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Follow-up brain imaging of 37 children with congenital Zika syndrome: case series study

BMJ 2017; 359 doi: (Published 13 October 2017) Cite this as: BMJ 2017;359:j4188
  1. Natacha Calheiros de Lima Petribu, radiologist and professor of radiology1 2,
  2. Maria de Fatima Vasco Aragao, neuroradiologist and professor of radiology3 4,
  3. Vanessa van der Linden, paediatric neurologist1 5,
  4. Paul Parizel, neuroradiologist and professor of radiology6,
  5. Patricia Jungmann, pathologist and professor of pathology7,
  6. Luziany Araújo, radiology resident1,
  7. Marília Abath, radiologist1,
  8. Andrezza Fernandes, radiologist1,
  9. Alessandra Brainer-Lima, neuroradiologist and professor of radiology8,
  10. Arthur Holanda, medical student9,
  11. Roberto Mello, pathologist and, professor of pathology9,
  12. Camila Sarteschi, statistician and, professor of epidemiology10,
  13. Maria do Carmo Menezes Bezerra Duarte, head of paediatric intensive care and, postgraduate professor11 12
  1. 1Barão de Lucena Hospital, Recife, Brazil
  2. 2Faculdade Pernambucana de Saúde, Recife, Brazil
  3. 3Centro Diagnóstico Multimagem, Recife, Brazil
  4. 4Catholic University of Pernambuco, Recife, Brazil
  5. 5Association for Assistance of Disabled Children, Recife, Brazil
  6. 6Antwerp University Hospital, Edegem, Belgium
  7. 7Department of Pathology, University of Pernambuco, Recife, Brazil
  8. 8PROCAPE, University of Pernambuco, Recife, Brazil
  9. 9Medical School, Federal University of Pernambuco, Recife, Brazil
  10. 10The Research Center Aggeu Magalhães (CPqAM), Oswaldo Cruz Foundation (Fiocruz) unit, Pernambuco, Brazil
  11. 11Esperança Hospital, Recife, Brazil
  12. 12The Professor Fernando Figueira Integral Medicine Institute, Recife, Brazil
  1. Correspondence to: N C Petribu natachacalheiros{at}
  • Accepted 29 August 2017


Objective To compare initial brain computed tomography (CT) scans with follow-up CT scans at one year in children with congenital Zika syndrome, focusing on cerebral calcifications.

Design Case series study.

Setting Barão de Lucena Hospital, Pernambuco state, Brazil.

Participants 37 children with probable or confirmed congenital Zika syndrome during the microcephaly outbreak in 2015 who underwent brain CT shortly after birth and at one year follow-up.

Main outcome measure Differences in cerebral calcification patterns between initial and follow-up scans.

Results 37 children were evaluated. All presented cerebral calcifications on the initial scan, predominantly at cortical-white matter junction. At follow-up the calcifications had diminished in number, size, or density, or a combination in 34 of the children (92%, 95% confidence interval 79% to 97%), were no longer visible in one child, and remained unchanged in two children. No child showed an increase in calcifications. The calcifications at the cortical-white matter junction which were no longer visible at follow-up occurred predominately in the parietal and occipital lobes. These imaging changes were not associated with any clear clinical improvements.

Conclusion The detection of cerebral calcifications should not be considered a major criterion for late diagnosis of congenital Zika syndrome, nor should the absence of calcifications be used to exclude the diagnosis.


  • We thank Carla Araújo, director of Barão de Lucena Hospital, and Samara Brelaz for their assistance.

    Contributors: All authors contributed to the clinical (VvdL, MdCMBD), radiological (NCdLP, MdFVA, LA, MA, AF, AB-L, PP), and pathological assessment (PJ, RM), according to their own specialty, and to the concept and design (NCdLP, MdFVA, PP) or analysis and interpretation of the data (NCdLP, CS) and to the draft of the final version (NCdLP, MdFVA, AH, MdCMBD). NCdLP is the guarantor.

  • Funding: No external funding provided.

  • 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: This study was approved by the research ethics committee from Otávio de Freitas Hospital (Pernambuco State Secretary of Health and the children’s carers gave consent for the publication of the results and images.

  • Data sharing: Initial and follow-up CT images, clinical data and statistical calculations are available from the corresponding author at

  • Transparency: The lead author (NCdLP) 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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