Donald School Journal of Ultrasound in Obstetrics and Gynecology

Register      Login

VOLUME 16 , ISSUE 1 ( January-March, 2022 ) > List of Articles


Evolution of Assessment of Fetal Brain Function

Panos Antsaklis, Sanja Malinac Malojčić, Maria Papamichail, Marianna Theodora, George Daskalakis

Keywords : Brain development, Evolution, Fetal brain function, Ultrasound

Citation Information : Antsaklis P, Malojčić SM, Papamichail M, Theodora M, Daskalakis G. Evolution of Assessment of Fetal Brain Function. Donald School J Ultrasound Obstet Gynecol 2022; 16 (1):66-78.

DOI: 10.5005/jp-journals-10009-1919

License: CC BY-NC 4.0

Published Online: 22-04-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Assessment of the structure and function of the fetal nervous system has been one of the greatest physicians’ challenges for decades. Advances in ultrasound techniques and especially the evolution of three-dimensional and four-dimensional (4D) ultrasound have made reality the evaluation of fetal anatomy and activity in real-time and in extreme detail. The process of human brain development and maturation is reflected by a specific behavioral pattern that undergoes changes and progresses reciprocal to each week of growth, mirroring the neurological integrity of the fetal brain. Therefore, evaluation of patterns of fetal behavior during the different stages of growth could make possible the distinction between normal and abnormal fetal neurodevelopment and more importantly facilitate early diagnosis of a wide variety of functional abnormalities of the fetal nervous system. To this direction, a pioneer test introduced by Kurjak; KANET (Kurjak Antenatal Neurodevelopmental Test) uses 4D ultrasound to assess fetal behavior and movements in a simulative way of postnatal neonatal neurological evaluation. Evidence from multicenter studies shows that the test indicates the potential to identify fetuses at risk for neurodevelopment impairment and it is applicable in everyday clinical practice.

PDF Share
  1. Antsaklis P, Kurjak A, Izetbegovic S. Functional test for fetal brain: the role of kanet test. Donald School J Ultrasound Obstet Gynecol 2013;7(4):385–399. DOI: 10.5005/jp-journals-10009-1309
  2. Kurjak A, Carrera JM, Stanojevic M, et al. The role of 4D sonography in the neurological assessment of early human development. Ultrasound Rev Obstet Gynecol 2004;4(3): 148–159. DOI: 10.3109/14722240400017075
  3. Salihagic-Kadic A, Kurjak A, Medic M, et al. New data about embryonic and fetal neurodevelopment and behaviour obtained by 3D and 4D sonography. J Perinat Med 2005;33(6): 478–490. DOI: 10.1515/JPM.2005.086
  4. Stanojevic M, Zaputovic S, Bosnjak AP. Continuity between fetal and neonatal neurobehavior. Semin Fetal Neonatal Med 2012;17(6):324–329. DOI: 10.1016/j.siny.2012.06.006
  5. Haak P, Lenski M, Hidecker MJ, et al. Cerebral palsy and aging. Dev Med Child Neurol 2009;51(Suppl 4):16–23. DOI: 10.1111/j.1469-8749.2009.03428.x
  6. Kurjak A, Antsaklis P, Stanojevic M, et al. Fetal behavior assessed by four-dimensional sonography. Donald School J Ultrasound Obstet Gynecol 2017;11(2):146–168. DOI: 10.5005/jp-journals-10009-1516
  7. Hadders-Algra M. General movements: a window for early identification of children at high risk for developmental disorders. J Pediatr 2004;145(Suppl 2):S12–S18. DOI: 10.1016/j.jpeds.2004.05.017
  8. Pomeroy SL, Voipe JJ. Development of the nervous system. In: Polin RA, Fox, WW, editors. Fetal and neonatal physiology. Philadelphia-London-Toronto-Montreal-Sydney-Tokyo: WB Saunders Company 1992;1491–1509.
  9. Kostovic I, Judas M, Petanjek Z, et al. Ontogenesis of goal-directed behavior: anatomo-functional considerations. Int J Psychophysiol 1995;19(2):85–102. DOI: 10.1016/0167- 8760(94)00081-o
  10. Vasung L, Lepage C, Radoš M, et al. Quantitative and qualitative analysis of transient fetal compartments during prenatal human brain development. Front Neuroanat 2016;10:11. DOI: 10.3389/fnana.2016.00011
  11. Stanojevic M, Antsaklis P, Salihagic-Kadic A, et al. Is Kurjak antenatal neurodevelopmental test ready for routine clinical application? Bucharest consensus statement. Donald Sch J Ultrasound Obstet Gynecol 2015;9(3):260–265. DOI: 10.5005/jp-journals-10009-1412
  12. Kostovic I. Prenatal development of nucleus basalis complex and related fibre system in man: a histochemical study. Neurosci 1986;17(4):1047–1077. DOI: 10.1016/0306- 4522(86)90077-1
  13. Schaher S. Determination and differentiation in the development of the nervous system. In: Kandel ER, Schwartz JH, editors. Principles of Neural Science. 2nd ed. New York: Elsevier Science Publishing 1985:730–732.
  14. Andonotopo W, Medic M, Salihagic-Kadic A, et al. The assessment of fetal behavior in early pregnancy: comparison between 2D and 4D sonographic scanning. J Perinat Med 2005;33(5):406–414. DOI: 10.1515/JPM.2005.073
  15. Kurjak A, Stanojevic M, Andonotopo W, et al. Behavioral pattern continuity from prenatal to postnatal life–a study by four-dimensional (4D) ultrasonography. J Perinat Med 2004;32(4):346–353. DOI: 10.1515/JPM.2004.065
  16. D‘Elia A, Pighetti M, Moccia G, et al. Spontaneous motor activity in the normal fetus. Early Human Dev 2001;65(2):139–144. DOI: 10.1016/s0378-3782(01)00224-9
  17. Kurjak A, Azumendi G, Vecek N, et al. Fetal hand movements and facial expression in normal pregnancy studied by four-dimensional sonography. J Perinat Med 2003;31(6):496–508. DOI: 10.1515/JPM.2003.076
  18. Kurjak A, Vecek N, Kupesic S, Azumendi G, Solak M. Four dimensional ultrasound: how much does it improve perinatal practice? In: Carrera JM, Chervenak FA, Kurjak A, editors. Controversies in perinatal medicine, studies on the fetus as a patient. New York: A CRC press company, Parthenon Publishing; 2003. p 222.
  19. Nijhuis JG. Fetal behavior. Neurobiol Aging 2003;24(Suppl 1): S41–S46. DOI: 10.1016/s0197-4580(03)00054-x
  20. Arabin B, Bos R, Rijlaarsdam R, et al. The onset of inter-human contacts: longitudinal ultrasound observations in early twin pregnancies. Ultrasound Obstet Gynecol 1996;8:166–173. DOI: 10.1046/j.1469-0705.1996.08030166.x
  21. Kurjak A, Antsaklis P, Stanojevic M. Fetal neurology: past, present and future. Donald School J Ultrasound Obstet Gynecol 2015;9:6–29. DOI: 10.5005/jp–journals–10009–1385
  22. Prechtl FHR. Ultrasound studies of human fetal behavior. Early Hum Dev 1985;12(2):91–98. DOI: 10.1016/0378-3782(85)90173-2
  23. lanniruberto A, Tajani E. Ultrasonographic study of fetal movements. Semin Perinatal 1981;5(2):175–181. WOS: A1981LJ40000008
  24. Joseph R. Fetal brain and cognitive development. Dev Rev 2000;20(1):81–98. DOI: 10.1006/drev.1999.0486
  25. Goto S, Kato TK. Early movements are useful for estimating the gestational weeks in the first trimester of pregnancy. In: Levski RA, Morley P, editors. Ultrasound ‚82. Oxford: Pergamon Press, 1983:577–582.
  26. Hata T, Kanenishi K, Sasaki M. Four-dimensional sonographic assessment of fetal movement in the late first trimester. Int J Gynaecol Obstet 2010;109(3):190–193. DOI: 10.1016/j.ijgo.2009.12.020
  27. Kurjak Asim, Ahmed Badreldeen, Abo-Yaquab Salwa, Younis Moayy, Saleh Huda, Shaddad Afaf, Vasilj Oliver, Bahar Awatif, Miskovic Berivoj, Khenyab, Najat. 2008/10/01; 29–44. An Attempt to Introduce Neurological Test for Fetus Based on 3D and 4D Sonography. 10.5005/jp–journals–10009–1076. Donald School Journal of Ultrasound in Obstetrics & Gynecology
  28. Kurjak A, Andonotopo W, Hafner T, et al. Normal standards for fetal neurobehavioural developments -longitudinal quantification by four-dimensional sonography. J Perinat Med 2006;34(1):56–65. DOI: 10.1515/JPM.2006.007
  29. Patrick J, Campbell K, Carmichael L, et al. Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol 1982; 142(4):363–371. DOI: 10.1016/s0002-9378(16)32375-4
  30. Kurjak A, Lausin I, Azumendi G. Assessment of fetal behavior by 3D and 4D sonography; in Hata T, Kurjak A, Kozuma S (Eds): Current Topics on Fetal 3D/4D Ultrasound Bentham Science Publishers 2009:234–265. (
  31. Hadders-Algra M. The neuronal group selection theory: a framework to explain variation in normal motor development. Dev Med Child Neurol 2000;42(8):566–572. DOI: 10.1017/s0012162200001067
  32. Vladareanu R, Lebit D, Constantinescu S. Ultrasound assessment of fetal neurobehavior in high-risk pregnancies. Donald School J Ultrasound Obstet Gynecol 2012;6(2):132–147. DOI: 10.5005/jp-journals-10009-1235
  33. Kurjak A, Barisic LS, Stanojevic M, et al. Are we ready to investigate cognitive function of fetal brain? the role of advanced four-dimensional sonography. Donald School J Ultrasound Obstet Gynecol 2016;10(2):116–124. DOI: 10.5005/jp-journals-10009-1453
  34. Stanojevic M, Kurjak A. Continuity from fetal to neonatal behavior: lessons learned and future challenges. Donald Sch J Ultrasound Obstet Gynecol 2011;5(2)107–118. DOI: 10.5005/jp-journals-10009-1185
  35. Stanojevic M, Talic A, Miskovic B, et al. An attempt to standardize Kurjak's antenatal neurodevelopmental test: osaka consensus statement. Donald Sch J Ultrasound Obstet Gynecol 2011;5(4):317–329. DOI: 10.5005/jp-journals-10009-1209
  36. Sekulić SR, Lukac DD, Naumović NM. The fetus cannot exercise like an astronaut: gravity loading is necessary for the physiological development during second half of pregnancy. Med Hypotheses 2005;64(2):221–228. DOI: 10.1016/j.mehy.2004.08.012
  37. Meigal AY. Synergistic action of gravity and temperature on the motor system within the lifespan: a “baby astronaut” hypothesis. Med Hypotheses 2013;80(3):275–283. DOI: 10.1016/j.mehy.2012.12.004
  38. Einspieler C, Prechtl HF. Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system. Ment Retard Dev Disabil Res Rev 2005;11(1):61–67. DOI: 10.1002/mrdd.20051
  39. Moster D, Wilcox AJ, Vollset SE, et al. Cerebral palsy among term and postterm births. JAMA 2010;304(9):976–982. DOI: 10.1001/jama.2010.1271
  40. de Vries JI, Visser GH, Prechtl HF. The emergence of fetal behaviour. I. qualitative aspects. Early Hum Dev 1982;7(4): 301–322. DOI: 10.1016/0378-3782(82)90033-0
  41. Nijhuis JG. Fetal behaviour: developmental and perinatal aspects. Oxford, Oxford University Press; 1992. Chapter 9. p. 489–498.
  42. Prechtl HF. State of the art of a new functional assessment of the young nervous system. an early predictor of cerebral palsy. Early Hum Dev 1997;50(1):1–11. DOI: 10.1016/s0378-3782(97)00088-1
  43. Kurjak A, Luetic AT. Fetal neurobehavior assessed by three-dimensional/four-dimensional sonography. Zdrav Vestn 2010;79(11):790–799. DOI: 10.5005/jp-journals-10009-1516
  44. Seme-Ciglenečki P. Predictive value of assessment of general movements for neurological development of high-risk preterm infants: comparative study. Croat Med J 2003;44(6):721–727.
  45. Kurjak A, Spalldi Barišić L, Stanojević M, et al. Multi-center results on the clinical use of kanet. J Perinat Med 2019;47(9):897–909. DOI: 10.1515/jpm-2019-0281 PMID: 31677378
  46. Kurjak A, Stanojevic M, Andonotopo W, et al. Fetal behavior assessed in all three trimesters of normal pregnancy by four- dimensional ultrasonography. Croat Med J 2005;46(5):772–780.
  47. Palmer FB. Strategies for the early diagnosis of cerebral palsy. J Pediatr 2004;145(Suppl 2):S8-S11. DOI: 10.1016/j.jpeds.2004.05.016
  48. Andonotopo W, Kurjak A. The assessment of fetal behavior of growth restricted fetuses by 4D sonography. J Perinat Med 2006;34(6):471–478. DOI: 10.1515/JPM.2006.092
  49. Kurjak A, Abo-Yaqoub S, Stanojevic M, et al. The potential of 4D sonography in the assessment of fetal neurobehavior–multicentric study in high-risk pregnancies. J Perinat Med 2010;38(1):77–82. DOI: 10.1515/jpm.2010.012
  50. Miskovic B, Vasilj O, Stanojevic M, et al. The comparison of fetal behavior in high risk and normal pregnancies assessed by four dimensional ultrasound. J Matern Fetal Neonatal Med 2010;23(12): 1461–1467. DOI: 10.3109/14767051003678200
  51. Talic A, Kurjak A, Ahmed B, et al. The potential of 4D sonography in the assessment of fetal behavior in high-risk pregnancies. J Matern Fetal Neonatal Med 2011;24(7):948–954. DOI: 10.3109/14767058.2010.534830
  52. Honemeyer U, Kurjak A. The use of KANET test to assess fetal CNS function. First 100 cases. 10th World Congress of Perinatal Med 2011;8–11.
  53. Talic A, Kurjak A, Stanojevic M, et al. The assessment of fetal brain function in fetuses with ventrikulomegaly: the role of the kanet test. J Matern Fetal Neonatal Med 2012;25(8):1267–1272. DOI: 10.3109/14767058.2011.634463
  54. Abo-Yaqoub S, Kurjak A, Mohammed AB, et al. The role of 4-D ultrasonography in prenatal assessment of fetal neurobehaviour and prediction of neurological outcome. J Matern Fetal Neonatal Med 2012;25(3):231–236. DOI: 10.3109/14767058.2011.568552
  55. Honemeyer U, Talic A, Therwat A, et al. The clinical value of kanet in studying fetal neurobehavior in normal and at-risk pregnancies. J Perinat Med 2013;41(2):187–197. DOI: 10.1515/jpm-2011-0251
  56. Kurjak A, Talic A, Honemeyer U, et al. Comparison between antenatal neurodevelopmental test and fetal doppler in the assessment of fetal well being. J Perinat Med 2013;41(1): 107–114. DOI: 10.1515/jpm-2012-0018
  57. Athanasiadis AP, Mikos T, Tambakoudis GP, et al. Neurodevelopmental fetal assessment using kanet scoring system in low and high risk pregnancies. J Matern Fetal Neonatal Med 2013;26(4):363–368. DOI: 10.3109/14767058.2012.695824
  58. Neto RM. kanet in Brazil: first experience. Donald School J Ultrasound Obstet Gynecol 2015;9(1):1–5. DOI: 10.5005/jp-journals-10009-1384
  59. Hanaoka U, Hata T, Kananishi K, et al. Does ethnicity have an effect on fetal behavior? a comparison of Asian and caucasian populations. J Perinat Med 2016;44(2):217–221. DOI: 10.1515/jpm-2015-0036
  60. Hata T, Kanenishi K, Mori N, et al. Prediction of postnatal developmental disabilities using the antenatal fetal neurodevelopmental test: kanet assessment. J Perinat Med 2018;47(1):77–81. DOI: 10.1515/jpm-2018-0169
  61. Tan KH, Smyth RMD, Wei X. Fetal vibroacoustic stimulation for facilitation of tests of fetal wellbeing. Cochrane Database Syst Rev 2013;7(12):CD002963. DOI: 10.1002/14651858.CD002963.pub2
  62. Antsaklis P, Porovic S, Daskalakis G, et al. 4D assessment of fetal brain function in diabetic patients. J Perinat Med 2017;45(6):711–715. DOI: 10.1515/jpm-2016-0394
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.