Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2) 5
Review article
MAGNETIC RESONANCE IMAGING IN THE ASSESSMENT OF 
FETAL CENTRAL NERVOUS SYSTEM ANOMALIES
Edina SALKIĆ1, Fuad JULARDŽIJA2,3*, Adnan ŠEHIĆ2,3, Merim JUSUFBEGOVIĆ2,4, Amela SOFIĆ5, 
Meris JUŠIĆ6, Jasmina BAJROVIĆ2,4
1 MSc student, Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2 Department of radiology technologies, Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
3 Insitute for health development, Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
4 Radiology clinic, Clinical center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
5 Radiology department, General hospital “Prim. dr Abdulah Hakaš”, Sarajevo, Bosnia and Herzegovina
6 PhD student, Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
* Corresponding author:  Fuad Julardžija, Department of radiology technologies, Faculty of Health Studies, University of 
Sarajevo, Stjepana Tomića 1, 71000 Sarajevo, Bosnia and Herzegovina e-mail: fuad.julardzija@fzs.unsa.ba
Received: 22. 11. 2021
Accepted: 11. 1. 2022
https://doi.org/10.47724/MIRTJ.2021.i02.a001
Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2)
ABSTRACT
Introduction: Fetal central nervous system (CNS) anomalies 
are among the most severe and common anomalies, with an 
incidence of 1: 100 to 1: 500 in newborns. Depending on the type 
of anomaly, the diagnosis can only be made at specifi c periods 
of pregnancy. The prenatal ultrasound (US) is an eff ective 
primary imaging modality for depicting these anomalies, and 
magnetic resonance imaging (MRI) is a method that provides 
useful confi rmation and resolves any doubts regarding the 
diagnosis made on prenatal ultrasound. In situations where 
ultrasound examination is diffi  cult, fetal MRI can provide 
superior information owing to its many advantages. The aim 
of this study was to determine the importance of prenatal MRI 
in making an accurate diagnosis and assessment of fetal CNS 
anomalies after neurosonographic doubt and in detecting 
additional anomalies that might have been overlooked on 
ultrasound, which infl uences clinical decision making and 
anomaly outcomes. 
Material and methods:  For this research, which was designed 
as a systematic review of the primary scientifi c research 
literature, numerous articles were used, i.e.17 scientifi c 
research papers, published in relevant scientifi c research 
online databases such as PubMed, Medline, Google Scholar, 
and the same were published in English in the period from 
2015 to 2021. 
Results: From the assessment of the quality of studies with 
a cohort design, most studies used in this systematic review 
are high-quality studies (11 in total) and a smaller number 
are medium-quality studies (6 in total). Out of 575 cases, MRI 
confi rmed the ultrasound diagnosis and agreed with it in 59.8% 
of cases, while in 20.2% of cases, it changed the diagnosis, 
i.e., in 16.5%, it rejected the ultrasound diagnosis. Additional 
anomalies detected only on MRI occurred in 236/1225 cases, 
which totals 19.3% of additional anomalies. Termination of 
pregnancy was reported in 82/317 cases, accounting for 
25.9%, while in 176 cases, the pregnancy continued. A total of 
11 cases of neonatal death were reported, and the number of 
stillbirths or deaths after birth was reported in 8 cases. 
Conclusion: MRI using T2W SSFSE sequences in 3 planes, T1W 
and DWI in the axial plane, is a complementary modality to 
prenatal ultrasound in making an accurate diagnosis and 
assessment of CNS anomalies and detecting associated 
anomalies previously overlooked on ultrasound. 
Keywords: fetal magnetic resonance imaging, fetal 
neurosonography, fetal central nervous system anomalies, 
prenatal diagnosis. 
6 Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2)
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
INTRODUCTION 
Magnetic Resonance Imaging (MRI) of the fetus or prenatal MRI 
is a non-invasive imaging method that shows the anatomical 
structures of the fetus without using ionizing radiation (1). 
Due to a higher contrast resolution than ultrasound, fetal MRI 
allows better diff erentiation of normal and abnormal tissue, 
thus providing detailed imaging data on fetal structures, 
especially the brain (2). MRI of the fetus is not recommended 
in the fi rst trimester of pregnancy unless the fetus is life-
threatening. The use of intravenous contrast agents is not 
recommended to reduce the potentially harmful eff ects on 
the fetus (3). The key function of fetal MRI is early detection 
of congenital anomalies incompatible with life that require 
termination of pregnancy or the detection of those anomalies 
that will undergo surgery (1). Although fetal ultrasound (US) is 
the fi rst and basic screening method and an eff ective primary 
imaging modality for a depiction of central nervous system 
(CNS) abnormalities, MRI is a recognized complementary 
method for identifying fetal CNS pathology. It can provide 
additional and diagnostically important information, thus 
adding security to ultrasound diagnosis and assisting in parent 
counseling (4,5). The CNS anomalies are among themselves 
the most severe and common anomalies, with an incidence 
of 1: 100 to 1: 500 in newborns (6). Depending on the type of 
anomaly, the diagnosis can only be made at certain periods 
of pregnancy. Half of the anomalies are such that they lead 
either to the death of the fetus or signifi cantly disrupt life after 
birth, which is why timely detection and treatment are of great 
importance (7). In situations where ultrasound examination is 
diffi  cult, fetal MRI can provide superior information, owing 
to its advantages such as superior contrast resolution, 
increased visual fi eld, the ability to shoot smoothly due to 
ossifi ed skull, increased amounts of adipose tissue on the 
front abdominal wall, oligohydramnios, fetal bones, a small 
amount of amniotic fl uid, the movements themselves, and 
an unfavorable position of the fetus are cases where MRI is a 
method of choice (8,9,10). In addition, a complete examination 
of the fetal CNS in the three spatial planes is obtained more 
consistently in the second and third trimesters by MRI than 
by ultrasound only (11). Prenatal fetal imaging has several 
challenges that require sequences that can minimize the 
eff ects of fetal movement and maternal breathing. The quality 
and resolution of the image should be such that they can 
adequately display essentially small anatomical details, and 
the diff erences in low tissue contrast should be made as large 
as possible to adequately defi ne the brain parenchyma (12). 
The development of a fast retrieval sequence from a single 
image with refocused echo (T2 weighted) has revolutionized 
fetal MRI because it has a layer acquisition time of less than a 
second and allows for eff ective “freezing” of fetal movements 
(13). Typically, the fetal CNS assessment protocol includes T2 
weighted images following three planes of the fetal head, 
axial and coronal T1 weighted images, axial diff usion images 
(DWI), and/or diff usion tensor images (DTI); and additional 
sequences are performed as needed (9). The aim of this study 
was to determine the importance of prenatal MRI in making 
an accurate diagnosis and assessment of fetal CNS anomalies 
after neurosonographic suspicion and in detecting additional 
anomalies missed on ultrasound, which infl uences clinical 
decision-making and anomaly outcomes.
MATERIAL AND METHODS
Numerous articles were used for this research, designed as a 
systematic review of the primary scientifi c research literature. 
There were 17 scientifi c research papers published in relevant 
scientifi c research online databases such as PubMed, Medline, 
Google Scholar, and the same were published in English. 
Based on them, an analysis was conducted, and the basic 
characteristics of the study were selected (country, author, 
year of publication, title, type, study objectives, research 
method, results, and study conclusion). The studies used in this 
paper were published from 2015 to 2021. Based on them, we 
compared the results of the two modalities (ultrasound and 
magnetic resonance). We tried to determine the advantage 
of magnetic resonance imaging in the accurate assessment 
of CNS anomalies and the detection of associated anomalies 
and their impact on decisions about further pregnancy. The 
criterion for inclusion in the study included those studies that 
included pregnant women who were diagnosed or suspected 
of certain CNS abnormalities on prenatal ultrasound 
diagnosis of the fetus and who were then subjected to 
magnetic resonance imaging. At the same time, the exclusion 
criterion included the omission of any inclusion criterion, 
studies published in the period before 2015, then studies 
involving other abnormalities outside the CNS, and cases 
with contraindications for performing magnetic resonance 
imaging, such as claustrophobia, implanted pacemakers, 
prostheses, etc. The Preferred Reporting Items for Systematic 
Reviews and Meta-Analyses (PRISMA) fl ow diagram was used 
to document and report on all decisions made during the 
study selection process for this review paper, including the 
initial number of identifi ed studies, the number of excluded 
and included studies, and the reasons for their exclusion from 
the research (Diagram 1).
The search keywords were: fetal magnetic resonance imaging, 
fetal neurosonography, central nervous system anomalies, 
prenatal diagnosis
Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2) 7
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
Total number of potential scientifi c research papers identifi ed by database search  (n=291)
Number of papers identifi ed after duplicate removal  (n=261)
Excluded papers (n = 145)
Published before 2015 (n = 54)
Other anatomical area outside CNS 
included (n = 18)
Not in English (n = 13)
Review papers / case reports, 
MERIDIAN studies / comments (n = 53)
Pediatric population (n = 4)
Not available for review (n = 3)
Full text papers excluded (n=99):
 
Abstract only / without full text (n = 25)
No comparison of ultrasound and MRI / 
no data on ultrasound and / or MRI (n = 28)
No data on CNS anomalies and / or 
additional CNS anomalies / present 
anomalies outside the CNS (n = 21)
Not relevant (n = 25)
Papers reviewed by title and abstract
(n = 261)
Full text papers considered suitable 
for research (n=116)
Studies included in the systematic review
(n=17)
Id
en
tifi
 c
at
io
n
PRISMA model
Sc
re
en
in
g
In
cl
ud
ed
Diagram 1. PRISMA model
RESULTS 
The quality assessment of the included cohort design studies 
(Table 1) was made according to the quality assessment tools 
developed by the National Heart, Lung and Blood Institute 
(NHLBI) in 2013 (14).
Studies in which all or nearly all criteria are met and the 
weaknesses of the study cannot change, the study's fi ndings 
are qualifi ed as high-quality studies. Furthermore, medium-
quality studies are considered to be those studies in which some 
of the criteria from the checklist are not met or if the criteria 
are not satisfactorily described. However, it is assumed that 
there is little chance that the weaknesses could have changed 
the study's fi ndings. In addition, there are inadequate/low-
quality studies that include those studies that meet several or 
no criteria from the checklist and in such studies, weaknesses 
may mean that the conclusion of the study is wrong (14) 
8 Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2)
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
Table 1. Quality assessment of included studies with a cohort design
Main author, year, country, title 1 2 3 4 5 6 7 8 9 10 11 12 Total assessment quality
The ENSO Working Group, 2020, Italy, Role of prenatal 
magnetic resonance imaging in fetuses with isolated mild or 
moderate ventriculomegaly in the era of neurosonography: an 
international multicenter study
Y Y Y Y Y Y N Y Y Y N Y Medium quality
Tanacan A. et al., 2020, Turkey, Prenatal diagnosis of central 
nervous system abnormalities: Neurosonography versus fetal 
magnetic resonance imaging
Y Y Y Y Y Y U Y Y Y Y Y High quality
Sefi dbakht S. et al., 2016, Iran, Fetal Central Nervous System 
Anomalies Detected by Magnetic Resonance Imaging: A Two-
Year Experience
Y Y Y Y N Y U Y Y Y Y Y Medium quality
Mazor MM. et al., 2018, Israel, Added Value of Fetal MRI in 
the Evaluation of Fetal Anomalies of the Corpus Callosum: A 
Retrospective Analysis of 78 Cases
Y Y Y Y Y Y N Y Y Y Y Y High quality
Raafat RME. et al., 2020, Egypt, The prevalence and the adding 
value of fetal MRI imaging in midline cerebral anomalies
Y Y Y Y Y Y Y Y Y Y Y Y High quality
Turkyilmaz G. et al., 2019, Turkey, Utilization of neurosonography 
for evaluation of the corpus callosum malformations in the era of 
fetal magnetic resonance imaging
Y Y Y Y Y Y U Y Y Y Y Y High quality
Irwin K. et al., 2016, Australia, Utility of fetal MRI for workup 
of fetal central nervous system anomalies in an Australian 
maternal-fetal medicine cohort
Y Y Y Y U Y U Y Y Y Y Y High quality
Linh LT. et al., 2021, Vietnam, Detecting Fetal Central Nervous 
System Anomalies Using Magnetic Resonance Imaging and 
Ultrasound
Y Y Y U Y N N Y Y Y Y Y Medium quality
Raafat M. et al., 2021, Egypt, Fetal brain MRI: how it added to 
ultrasound diagnosis of fetal CNS anomalies-1 year experience
Y Y Y Y Y Y U Y Y Y Y Y High quality
Jarre A. et al., 2017, Spain, Value of brain MRI when sonography 
raises suspicion of agenesis of the corpus callosum in fetuses 
Y Y Y Y Y Y N Y Y Y Y Y High quality
Kandula T. et al., 2015, Australia, Isolated ventriculomegaly on 
prenatal ultrasound: what does fetal MRI add?
Y Y Y Y Y Y N Y Y Y Y Y High quality
Mahmod M. et al., 2021, Egypt, The impact of adding fetal MRI 
to sonographically diagnosed intrauterine ventriculomegaly: a 
prospective cohort study
Y Y Y U Y U U Y Y Y Y Y Medium quality
Yilmaz E. et al., 2018, Turkey, Additional Findings from Fetal 
Magnetic Resonance Imaging for Prenatal Sonographic 
Diagnosis of Central Nervous System Abnormalities
Y Y Y Y Y Y U Y Y Y Y Y High quality
Ziaulhaq P. et al. 2020, India, The comparative study of antenatal 
magnetic resonance imaging and ultrasound in the evaluation of 
fetal central nervous system abnormalities
Y Y Y Y N U N Y Y Y Y Y Medium quality
Velipaşaoğlu M. et al. 2018, Turkey, Assessment of the Additional 
Value of Fetal Magnetic Resonance Imaging to Prenatal 
Ultrasound in a Single Institution
Y Y Y Y N U N Y Y Y Y Y Medium quality
Katz JA. et al. 2018, USA, Utility of prenatal MRI in the evaluation 
and management of fetal ventriculomegaly
Y Y Y Y Y U U Y Y Y Y Y High quality
Frick N. et al. 2015, Austria, The Reliability of Fetal MRI in the 
Assessment of Brain Malformations
Y Y Y Y Y U U Y Y Y Y Y High quality
Checklist for cohorts studies (1)  Is the purpose of the study formulated? (2) Were subjects recruited for the cohort satisfactorily? (3) Was the 
exposure accurately measured? (4) Was the outcome accurately measured? (5) Have the authors identifi ed and/or taken into account all-
important/known possible confounders in the design and analysis of the study? (6) Were any of the people in the cohort followed up? (7) Were 
the people followed up long enough? (8) What is the result of this study? (9) Do you trust the results? (10) Can the results be transferred to 
practice? (11) Do the results of this study fi t with the results of other available studies? (12) What are the implications of this study for practice? 
(Answers Yes: Y; No: N; Unclear: U)
Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2) 9
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
From the above assessment of the quality of studies with 
cohort design, it can be concluded that most of the studies 
used in this systematic review are in the category of high-
quality studies (11 in total), with a smaller number of medium-
quality studies (6 in total).
Table 2 determines the importance of prenatal magnetic 
resonance imaging in making an accurate diagnosis and 
assessment of CNS anomalies after neurosonographically 
determined suspicions. Signifi cance was observed through 
several cases in which prenatal magnetic resonance imaging 
confi rmed the diagnosis of previously established suspicion 
on ultrasound. Even more signifi cant is the number of cases 
in which MRI changed the ultrasound diagnosis and thus 
established a fi nal, accurate diagnosis. It also ruled out certain 
cases of CNS anomalies and declared them a normal fi nding 
without the presence of anomalies. Also, the total percentage 
(%) for each group of the cases mentioned above is shown.
Table 2. Signifi cance of prenatal magnetic resonance imaging in making an accurate diagnosis and assessment of central nervous system 
anomalies after neurosonographically determined suspicion
Main author/
year of publication
MRI confi rmed 
ultrasound diagnosis 
(n/%)
MRI changed 
ultrasound diagnosis 
or added information 
(n/%)
MRI ruled out 
ultrasound diagnosis 
(normal fi ndings) 
(n/%)
UZ provided additional 
information for MRI 
(n/%)
Tanacan A.et al./2020. 59/110 (53,6%) 13/110 (11,8%) 38/110 (34,6%) 0
Mazor MM. et al./2018. 50/78 (64,1%) 9/78 (11,5%) 19/78 (24,4%) 0
Raafat RME. et al./2020. 21/37 (56,8%) 16/37 (43,2%) ND 3/37 (8,1%)
Turkyilmaz G. et al./2019. 33/36 (91,7%) 3/36 (8,3%) ND 0
Irwin K. et al./2016. 26/57 (45,6%) 31/57 (54,4%) 6/57 (10,5%) 0
Raafat M. et al./2021. 23/40 (57,5%) 6/40 (15%) NP 0
Jarre A. et al./2017. 38/78 (48,7%) 12/78 (15,4%) 28/78 (35,9%) 0
Mahmod M. et al./2021. 45/60 (75%) 1/60 (1,6%) ND 0
Ziaulhaq P. et al./2020. 9/23 (39,1%) 11/23 (47,8%)
2/23 (8,7%)
ND 1/23 (4,4%)
Frick N. et al./2015. 40/56 (71%) 12/56 (21,4%) 4/56 (7,1%) 0
Total percentage (%) 59,8% 20,2% 16,5% 0,8%
(Notes and abbreviations (since several cases from these studies were used in Table 3, the total percentage in this table is below 100%; ND- no data)
Sequence protocols on which the success of MRI detection 
itself depends and the importance of magnetic resonance 
imaging in making an accurate and precise diagnosis of CNS 
anomalies were also analyzed. Table 3 lists the primary data 
(magnetic fi eld strength, type of MRI device, sequences used, 
and sequence parameters) relevant to each study used in this 
review and related to magnetic resonance imaging of the fetal 
CNS. 
10 Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2)
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
Table 3. Technical parameters based on which magnetic resonance imaging was performed
Main author/year of 
publication
Magnetic fi eld strength/ 
type of MRI device Sequence protocol
The ENSO Group/2020. ND ND
Tanacan A.et al./2020. 1,5 T Siemens
T2W HASTE (TR/TE 2290/185ms, thickness 3mm);
T1 FLASH (TR/TE 140/2,4; FA=70º); DWI (TR/TE 4800/116ms; 
bmax 600s/mm2
Sefi dbakht S.et al./2016. 1,5 T Siemens Avanto T2W HASTE and TRUFI SP (thickness 4-6mm); T1 FLASH
Mazor MM. et al./2018. 1,5 T GE Optima
T2W SSFSE (TR/TE 1298/90ms; matrix 320x224; FOV 24-30cm; thickness/
gap 3-4/0mm); spoiled T1 GRE(TR/TE 160/2,3ms; FOV 40cm; thickness/
gap 4/0,5mm); DWI (b= 0 and 1000 or 700s/mm2)
Raafat RME. et al./2020. 1,5 T Philips Achieva XR T2W SSFSE; SSTSE; spoiled T1 GRE
Turkyilmaz G. et al./2019. 1,5 T GE- Explorer T2W SSFSE (thickness 2-3mm); T1 WI
Irwin K. et al./2016. 1,5 T Siemens Avanto T1, T2 (HASTE, FLASH), DWI (thickness 3-5mm)
Linh LT. et al./2021. 1,5 T GE Signa HD T2W SSFSE in 3 planes; axial T1W and DWI 
Raafat M. et al./2021. 1,5 T Philips
T2W B-FFE (TR/TE 3,5/1,7ms; matrix 256x256; FOV 300-400mm; thickness/
gap 5/0mm; FA=80º); T2W SSFSE (TR/TE 1500/120ms; matrix 169x256; 
FOV 200-300mm; thickness/gap 3-4/0,5mm; FA=90º); T1W (TR/TE 
120/4ms; matrix 166x256; FOV 300mm; thickness/gap 5/0,5mm; FA=70º)
Jarre A. et al./2017. 1,5 T Siemens Avanto1,5 T GE Signa Excite
T2W FSE (HASTE/SSFSE) (thickness/gap 3/0,3mm); 
True Fisp/FIESTA (thickness/gap 4/0,4mm; FOV 260-320mm); 
EPI DWI (b=600s/mm2)
Kandula T. et al./2015. 1,5 T Siemens Avanto T2W HASTE
Mahmod M. et al./2021. 1,5 T Philips ND
Yilmaz E. et al./2018. 1,5 T Siemens
T2W HASTE (TR/TE 1200/91ms; matrix 192x256; thickness 3mm, FOV 
207x100; FA 150º); axial T1 FLASH(TR/TE 199/4ms; matrix 134x256; 
thickness 4mm; FOV 300x75; FA 70º); sag and cor T1 FLASH in suspected 
bleeding and parenchymal lesions
Ziaulhaq P. et al./2020. 3T Siemens Skyra T2W SSFSE; DWI (b=0-600s/mm2)
Velipaşaoğlu M. et al./2018. 3T GE SSFSE (CUBE) sequence (ND)
Katz JA. et al./2018. 1,5T and 3T GE T2W SSFSE sequence in 3 planes (ND)
Frick N. Et al/2015.
1,0T Siemens
1,5T Ingenia Philips
3T Achiva Philips
T2W SSFSE (TR/TE 2100/90ms; thickness 5mm; FOV 330x300mm; matrix 
138x256; acquisition time 40s); T1W axial; TRUFI SP-sag; DWI; FLASH; 
FLAIR (rarely used sequences)
Abbreviations: T (Tesla); DWI (diff usion weighted imaging); W (weighted); HASTE (Half-Fourier Acquired Single-shot Turbo spin Echo); FLASH (fast low 
angle shot); SSFSE (single shot fast spin-echo); TR/TE (time to repeat/time to echo); TRUFI SP (True FISP); FOV (Field of view); FA ( fl ip angle); GE (General 
Electric); GRE (gradient echo); SSTSE (single shot turbo spin-echo); B-FFE (Balanced Fast Field Echo); FIESTA (Fast Imaging Employing Steady-state 
Acquisition); EPI (Echo-planar imaging); WI (weighted imaging); sag (sagital); cor (coronal); FLAIR (fl uid attenuated inversion recovery ); ND (no data)
Then, if additional anomalies detected only by magnetic 
resonance are considered, Table 4 was created for this purpose 
in which the incidence of fetal CNS anomalies missed on 
ultrasound imaging and diagnosed on magnetic resonance 
imaging was analyzed. Relevant data from 12 studies were 
used for this analysis, which off ered the exact number of 
cases in which MRI revealed additional anomalies missed on 
prenatal ultrasound. For easier analysis, in addition to the 
number of cases of additional anomalies, the table also lists 
the initial ultrasound suspicions or diagnoses and, most often, 
additional anomalies detected within each study by magnetic 
resonance 
Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2) 11
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
Table 4. Anomalies of the central nervous system missed on ultrasound and detected by prenatal magnetic resonance imaging
Main author/year of 
publication
Initial ultrasound suspicion/
diagnosis
Additional anomalies were 
identifi ed on MRI and missed 
on ultrasound (n / N /%)
Most common additional anomalies 
(n)
The ENSO Group/2020. Isolated mild or moderate VM 30/556; 5,4% ICH (8); polymicrogyria (6); lissencephaly (4); hypoplasia of CC (2)
Sefi dbakht S.et al./2016.
Suspicion of CNS anomalies / 
the most common indication of 
isolated VM
18/107; 16,82% DW variants (3); Chiari II malformation (3); PACC, CACC, aqueductal stenosis (2)
Mazor MM. et al./2018. Suspicion of corpus callosum anomalies 22/78; 28,2%
Calpocephaly (13); intrahemispheric 
cysts (4); ventricular asymmetry and 
gyration disorder (2)
Turkyilmaz G. et al./2019. Suspicion of corpus callosum anomalies 3/36; 8,1% PFA (1); cortical malformations (2)
Linh LT et al./2021. Suspicion of CNS anomalies 8/66; 12,1% Intracranial hemorrhage (6); vascular malformations (2)
Raafat M. et al./2021. Suspicion of CNS anomalies 11/40; 27,5% Meningocele (4); polymicrogyria (2); PACC (2); vermian hypoplasia (2)
Jarre A. et al./2017. Suspected agenesis of the corpus callosum 28/45; 62,2%
VM (22); cortical malformations (15); 
PFA (7); midline malformations (3)
Kandula T. et al./2015. Bilateral or unilateral VM 10/59; 17%
ICH; lesions of the corpus callosum; 
periventricular anomalies; CSP 
anomalies (1)
Mahmod M. et al./2021. Isolated ventriculomegaly 14/60; 23% CC and CSP lesions (29%); PFA (28%); cortical malformations (21%)
Yilmaz E. et al./2018.
Suspicion of CNS anomalies / 
the most common indication 
of VM
22/54; 40% Subependymal nodules (2); cortical tuber (2)
Velipaşaoğlu M. et al./2018. The most common indication is isolated ventriculomegaly 12/50; 24% Posterior fossa defects (36,4%)
Katz JA. et al./2018. All cases of ventriculomegaly 58/74; 78% Cortical anomalies; PFA; midline; additional vascular anomalies
Total percentage (%) 19,3%
Abbreviations: UZ (ultrasound), MRI (magnetic resonance imaging), CNS (central nervous system), VM (ventriculomegaly), ICH 
(intracranial hemorrhage), CC (corpus callosum), CSP (cavum septum pellucid), PFA (posterior fossa anomalies), DW (Dandy-Walker), 
CACC/PACC (complete/partial agenesis of corpus callosum)
Finally, Table 5 depicts an analysis of the impact of prenatal 
magnetic resonance imaging on clinical decision-making and 
outcomes of central nervous system anomalies. Data from 7 
studies were used for this analysis, which provided information 
on the number of cases of termination and continuation of 
pregnancy and data on neonatal death and the number of 
stillbirths. In several studies, some cases were lost for follow-
up. In contrast, in others, postnatal MRI was not available, so 
only certain studies could compare their data with postnatal 
MRI data and provide information on the outcome of the 
anomalies. 
12 Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2)
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
Table 5. The impact of prenatal magnetic resonance imaging on clinical decision making and outcomes of central nervous system anomalies
Clinical 
outcomes ACCEPTABLE STUDIES
Ta
na
ca
n 
A
. e
t a
l./
20
20
.
Tu
rk
yi
lm
az
 G
. e
t a
l./
20
19
.
Irw
in
 K
. e
t a
l./
20
16
.
Ra
af
at
 M
. e
t a
l./
20
21
.
Ja
rr
e 
A
. e
t a
l./
20
17
.
Ka
nd
ul
a 
T.
 e
t a
l./
20
15
.
Zi
au
lh
aq
 P
. e
t a
l. 
/2
02
0.
Termination of 
pregnancy
14/72
12,7%
18/36
50%
11/57
19%
7/40
17,5%
21/30
47,7%
4/59
6,8%
7/23
30,4%
Continuation 
of pregnancy
ND 17/36
47,2%
46/57
81%
33/40
82,5%
9/30
20,5%
55/59
93,2%
16/23
69,6%
Neonatal death 3/72
2,7%
ND 1/46
2,2%
4/40
10%
ND 3/55
5,5%
ND
Stillborn 2/72
1,8%
1/36
2,8%
2/46
4,3%
2/40
5%
1/9
11%
ND ND
Characteristics 
of the study
Termination 
of pregnancy 
in 50% of 
cases of ACC
Normal 
neurodevelopment 
in 8 cases and 
developmental 
delay expected in 
the remaining 8 
cases
Developmental 
delay in 14/43 
cases; childbirth 
(33%)
27/40 (67.5%) 
studies 
resulted in 
childbirth
In 8 live 
births, 
postnatal MRI 
confi rmed 
the prenatal 
diagnosis of 
ACC
Greater MRI 
specifi city 
results in 
additional 
important 
information 
that can help 
advise parents 
on the clinical 
outcome, the 
likelihood of 
recurrence
The study did 
not provide 
data on 
postnatal 
imaging and 
follow-up of 
patients
Abbreviations: ND (No data), ACC (agenesis of corpus callosum), MRI (magnetic resonance imaging)
DISCUSSION
In the 10 studies applied in Table 2 and 575 cases, MRI confi rmed 
the ultrasound diagnosis in 59.8% of cases. In contrast, in 20.2% 
of cases, it changed the diagnosis established on ultrasound, 
or in 16.5% of cases in which ultrasound established the 
diagnosis, MRI confi rmed the normal fi nding. Our results are 
consistent with the results of the study conducted by Jarvis D. 
and colleagues (32), who in their meta-analysis confi rmed the 
agreement of ultrasound and magnetic resonance imaging in 
55% of cases; discrepancy in 23% of cases and 25% of cases 
in which ultrasound established the diagnosis, MRI confi rmed 
the normal fi nding. Also, Van Doorn M. and colleagues (33) 
noted in 65% of cases the agreement of these two modalities; 
in 26% of cases, MRI provided additional or diff erent pathology, 
and 12% rejected ultrasound diagnosis. In our study, only 2/10 
of the studies, conducted by Raafat RME et al., and Ziaulhaq 
P. et al. (19,28), provided data in which ultrasound provided 
additional information to magnetic resonance imaging. These 
rates were 8.1% (19) and 4.3% (28) and mainly related to facial 
abnormalities and restriction of intrauterine growth, which 
can be explained as technological advances in ultrasound and 
the skills of the radiologist performing the examination. While 
Rossi AC. and colleagues (34) in their study recorded only 2% 
of cases in which ultrasound was more accurate than MRI.
Consequently, based on the data from Table 3, it is possible to 
conclude that a 1.5T MRI device was most often used to record 
the fetal CNS, while 3T devices were used in our work in only 
4/17 studies. As the best protocol based on the data off ered 
by our studies, we can accept the one that contains the fi rst 
SSFSE (HASTE) T2 weighted sequences in the sagittal, coronal 
and axial planes, as they are key to reducing fetal movement 
(thus reducing artifacts). In addition, most studies as additional 
sequences, and depending on the indications themselves, 
most often used T1 weighted sequences (FLASH, GRE) in the 
axial plane, which proved to be the best for detecting bleeding, 
fat and calcifi cations or myelin; and DWI sequences in the axial 
plane which, as an advanced technique, enable the distinction 
between developmental and destructive pathologies.
Based on our results in Table 4, anomalies missed on 
ultrasound and detected on MRI occurred in 236/1225 cases, 
totaling 19.3% of additional anomalies. The most common 
additional anomalies were: intracranial hemorrhage; cortical 
anomalies, medial anomalies; and PFA. This rate of additional 
Medical Imaging and Radiotherapy Journal (MIRTJ) 38 (2) 13
Salkić E. et al./ Magnetic resonance imaging in the assessment of fetal central nervous system anomalies
anomalies in the study conducted by Reda AM. and colleagues 
(35) was slightly higher, 22.5%. Also, studies conducted by 
Jarvis D. and colleagues and Rossi AC. and colleagues (32,34) 
were reported additional information provided by MRI in 15% 
and 22.1% of cases, respectively. Most authors claim that the 
risk of fi nding additional CNS abnormalities in fetuses with 
isolated ventriculomegaly is high and that it increases with the 
increasing severity of ventriculomegaly (36,37). This confi rms 
that in 7/12 of the studies used in Table 4, with a signifi cant 
incidence of associated anomalies, the initial suspicion or 
diagnosis on ultrasound was precisely ventriculomegaly. 
This is also supported by the study results conducted by Di 
Mascio D. and colleagues (37), who reported 3.5% and 22.6% 
of associated anomalies detected on MRI and missed on 
ultrasound in fetuses with isolated mild, that is, moderate 
ventriculomegaly.
The detection of these additional anomalies by MRI indicates its 
importance in making clinical decisions and enabling parents 
to make a more conscious decision about their pregnancy. All 
of our 7 studies from Table 5 were provided information on the 
number of terminations of pregnancy that occurred in 82/317 
cases, accounting for 25.9%. One study that was used did not 
provide data on the continuation of pregnancy, so based on 
the remaining studies, the pregnancy was continued in a total 
of 176 cases. Data on neonatal deaths were not available in the 
3 studies used, and 11 cases of neonatal death were recorded 
in other studies. The number of stillbirths or deaths after birth 
was reported in 8 cases, as 2 studies did not provide data. Di 
Mascio D. and colleagues (37) sought to determine whether 
the detection of associated anomalies by MRI led to a change 
in prenatal management of pregnancy due to a higher risk of 
abnormal neurodevelopment outcomes. They proved that 
4.6% of fetuses who had an isolated VM on ultrasound and 
then an additional anomaly on MRI had a signifi cant change 
in perinatal treatment (mostly termination of pregnancy at 
the parents' request). Furthermore, in their study Mazor MM. 
and colleagues (18) state that MRI contributed to a change in 
management of pregnancy for 28 fetuses (35.9%), of which 25 
fetuses (32.1%) are in favor of preserving pregnancy. 
CONCLUSION 
Ultrasound is the standard way of recording anomalies in 
the second and third trimesters. Still, MRI using T2W SSFSE 
sequences in 3 planes, T1W and DWI in the axial plane, is a 
complementary modality to prenatal ultrasound in making 
an accurate diagnosis and assessment of CNS anomalies 
off ering a signifi cant percentage of change cases or complete 
exclusion of previously established ultrasound suspicion. 
The incidence of additional detected CNS anomalies on 
magnetic resonance imaging, which were previously missed 
on ultrasound, indicates the benefi t of performing the same in 
cases when ultrasound examination is unclear or incomplete 
and when these additional anomalies are far beyond the 
range and ability of ultrasound to diagnose them. Finally, 
prenatal MRI with the diagnosis of associated / additional 
CNS abnormalities may infl uence clinical decision-making 
regarding the continuation or termination of pregnancy and, 
fi nally, the preparation of family and clinicians for postnatal 
care depending on the presence or absence of abnormal 
neurodevelopmental outcomes. 
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