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Clinical features and neuroimaging (CT and MRI) findings in presumed Zika virus related congenital infection and microcephaly: retrospective case series study

BMJ 2016; 353 doi: (Published 13 April 2016) Cite this as: BMJ 2016;353:i1901

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  1. Maria de Fatima Vasco Aragao, neuroradiologist and professor of radiology1,
  2. Vanessa van der Linden, paediatric neurologist2,
  3. Alessandra Mertens Brainer-Lima, neuroradiologist and professor of radiology3,
  4. Regina Ramos Coeli, paediatric infectologist and professor4,
  5. Maria Angela Rocha, infectologist4,
  6. Paula Sobral da Silva, paediatric neurologist4,
  7. Maria Durce Costa Gomes de Carvalho, paediatric neurologist4,
  8. Ana van der Linden, paediatric neurologist5,
  9. Arthur Cesario de Holanda, medical student6,
  10. Marcelo Moraes Valenca, neurosurgeon and full professor of neurology and neurosurgery7
  1. 1Centro Diagnostico Multimagem, Rua Frei Matias Tevis, 194, Ilha do Leite Recife Pernambuco 52010-450, Brazil; Medical School, Mauricio de Nassau University, Recife, Pernambuco, Brazil
  2. 2Association for Assistance of Disabled Children, Recife, Brazil; Barão de Lucena Hospital, Recife, Brazil
  3. 3PROCAPE, University of Pernambuco, Recife, Brazil
  4. 4Oswaldo Cruz University Hospital, Recife, Brazil
  5. 5Prof Fernando Figueira Integral Medicine Institute, Recife, Brazil
  6. 6Medical School, Federal University of Pernambuco, Recife, Brazil
  7. 7Neurology and Neurosurgery, Federal University of Pernambuco, Recife, Brazil
  1. Correspondence to: M de Fatima Vasco Aragao fatima.vascoaragao{at}
  • Accepted 1 April 2016


Objective To report radiological findings observed in computed tomography (CT) and magnetic resonance imaging (MRI) scans of the first cases of congenital infection and microcephaly presumably associated with the Zika virus in the current Brazilian epidemic.

Design Retrospective study with a case series.

Setting Association for Assistance of Disabled Children (AACD), Pernambuco state, Brazil.

Participants 23 children with a diagnosis of congenital infection presumably associated with the Zika virus during the Brazilian microcephaly epidemic.

Main outcome measures Types of abnormalities and the radiological pattern of lesions identified on CT and MRI brain scans.

Results Six of the 23 children tested positive for IgM antibodies to Zika virus in cerebrospinal fluid. The other 17 children met the protocol criteria for congenital infection presumably associated with the Zika virus, even without being tested for IgM antibodies to the virus—the test was not yet available on a routine basis. Of the 23 children, 15 underwent CT, seven underwent both CT and MRI, and one underwent MRI. Of the 22 children who underwent CT, all had calcifications in the junction between cortical and subcortical white matter, 21 (95%) had malformations of cortical development, 20 (91%) had a decreased brain volume, 19 (86%) had ventriculomegaly, and 11 (50%) had hypoplasia of the cerebellum or brainstem. Of the eight children who underwent MRI, all had calcifications in the junction between cortical and subcortical white matter, malformations of cortical development occurring predominantly in the frontal lobes, and ventriculomegaly. Seven of the eight (88%) children had enlarged cisterna magna, seven (88%) delayed myelination, and six each (75%) a moderate to severe decrease in brain volume, simplified gyral pattern, and abnormalities of the corpus callosum (38% hypogenesis and 38% hypoplasia). Malformations were symmetrical in 75% of the cases.

Conclusion Severe cerebral damage was found on imaging in most of the children in this case series with congenital infection presumably associated with the Zika virus. The features most commonly found were brain calcifications in the junction between cortical and subcortical white matter associated with malformations of cortical development, often with a simplified gyral pattern and predominance of pachygyria or polymicrogyria in the frontal lobes. Additional findings were enlarged cisterna magna, abnormalities of corpus callosum (hypoplasia or hypogenesis), ventriculomegaly, delayed myelination, and hypoplasia of the cerebellum and the brainstem.


  • We thank anesthesiology staff Antonio Monteiro and Cristovam A de Lira Terceiro, magnetic resonance imaging technician Edineide Cristina Leite Lopes, and the Centro Diagnostico Multimagem for their help.

  • Contributors: All authors contributed to the clinical (VvdL, RRC, MAR, PSdS, MDCGdC, AvdL) or radiological (MdFVA, AMB-L) assessment, according to their own specialty, to the concept and design of the study, to analysis and interpretation of the data, and to the draft of the final version of the manuscript (MdFVA, VvdL, AMB-L, ACdH, MMV). MdFVA is the guarantor.

  • Funding: This study received no external funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The investigations were conducted in accordance with the emergency clinical protocol of the Brazilian Ministry of Health.

  • Data sharing: Additional information is available on request from the corresponding author (

  • Transparency: The lead author (MdFVA) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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