted against every Zika funding measure that has come before him in Congress." -- Michael Ahrens, a spokesman for Sen. Marco Rubio http://www.tampabay.com/blogs/the-buzz-florida-politics/florida-politicians-respond-to-zikas-spread-in-tampa-bay/2290661?utm_source=twitterfeed&utm_medium=twitter

Images Show Zika's Destruction of Babies' Brains By NBC News Published 08/23 2016 12:03PM Updated 08/23 2016 12:03PM 34yr old woman w confirmed Zika virus, initially seen for a rash @ 8 wks of gestation. Fetal head circumference was in the normal range @ 12 & 16 weeks but decreased to 10th % @ 22 wks. Below 3rd percentile in subsequent imaging examinations. /RSNA The pictures are hard to look at. Rough ridges appear where a baby's soft skull should be round and smooth. Inside, big patches of white show where brain tissue should be, and isn't. Brazilian and American doctors released a package of scans Tuesday showing the range of destruction that Zika virus can wreak on a developing child. Their aim isn't to horrify, but to help educate radiologists and other specialists about what they need to be on the lookout for as Zika spreads across the Western Hemisphere. Pregnant women, or women who might become pregnant, are being cautioned to stay away from Zika zones if at all possible, per guidance from the Centers for Disease Control and Prevention and the World Health Organization. But not all women can — especially if they live there. And the women whose babies are included in the special report in the journal Radiology were affected before WHO and CDC warned the world of the danger caused by a virus that experts all believed was harmless until last year. The virus is being spread locally in three places in Florida — Miami Beach, an area north of Miami and now in the St. Petersburg area. Health officials expect more U.S. outbreaks. Brazil has now reported more than 8,000 cases of microcephaly and confirmed that women were infected with Zika in more than 1,600 of them. It's harder to test people for Zika infection after they've recovered. Dr. Fernanda Tovar-Moll of the D'Or Institute for Research and Education and the Federal University of Rio de Janeiro in Brazil and colleagues examined some of them. They found a large range of birth defects, from missing brain tissue to deformed limbs. But they focused on what could be seen in images of the brain before and after birth. Not all babies are born with the characteristically small head, a condition known as microcephaly, they said. Some babies may have brains damaged later in pregnancy, or may have swelling called ventriculomeg­aly that keeps the growing skull supported so that they appear physically normal at birth. Others have skull deformities caused as the virus destroys brain tissue while bones are still forming. "The striking imaging features of the severe micrencephaly associated with Zika virus include a markedly abnormal head shape," the team wrote. "The unusual appearance of the skull, we hypoth­esize, is due to a combination of the small brain as it develops and a result of what, at some point, was likely a larger head size (due to ventriculomeg­aly) that then decompresses," they added. There are also strange ridges and projections on the heads of some babies and fetuses. "This is also likely due to the head and skin continuing to grow, while the size of the brain regresses," they wrote. As suspected, the earlier a woman is infected in pregnancy, the worse the damage is. Zika is the first mosquito-borne virus to cause birth defects but other infections are known to cause similar damage -including rubella and cytomegalovirus. But Zika's damage appears to be worse than the damage caused by other infections, the team said. "The first trimester is the time where infection seems to be riskiest for the pregnancy," said Dr. Deborah Levine, the director of Obstetric & Gynecologic Ultrasound at Beth Israel Deaconess Medical Center and a professor of radiology at Harvard Medical School in Boston. The team included 438 patients seen from June of 2015 to May 2016. Of them 17 of the babies were confirmed to have been infected with Zika. The damage did not always immediately show up. The CDC now recommends that pregnant women who have had Zika or suspect they were exposed to it have a series of ultrasounds throughout pregnancy. "More than one ultrasound or MRI scan in pregnancy may be needed to assess the growth and development abnormalities of the brain," Levine said. Zika appears to stay in the bodies of developing babies, doing damage over weeks and months. It may also stay in the brain after birth, or at least continue to affect brain development, the researchers said. "We are also interested in investigating how congenital Zika virus infection can interfere with not only prenatal, but also postnatal gray and white brain maturation," Tovar-Moll said. What researchers cannot predict is exactly how the brain damage will affect a child - if the baby survives. "The reality is with all of the technology that we have you can't tell someone that this is what's going happen to your baby," said Dr. Roberta DeBiasi, who helps head the Congenital Zika Virus Program at Children's national health System in Washington, D.C. "We can't say this baby will survive or not survive or if they survive this is how disabled they are going to be. We just don't have that precision." Doctors also cannot yet say what percentage of women infected with Zika will have a baby with birth defects. And they cannot say whether the odds are worse if a woman has symptoms from Zika. At least three-quarters of those infected don't remember any specific symptoms. In this study, the team found that more than 80 percent of the women infected in the first trimester of pregnancy who had Zika-affected babies had the characteristic Zika rash. But they stress their group doesn't represent the population as a whole. "Thus, we have no information on inci­dence of the Zika virus in the general population or risk estimates for trans­mission to the fetus," they said. by MAGGIE FOX http://www.arklatexhomepage.com/news/local-news/images-show-zikas-destruction-of-babies-brains

SUPPLEMENTAL TABLES Tables E1-E2 (PDF) ▲ Back To Top SUPPLEMENTAL FIGURES Click to view full image Figure E1: Axial CT image obtained in a 1-month-old male neonate with a head circumference of 31 cm at birth, with presumed Zika infection. Note moderate ventriculomegaly with ventricular septa in the occipital horns, subcortical calcification, thin parenchymal in occipital regions, and diffuse cortical abnormality. ▲ Back To Top Click to view full image Figure E2: Axial CT image obtained in a 1-month-old female neonate with a head circumference of 32 cm at birth, with presumed Zika infection. The image shows asymmetry of the gyri, with focal abnormalities most marked on the left (arrow). Note also the left basal ganglia calcifications. ▲ Back To Top Click to view full image Figure E3: Axial CT image obtained in a 6-month-old male infant born with a head circumference of 30 cm, with presumed Zika infection. Note the relatively small frontal lobes, failure of opercularization of the sylvian fissures, and calcifications at the gray matter–white matter junction.

References Section: ChooseChoose Top of page Abstract Introduction Materials and Methods Results Discussion References << prev 1. Campos GS, Bandeira AC, Sardi SI. Zika virus outbreak, Bahia, Brazil. Emerg Infect Dis 2015;21(10):1885–1886. CrossRef,Medline 2. Calvet G, Aguiar RS, Melo AS, et al. Detection and sequencing of Zika virus from amniotic fluid of fetuses with microcephaly in Brazil: a case study. Lancet Infect Dis 2016;16(6):653–660. CrossRef, Medline 3. Brasil P, Pereira JP Jr, Raja Gabaglia C, et al. Zika virus infection in pregnant women in Rio de Janeiro—preliminary report. N Engl J Med 2016 Mar 4. [Epub ahead of print] Medline 4. Melo A, Aguiar R, Amorim M, et al. Congenital Zika virus infection: beyond neonatal microcephaly. JAMA Neurol (in press). 5. Oliveira Melo AS, Malinger G, Ximenes R, Szejnfeld PO, Alves Sampaio S, Bispo de Filippis AM. Zika virus intrauterine infection causes fetal brain abnormality and microcephaly: tip of the iceberg? Ultrasound Obstet Gynecol 2016;47(1):6–7.CrossRef, Medline 6. Mlakar J, Korva M, Tul N, et al. Zika virus associated with microcephaly. N Engl J Med 2016;374(10):951–958. CrossRef,Medline 7. Sarno M, Sacramento GA, Khouri R, et al. Zika virus infection and stillbirths: a case of hydrops fetalis, hydranencephaly and fetal demise. PLoS Negl Trop Dis 2016;10(2):e0004517. CrossRef 8. Driggers RW, Ho CY, Korhonen EM, et al. Zika virus infection with prolonged maternal viremia and fetal brain abnormalities. N Engl J Med 2016;374(22):2142–2151. CrossRef, Medline 9. Schuler-Faccini L, Ribeiro EM, Feitosa IM, et al. Possible association between Zika virus infection and microcephaly—Brazil, 2015. MMWR Morb Mortal Wkly Rep 2016;65(3):59–62. CrossRef, Medline 10. Hazin AN, Poretti A, Turchi Martelli CM, et al. Computed tomographic findings in microcephaly associated with Zika virus. N Engl J Med 2016;374(22):2193–2195. 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Ocular findings in infants with microcephaly associated with presumed Zika virus congenital infection in Salvador, Brazil. JAMA Ophthalmol 2016 Feb 9. [Epub ahead of print] 21. Miranda-Filho DdeB, Martelli CM, Ximenes RA, et al. Initial description of the presumed congenital Zika syndrome. Am J Public Health 2016;106(4):598–600. CrossRef, Medline 22. Johansson MA, Mier-y-Teran-Romero L, Reefhuis J, Gilboa SM, Hills SL. Zika and the risk of microcephaly. N Engl J Med2016;375(1):1–4. CrossRef, Medline 23. Brazilian Ministry of Health. Ministério da Saúde Confirma 1.656 Casos de Microcefalia.http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/24437-ministerio-da-saude-confirma-1-656-casos-de-microcefalia. Updated July 7, 2016. Accessed July 7, 2016. 24. França GV, Schuler-Faccini L, Oliveira WK, et al. Congenital Zika virus syndrome in Brazil: a case series of the first 1501 livebirths with complete investigation. Lancet 2016 Jun 29. [Epub ahead of print] 25. 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Discussion Section: ChooseChoose Top of page Abstract Introduction Materials and Methods Results Discussion << References prevnext Zika virus is a single-strand RNA Flavivirus (1). It is transmitted by infected female mosquito vectors, such as the Aedes aegyptimosquito. Diagnosis of Zika virus infection is complicated by the fact that it is asymptomatic in up to 80% of infections (14). The common symptoms tend to be mild and nonspecific, including headache, fever, and rash. Other symptoms include conjunctivitis, and, in rare instances, Guillain-Barré syndrome (15). It is well recognized that Zika virus crosses the fetal-placental barrier. Zika virus has been isolated from the brain and cerebrospinal fluid of neonates born with congenital microcephaly and identified in the amniotic fluid and placental tissue of mothers who had experienced clinical symptoms consistent with Zika virus infection during their pregnancies (2–5,8,15,16). Zika virus has also been shown to lead to neurotoxiticity and to impair human neurosphere growth in experimental models (17). Microcephaly is a nonspecific term that refers to a head circumference smaller than normal for gestational age. There are many causes of microcephaly, the most common being infections (such as TORCH infections and human immunodeficiency virus), teratogens (including maternal exposure to heavy metals, alcohol, and radiation), genetic abnormalities and syndromes, and growth restriction. In the case of Zika virus, it is clear that there are developmental insults that lead to micrencephaly (small brain) and associated microcephaly (small head) (6,18–21). It is important to recognize that almost all of the infections at our institution occurred in women who had a characteristic rash in the late first trimester. This correlates well with the finding of severe cerebral dysmorphisms associated with infection during a time of rapid brain development. According to the U.S. Centers for Disease Control and Prevention, the risk of microcephaly after maternal infection with Zika virus in the first trimester of pregnancy is 1%–13% (22). However, as the flow of women referred to the IPESQ for assessment demonstrates, it is clear that many pregnant women with a rash in Brazil are never shown to have congenitally infected fetuses, although some certainly could have less severe infection that has thus far been undiagnosed. For women who have neonates with findings suggestive of severe microcephaly but who have a history of rash or for those who had a rash in the third trimester, we can hypothesize that there was an unrecognized or asymptomatic first-trimester exposure and/or infection. As of July 2, 2016, the Brazilian Ministry of Health had been notified of 8301 cases of microcephaly and confirmed 1656 infections (23). In a recent study, França et al reported on the follow-up of 1501 cases in which Zika virus infection was suspected, of which 602 were deemed to be definitely or probably due to Zika virus (76 definite infections, 54 highly probable infections, 181 moderately probable infections, and 291 somewhat probable infections) (24). The incidence of confirmed infection in our study with respect to referral population is similar to what has been seen in the larger Brazilian population. In our study, of 432 women initially screened, only findings in 44 patients are reported here after applying our exclusion criteria. In the report by França et al, one in five definite or probable Zika virus infections yielded head circumferences in the normal range (more than −2 standard deviations below the median of the International Fetal and Newborn Growth Consortium for the 21st Century, or INTERGROWTH-21st, standard), and for one-third of definite and probable infections, there was no history of a rash during pregnancy (24). This suggests that our series is biased to the more severe infections. However, in the series by França et al (24), the more severe infections were localized in the northeast region of Brazil, since 97% of definite or probable infections were from the northeast region, where 28% of all births in Brazil occur. This suggests that there could be additional unknown factors that exacerbate the fetal infection in this region. Coinfections, in addition to those already excluded, as well other environmental factors, will need to be explored further. There are many nomograms for head circumference size. Current guidance in Brazil is to use the standards from the INTERGROWTH-21st study for fetuses (25), the INTERGROWTH-21st study for infants (25), and World Health Organization criteria for full-term neonates (26). These charts show that a head circumference of 32 cm is at about −2 standard deviations below the mean for both boys and girls at term. However, this threshold will naturally include some normally developing neonates and also be inaccurate for neonates born prematurely. However, it should be recognized that to cast a broad net to find neonates with congenital Zika virus infection, we must bear in mind that not all neonates will have microcephaly at birth. The striking imaging features of the severe micrencephaly associated with Zika virus include a markedly abnormal head shape. The unusual appearance of the skull, we hypothesize, is due to a combination of the small brain as it develops and a result of what, at some point, was likely a larger head size (due to ventriculomegaly) that then decompresses. Cerebral atrophy may also contribute, giving the skull the collapsed shape with everted and/or cupped sutures and overriding bones in the occipital region, causing redundant and folded skin. In part, this is also likely due to the head and skin continuing to grow, while the size of the brain regresses. However, in some fetuses and/or neonates, the ventricle and/or brain atrophy has not yet occurred, and in these instances, a normal (or even increased) head circumference may be present. Another unusual finding that suggests skull collapse is that neonates have orbital fat herniation into the cranial vault. Thus, some of the ocular findings could be secondary to the process of skull deformation itself rather than direct infection of the eye. For example, nerve and blood flow interruption could be due to herniated tissue. We used brain calcifications as inclusion criteria for the postnatal assessment to exclude microcephaly from causes other than infection, such as unrecognized prematurity or congenital syndromes. While this could have led to exclusion of some infections without intracranial calcifications, it led to a homogeneous group of neonates with strikingly similar parenchymal abnormalities. In our series, the most common location for calcifications was the gray matter–white matter junction (88% in the confirmed infection cohort and 100% in the presumed infection cohort), which is an area not classically or commonly targeted in other congenital infections. The location of the calcifications at the gray matter–white matter interface could suggest a vascular component to the infection, as other processes that preferentially affect the gray matter–white matter junction have been posited to be due to changes in arterial configuration from straight vessels in the cortex to coiled vessels in the subcortical white matter (27). In the classic TORCH infections, the brain calcifications are periventricular and cortical, although rare cases of basal ganglia and thalamus calcifications have been reported (28,29). Other findings include intraventricular adhesions, callosal abnormalities, periventricular pseudocysts, sulcation, and gyral abnormalities (29–31), similar to what we describe in this report. However, unlike most patients with congenital Cytomegalovirus, the patients with documented or presumed Zika virus infection described in this report had severe microcephaly. This may be due to the first-trimester nature of most of the infections reported herein. It could also be due to the viral load in the Zika virus infections, which we assume are severe infections. It could be that congenital Cytomegalovirus is diagnosed in a range of infections from mild to severe, whereas we may be focusing our results on the severe Zika virus infections. In our cohort, almost all fetuses and neonates had dramatically abnormal cerebral volume, abnormal cortical folding pattern, and/or regions of lissencephaly, pachygyria, and/or polymicrogyria. We hypothesize that the cortical abnormalities visualized are due at least in part to arrested cortical development at various stages. There have been many reports of small series of imaging findings in fetuses and neonates with congenital Zika virus infection. In 2016, Mlakar et al described one pregnancy at 29 weeks with microcephaly and intracranial calcifications, with an earlier, second-trimester sonogram that showed no abnormality (6). Also in 2016, Calvet et al described two pregnant women who underwent US at 22 weeks, which showed microcephaly (2). Sarno et al described a stillbirth at 32 weeks, with microcephaly, intracranial calcifications, and fetal hydrops (7). Driggers et al in 2016 described decreased fetal head circumference between 16 and 21 weeks, with brain abnormalities (8). In a study by Brasil et al (3), of 88 pregnant women with rash, 72 tested positive for Zika virus. Fetal US was performed in 42 fetuses, and abnormalities were seen in 12, including intrauterine growth restriction with or without microcephaly and ventricular calcifications (3). Schuler-Faccini et al described 35 neonates with microcephaly, including brain calcifications, ventriculomgaly, and cortical and/or subcortical atrophy (9). In 2016, Hazin et al (10) and de Fatima Vasco Aragao et al (11) each described 23 neonates with microcephaly who had CT findings that included intracranial calcifications, ventriculomegaly, abnormal gryal pattern, and abnormal white matter attenuation. Guillemette-Artur et al described three neonates with congenital Zika virus infection, with micrencephaly in all three, small cerebellum in two, occipital subependymal pseudocysts in two, polymicrogyria in three, corpus callosum abnormalities in two, and hypoplastic brainstem in one (32). These findings are all similar to what we report. Our study had limitations. What we present here is a convenience sample of imaging findings for illustrative purposes. Our cohort was obtained from a referral center for high-risk pregnancy. Thus, we have no information on incidence of the Zika virus in the general population or risk estimates for transmission to the fetus. Because of the manner in which we accrued subjects, neonates with congenital infection but with normal head size or brain abnormalities without calcifications could have been missed. In addition, it could be that some of the cohort had disease origin for microcephaly other than Zika virus. For example, we excluded a neonate with microcephaly and confirmed Zika virus infection due to aneuploidy with trisomy 13 syndrome. However, other infections or syndromes could be present but not yet identified in either our confirmed infection cohort or our presumed infection cohort. Findings on MR images can lead to underestimation of the incidence of calcifications, and evaluation of CT images makes characterization of subtle parenchymal abnormalities and corpus callosum abnormalities difficult. Further imaging studies on these neonates as they grow will be helpful in further assessment of areas involved with the infection. Finally, we focused on brain findings in this review. Additional sites of infection and associated pathologic abnormalities will likely be identified in the future. It is well recognized that transplacental transmission of viruses, even in subclinical maternal infection, can lead to severe congenital abnormalities. As in other infections, serial imaging can demonstrate evolution of findings. Prenatal sonograms may show normal or decreased head circumference and, rarely, increased head circumference. Almost all neonates will show intraparenchymal calcifications more severe than what are typically seen in TORCH infections and frequently occur at the gray matter–white matter junction, which is an unusual location for the calcifications of other congenital infections. We hope the illustrations of these many fetuses and neonates will aid others in the event that the unfortunate epidemic of congenital Zika virus continues. Acknowledgments We gratefully acknowledge the members of the Brazilian Network BRAZIKA (Rede Internacional de Estudos Sobre Zika no Brasil). Received July 7, 2016; revision requested July 14; revision received July 22; accepted July 27; final version accepted August 3.

In all but one fetus with confirmed Zika virus infection at prenatal imaging, the head circumference percentile was at or below the 5th percentile in at least one US examination performed during the second trimester of pregnancy (Table 2). However, one fetus with severe parenchymal and brainstem malformation had severe ventriculomegaly and normal head circumference at a scan conducted at 17 weeks of gestational age, and the circumference remained within the normal range later in pregnancy. In 23 of 26 fetuses that underwent serial prenatal US, head circumference remained under the 5th percentile until birth, which led to a diagnosis of microcephaly at birth. However, it is notable that the three fetuses with head circumference in the normal range at birth showed severe ventriculomegaly, which we presume was due to the enlarged, obstructed ventricles. For this reason, we included Figure 16, which depicts a neonate referred to IPESQ for potential Zika virus infection, but the head circumference was 38 cm at birth. The CT images showed calcifications in the subcortical region, thalamus, basal ganglia, and brainstem. No sulci were seen; however, the parenchyma was extremely thin. There was pontocerebellar hypoplasia and Dandy-Walker spectrum anomaly, and the corpus callosum was not visualized. Table 2 Head Circumference Percentiles with Respect to Gestational Age in Fetuses with Prenatal US Images Table 2Head Circumference Percentiles with Respect to Gestational Age in Fetuses with Prenatal US Images Click image to enlarge Note.—Data are percentages, unless indicated otherwise. If more than one examination was conducted in a given time period, measurements from the first examination were used. View larger version The most remarkable change in the brain parenchyma, present on all neonatal images, was the reduction in parenchymal volume. Abnormalities of cortical development associated with volume changes were observed in 16 of 17 confirmed infections (94%) and 28 of 28 presumed infections (100%). Abnormalities of the corpus callosum were present in 16 of 17 confirmed infections (94%) and 22 of 28 presumed infections (78%). Lateral ventricles were enlarged in 16 of 17 confirmed infections (94%) and 27 of 28 presumed infections (96%). This was asymmetrical in six of 17 confirmed infections and five of 28 presumed infections. Despite ventriculomegaly, the extra-axial spaces are frequently still prominent because of cortical underdevelopment or atrophy. Other findings associated with the ventricles were septations in the ventricle (typically in the occipital horns), which were frequently difficult to distinguish from subventricular cysts. Subependymal cysts were occasionally visualized. Abnormalities of cortical development were present in all patients but with a substantial variation regarding the type of abnormality, hemispheric symmetry, and severity (Table 1). The most common finding was irregular areas of sulci and/or gyri not otherwise specified, but focal cortical malformation was also observed. In addition, six patients had the appearance of lissencephaly. In three fetuses, this was diagnosed prenatally. Of the other three, two did not have a fetal sonogram for review, and one only underwent a scan at 10 weeks of gestation, which is too early to assign this diagnosis. The cortical development abnormalities were usually asymmetrical. In general, the sulci were less prominent, and wide sylvian and interhemispheric fissures were identified in most neonates, as well as abnormal myelination. Calcification regions were predominantly located in the gray matter–white matter junction in our series (88% in the confirmed infection cohort and 100% in the presumed infection cohort). Calcifications were also identified in the thalamus, basal ganglia, cortex, and periventricular regions. It is important to mention that the latter were only present in neonates where there was substantial thinning of the brain parenchyma; thus, the precise location of calcifications was difficult to determine. Although less common, infratentorial calcifications were also identified. However, these were usually present in more severe manifestations of infection, being associated with dysmorphic brainstem, stenosis of the aqueduct, and secondary supratentorial hydrocephaly. Calcification in the brainstem was a common finding at autopsy (in three of three of the neonates with confirmed infection that underwent autopsy). Abnormalities of the brainstem were identified. The pons was often thin and atrophic. There was frequently a kink seen at the pontomedullary junction. The spinal cord was thinned and at times irregular in its appearance. Other posterior fossa abnormalities included cerebellar hemisphere hypoplasia, vermis hypoplasia, and elevation of the vermis, associated with an enlarged cisterna magna. Abnormalities of the corpus callosum—usually thin, dysgenetic, and hypoplastic or even absent—were frequently observed. Other changes included under-rotation of the hippocampus and thickened fornices. In some imaging studies, an enlarged confluence of the dural venous sinuses had heterogeneous material. In a few fetal sonograms that were available for review, this was demonstrated to be blood clot (Fig 3g). In many postnatal CT studies, there was hyperattenuating material in this region, which could be either thrombus or hematocrit effect (due to dehydration with hemoconcentration). In many fetal and neonatal MR studies, there was fluid posterior to the confluence of the sinuses that was either similar to cerebrospinal fluid in attenuation or signal intensity or contained fluid with a higher protein content than that of cerebrospinal fluid. The location of the fluid collection is likely related to the unusual head shape and overlapping sutures. This abnormal head shape was frequently associated with redundant skin folds. Other findings include orbital abnormalities, such as asymmetrical micropthalmia, cataracts, and herniation of the orbital fat into the cranial vault. Body abnormalities included arthrogryposis.

Figure 16a: Axial CT images in a 5-month-old male infant with a head circumference of 38 cm at birth. The mother had a rash at 11 weeks. The size of the head is likely secondary to hydrocephalus. Unlike most of our cohort, the head was still round in shape. However, calcifications are present in the subcortical region, thalamus, basal ganglia, and brainstem. No sulci were seen; however, the parenchyma is extremely thin. There is pontocerebellar hypoplasia, nonvisualization of the corpus callosum, and Dandy-Walker spectrum anomaly. This is an example of how Zika virus infection can be missed if only newborns with microcephaly are assessed. Open in Image Viewer Figure 16b: Axial CT images in a 5-month-old male infant with a head circumference of 38 cm at birth. The mother had a rash at 11 weeks. The size of the head is likely secondary to hydrocephalus. Unlike most of our cohort, the head was still round in shape. However, calcifications are present in the subcortical region, thalamus, basal ganglia, and brainstem. No sulci were seen; however, the parenchyma is extremely thin. There is pontocerebellar hypoplasia, nonvisualization of the corpus callosum, and Dandy-Walker spectrum anomaly. This is an example of how Zika virus infection can be missed if only newborns with microcephaly are assessed. Open in Image Viewer Figure 16c: Axial CT images in a 5-month-old male infant with a head circumference of 38 cm at birth. The mother had a rash at 11 weeks. The size of the head is likely secondary to hydrocephalus. Unlike most of our cohort, the head was still round in shape. However, calcifications are present in the subcortical region, thalamus, basal ganglia, and brainstem. No sulci were seen; however, the parenchyma is extremely thin. There is pontocerebellar hypoplasia, nonvisualization of the corpus callosum, and Dandy-Walker spectrum anomaly. This is an example of how Zika virus infection can be missed if only newborns with microcephaly are assessed. Open in Image Viewer

Figure 15: Axial CT image in a 3-month-old female infant with cord blood positive for Zika virus (confirmed Zika virus infection) and a head circumference of 28.5 cm at birth. The mother had a rash at 12 weeks. Bilateral cataracts are seen, as well as abnormal cerebellar vermis and fat herniating posteriorly from the orbits through the superior orbital fissure into the cranial vault. Open in Image Viewer

Figure 14: Axial CT image in a 2-month-old female infant with a head circumference of 32.5 cm at birth, with presumed Zika virus infection. Note the asymmetrical volume loss, more marked on the right than the left. Also note the diffusely irregular sulci and gyri bilaterally. Open in Image Viewer

Figure 13: Axial CT image in a 1-month-old female neonate with a head circumference of 31 cm at birth, with presumed Zika virus infection. Note severe ventriculomegaly, subcortical calcifications, and diffuse gyral abnormality. Open in Image Viewer

Figure 12: Oblique coronal CT image in a 1-month-old male neonate with a head circumference of 29.5 cm at birth, with presumed Zika virus infection. Note the misshapen skull; ventriculomegaly; absent corpus callosum; cerebellar hypoplasia (arrows); thin parenchyma with diffuse gyral abnormality; calcifications in the thalamus, basal ganglia, and subcortical white matter; and cerebellar hemispheres. Open in Image Viewer

Figure 11: Axial CT image in a 1-month-old male neonate with a head circumference of 27 cm at birth, with presumed Zika virus infection. Note ventriculomegaly with septation (arrow) in the right occipital horn and striking subcortical calcifications. There are also cortical and periventricular calcifications. The gyral pattern is diffusely abnormal, and the skull is deformed. Open in Image Viewer

Figure 10: Oblique axial CT image in a 3-month-old male infant with a head circumference of 27.5 cm at birth, with presumed Zika virus infection. Note the misshapen skull, ventriculomegaly, absent corpus callosum, diffuse parenchymal volume loss, diffuse cortical migrational abnormality, and calcifications, most likely subcortical but difficult to classify secondary to parenchymal thinning. Open in Image Viewer

Figure 9: Axial CT image in a 1-week-old female neonate with a head circumference of 31 cm at birth and presumed Zika virus infection. The frontal lobes are slightly hypoplastic, with mild underopercularization of the hypoplastic sylvian fissures. There are scattered subcortical calcifications (arrowheads), and there is high-attenuating material (arrow) in the region of the confluence of sinuses, likely representing blood products. Open in Image Viewer

Figure 8a: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b) Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer Figure 8b: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b) Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer Figure 8c: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b)Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer Figure 8d: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b) Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer Figure 8e: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b) Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer Figure 8f: Fetal and postnatal images in the case of an 18-year-old pregnant woman initially seen for a rash at 12 weeks of gestation, with confirmed Zika virus infection. Signs of joint contractures were identified at US at 17 weeks, but head circumference was in the normal range, then decreased to the 15th percentile at 21 weeks and was below the 3rd percentile at subsequent scans at 24 and 36 weeks (19.0 cm and 25.0 cm, respectively). (a) Axial transabdominal US performed at 36 weeks shows ventriculomegaly, calcifications in the thalamus and basal ganglia, and enlarged cisterna magna. (b)Soft-tissue, (c) body bone reconstruction, and (d, e) axial postmortem CT images show an abnormal profile, moderate ventriculomegaly, parenchymal atrophy, splaying of the cerebellar hemispheres, inferior vermian hypoplasia, and calcifications in the subcortical white matter, thalamus, and basal ganglia. The corpus callosum is not visualized. The gyral pattern is abnormally smooth for a term neonate. The postnatal bone reconstruction image showed the severe joint contractures, similar to those observed on (f) a photograph of the neonate. Open in Image Viewer

Figure 7a: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7b: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7c: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7d: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7e: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7f: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7g: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer Figure 7h: Images in the case of a pregnant 20-year-old woman, without history of rash, who was referred for fetal brain abnormality at US with confirmed Zika virus infection. (a) Graph of head circumference during pregnancy shows small head size in the second trimester, which increased in the third trimester. US (not shown) showed moderate ventriculomegaly starting at 23 weeks, which progressed to severe ventriculomegaly by the third trimester, associated with the increase in head circumference. (b) Axial, (c) sagittal, and (d) coronal fetal MR images obtained at 36 weeks show severe asymmetric ventriculomegaly, marked parenchymal thinning and/or atrophy, sloping forehead, and elevation of the hypoplastic cerebellar vermis with hypoplastic cerebellar hemispheres. The brainstem is thin, and the midbrain is foreshortened. The spinal cord is irregular, thin, and nonvisualized in parts, and then thicker and possibly mineralized. (e, f)Axial CT images obtained 1 day postnatally show severe asymmetrical ventriculomegaly with dense calcifications in the brainstem, cerebellum, and gray matter–white matter interface (temporal lobes on f) and marked parenchymal atrophy. (g)Axial CT image obtained in the 6-week-old infant, after shunting, showed persistent ventriculomegaly and periventricular, midbrain, thalamic, and cerebellar calcifications. (h) Photograph of the neonatal face shows redundant skin folds and skull asymmetry. Open in Image Viewer

Figure 6a: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6b: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6c: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6d: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6e: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6f: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6g: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6h: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6i: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6j: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6k: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer Figure 6l: Images in the case of a 24-year-old woman pregnant with twins, with characteristic rash at 9 weeks of pregnancy and confirmed Zika virus infection. (For each pair of images, the first image is of twin A, and the second image is of twin B.) At 14 weeks of gestational age, the fetal head size of both twins was normal. The head size never went below the 3rd percentile for either fetus in examinations at 19–28 weeks. (a, b) Sagittal and (c, d) axial fetal MR images were obtained at 36 weeks. (e, f) Axial and (g, h) surface reconstruction postnatal CT images and (i, j) axial T2-weighted and (k, l) coronal MR images were obtained 1 week after delivery at 38 weeks of gestational age. There is severe microcephaly with profound frontal lobe hypoplasia. Calcifications in the subcortical white matter at the gray matter–white matter junction are visualized. Both twins have a flattened appearance of the pons. The spinal cord is atrophic (best seen ona). Redundant skin is seen in the occipital region. There is polymicrogyria involving the frontal and parietal regions and atrophic cortex and white matter in the occipital regions. Each twin has hypoplasia of the corpus callosum, with prominent fornices. There is abnormal myelination in the occipital region that, in twin A (i), has the appearance of a cyst or septation within the ventricle. The cerebellum is somewhat small and nodular. There is lack of rotation of the hippocampi. Open in Image Viewer

Figure 5a: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5b: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5c: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5d: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5e: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5f: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5g: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5h: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer Figure 5i: Images in the case of a 33-year-old woman who had a rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US performed at 19 weeks of gestational age showed a head circumference in the normal range (16.6 cm). (a, b) Sagittal and (c) coronal transvaginal US images obtained at the next US examination at 27 weeks 2 days of gestational age, however, showed the fetal head circumference to be 21.6 cm, which corresponded to 23 weeks 3 days (<2.3 percentile, not shown). There was mild ventriculomegaly with septations in the occipital horns. Calcifications could be seen at the gray matter–white matter junction. The cerebrum was atrophic. There was blood clot in the region of the confluence of sinuses (arrow). (d) Coronal, (e) axial, and (f) sagittal T2-weighted fetal MR images obtained at 32 weeks show septations in the ventricles and an abnormal-appearing cortex, with a thickened and undersulcated cortex most marked on the left, compatible with polymicrogyria. The sagittal midline view shows microcephaly, blood clot in the region of the confluence of sinuses, and prominent skin folds. (g, h) Axial T2-weighted and (i) sagittal T1-weighted postnatal MR images obtained in the 4-week-old neonate show diffuse gyral abnormality and abnormal myelination. The septations in the ventricles are again seen. The sagittal image shows thinning of the spinal cord at the craniocervical junction. Open in Image Viewer

Figure 4a: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4b: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4c: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4d: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4e: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4f: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4g: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4h: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4i: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4j: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4k: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity. Open in Image Viewer Figure 4l: Images in the case of an 18-year-old woman, first seen for rash at 10 weeks of pregnancy, with confirmed Zika virus infection. US findings obtained at 20 weeks of gestational age were reportedly normal, with normal head circumference of 17.5 cm. At 37 weeks of gestational age, (a)sagittal transvaginal and (b) coronal transabdominal US images obtained with the head upside down show a small head circumference (26.4 cm, corresponding to 28 weeks 5 days, below the 3rd percentile), moderate ventriculomegaly with dense intracranial calcifications (arrowheads on a), and abnormal head shape with flattened appearance and thickened skin (arrow on a). On the sonogram, it is difficult to precisely localize the calcifications, given the thin parenchyma. (c, d) Axial bone window CT images, (e) sagittal localizer CT image, and (f–h) axial CT images show microcephaly with cerebral atrophy, and, despite ventriculomegaly, the extra-axial cerebrospinal fluid spaces are still prominent. The dense calcifications are predominantly located in the subcortical white matter at the gray matter–white matter interface. There is markedly abnormal skull shape with some eversion of the bones at the suture sites (particularly frontoparietal sites), with redundant skin folds (particularly in the parieto-occipital region). (i)Sagittal T1-weighted, (j, k) coronal T2-weighted, and (l) axial susceptibility-weighted MR images obtained at 1 month of age show an undersegmented midbrain, severe microcephaly, open sylvian fissures, and polymicrogyria. The dense calcifications are evident on the susceptibility-weighted image. On the sagittal images (a, e, i), note the small supratentorial compartment and associated skull deformity.

Figure 3a: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3b: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3c: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3d: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3e: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3f: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3g: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3h: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3i: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3j: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3k: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth. Open in Image Viewer Figure 3l: Images in the case of a 34-year-old woman with confirmed Zika virus infection, initially seen for a rash at 8 weeks of gestation. Fetal head circumference was in the normal range at 12 and 16 weeks (5.8 cm and 11.9 cm, respectively) but then decreased to the 10th percentile at 22 weeks and was below the 3rd percentile in subsequent imaging examinations. (a–h) US images obtained at 30 weeks. Head circumference on the axial image (a) measured 24 cm (<2.3 percentile, corresponding to a gestational age of 26 weeks 3 days). Note the open sylvian fissures and relatively smooth cortex, which are abnormal findings at this gestational age. Oblique axial image (b) shows cerebellar calcifications (seen as the echogenic outer contour of the cerebellar hemispheres) and inferior vermian hypoplasia with associated enlarged cisterna magna. A sagittal transvaginal image (c) shows calcifications in the basal ganglia (arrowheads) and more bulky calcification at the gray matter–white matter junction. Another sagittal transvaginal image (d) shows a relatively small corpus callosum (arrows). A coronal image (e) shows cortical and subcortical white matter calcifications in a linear pattern. The gyral pattern is abnormal, which is suggestive of polymicrogyria. A sagittal color Doppler image (f) shows a stretched appearance of vessels coursing into the posterior fossa. An oblique axial gray-scale transvaginal image in the posterior fossa (g) shows heterogeneous material in the confluence of sinuses due to blood clot (arrow). A three-dimensional US image of the face (h) shows a sloping forehead, compatible with frontal lobe hypoplasia. (i) Axial and (j) sagittal fetal MR images obtained at 29 weeks show atrophic frontal lobes, wide sylvian fissures, enlarged posterior fossa, abnormal gyral pattern, prominent cerebrospinal fluid spaces, and inferior vermian hypoplasia. On i, note the diffuse hypointense and undersulcated cortex, which is suggestive of mineralization and polymicrogyria. The hypoplastic corpus callosum can be seen on the sagittal view (j), as well as the inferior vermian hypoplasia, enlarged cisterna magna, and heterogeneous signal intensity in the confluence of sinuses. There is a subjectively thin spinal cord. (k) Postnatal axial MR image obtained at 81 days shows small frontal lobes and cortical thickening. The choroid plexi are enlarged. (l) Photograph of the neonate after birth.

Table 1Imaging Findings in 17 Confirmed and 28 Presumed Zika Virus Infections Click image to enlarge Note.—Numbers in parentheses are percentages. View larger version Figure 2a: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2b: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2c: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2d: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2e: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2f: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2g: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images. Open in Image Viewer Figure 2h: (a) Axial, (b) sagittal, and (c) coronal fetal T2-weighted MR images in a 29-year-old woman with confirmed Zika virus infection, initially seen for characteristic rash at 12 weeks of gestational age. (d) Axial postnatal CT image and (e–g) axial and (h) coronal T2-weighted MR images obtained in her male neonate. The fetal MR images obtained at 34 weeks (a–c) show asymmetrical ventriculomegaly with a septation in the right occipital horn (arrowhead on a), small frontal lobes, thinning of the occipital parenchyma (left worse than right), underdeveloped sylvian fissures, and regions of thickened cortex, as in the right frontal lobe, which is suggestive of polymicrogyria (arrow on a). There is abnormal, increased signal intensity in the white matter. The postnatal CT image (d) obtained in the 22-day-old neonate shows punctate calcifications at the gray matter–white matter junction and asymmetrical ventriculomegaly. The T2-weighted MR images obtained at 26 days (e–h) show septation in the ventricle (arrowhead on e). Note how the right ventricle has relatively decreased in size compared with the prenatal image, whereas the left ventricle has increased in size. Under-rotation of the hippocampus (arrowheads on f) is demonstrated. There is clear asymmetry of the gyral pattern on g, which is relatively smooth in the left occipital region, with abnormal folds in the right occipital and frontoparietal regions (arrows on g). Subependymal cysts are visualized on h, which are not seen on fetal MR images.