Donald School Journal of Ultrasound in Obstetrics and Gynecology

Register      Login

VOLUME 17 , ISSUE 2 ( April-June, 2023 ) > List of Articles


KANET Test in Clinical Practice: Lessons Learned and Future Challenges

Panos Antsaklis, Asim Kurjak

Keywords : Cerebral palsy, Early diagnosis, Fetal neurology, Fetal neurological profile, Fetal assessment, Kurjak's antenatal neurodevelopmental test

Citation Information : Antsaklis P, Kurjak A. KANET Test in Clinical Practice: Lessons Learned and Future Challenges. Donald School J Ultrasound Obstet Gynecol 2023; 17 (2):165-180.

DOI: 10.5005/jp-journals-10009-1970

License: CC BY-NC 4.0

Published Online: 05-07-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Assessing fetal neurobehavior during pregnancy has been challenging due to limited evaluation methods. Conditions such as cerebral palsy, often misattributed to labor incidents, actually originate during fetal development. This highlights the poor understanding and diagnosis of neurological problems. Recent advancements, such as Kurjak's antenatal neurodevelopmental test (KANET) test utilizing four-dimensional (4D) ultrasound technology, offer a way to study fetal neurobehavior in utero, define normal profiles, and identify abnormalities. Multicentric studies have demonstrated the utility of KANET, which has been standardized and successfully integrated into clinical practice for both high and low-risk cases, in understanding fetal neurology, particularly in uncertain cases like ventriculomegaly, providing comprehensive assessment and counseling for affected couples. KANET exhibits good sensitivity, specificity, predictive values, and acceptable variability among observers. With proper training and access to 4D ultrasound machines, ultrasound specialists can easily learn and apply KANET. This method has the potential to identify fetuses at risk for neurological impairment, enabling timely interventions, and improved outcomes through early diagnosis and appropriate follow-up.

  1. Yigiter AB, Kavak ZN. Normal standards of fetal behavior assessed by four-dimensional sonography. J Matern Fetal Neonatal Med 2006;19(11):707–721. DOI: 10.1080/14767050600924129
  2. Rees S, Harding R. Brain development during fetal life: influences of the intra-uterine environment. Neurosci Lett 2004;361(1-3):111–114. DOI: 10.1016/j.neulet.2004.02.002
  3. Joseph R. Fetal brain and cognitive development. Dev Rev 1999;20:81–98. DOI: 10.1006/drev.1999.0486
  4. 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
  5. Eidelman AI. The living fetus - dilemmas in treatment at the edge of viability. In: Blazer S & Zimmer EZ (eds): The embryo: scientific discovery and medical ethics. Karger, Basel, 2005:351–370.
  6. 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
  7. Haak P, Lenski M, Hidecker MJ et al. Cerebral palsy and aging. Dev Med Child Neurol 2009;51 Suppl 4(0 4):16–23. DOI: 10.1111/j.1469-8749.2009.03428.x
  8. 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
  9. Salihagic-Kadic A, Kurjak A, Medić M, et al. New data about embryonic and fetal neurodevelopment and behavior obtained by 3D and 4D sonography. J Perinat Med 2005;33(6):478–490. DOI: 10.1515/JPM.2005.086
  10. 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
  11. Almli CR, Ball RH, Wheeler ME. Human fetal and neonatal movement patterns: Gender differences and fetal-to-neonatal continuity. Dev Psychobiol 2001;38(4):252–273. DOI: 10.1002/dev.1019
  12. DiPietro JA, Bornstein MH, Costigan KA, et al. What does fetal movement predict about behavior during the first two years of life? Dev Psychobiol 2002;40(4):358–371. DOI: 10.1002/dev.10025
  13. DiPietro JA, Hodgson DM, Costigan KA, et al. Fetal antecedents of infant temperament. Child Dev 1996;67(5):2568–2583.
  14. DiPietro JA, Costigan KA, Pressman EK. Fetal state concordance predicts infant state regulation. Early Hum Dev 2002;68(1): 1–13. DOI: 10.1016/s0378-3782(02)00006-3
  15. Thoman EB, Denenberg VH, Sievel J, et al. State organization in neonates: developmental inconsistency indicates risk for developmental dysfunction. Neuropediatrics 1981;12(1): 45–54. DOI: 10.1055/s-2008-1059638
  16. St James-Roberts I, Menon-Johansson P. Predicting infant crying from fetal movement data: an exploratory study. Early Hum Dev 1999;54(1):55–62. DOI: 10.1016/s0378-3782(98)00084-x
  17. Einspieler C, Prechtl HF, Ferrari F, et al. The qualitative assessment of general movements in preterm, term and young infants–review of the methodology. Early Hum Dev 1997;50(1):47–60. DOI: 10.1016/s0378-3782(97)00092-3
  18. Prechtl HF. Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Hum Dev 1990;23(3):151–158. DOI: 10.1016/0378-3782(90)90011-7
  19. de Vries JI, Visser GH, Prechtl HF. The emergence of fetal behaviour. II. Quantitative aspects. Early Hum Dev 1985;12(2):99–120. DOI: 10.1016/0378-3782(85)90174-4
  20. de Vries JI, Visser GH, Prechtl HF. The emergence of fetal behaviour. III. Individual differences and consistencies. Early Hum Dev 1988;16(1):85–103. DOI: 10.1016/0378-3782(88)90089-8
  21. 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
  22. Nijhuis JG. Fetal Behaviour: Developmental and Perinatal Aspects. Oxford: Oxford University Press; 1992.
  23. 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
  24. Kurjak A, Luetic AT. Fetal neurobehavior assessed by three-dimensional/four dimentional sonography. Zdrav Vestn 2010; 79(11):790–799. DOI: 10.1080/14767050802212166
  25. Salihagic-Kadic A, Medic M, Kurjak A, et al. 4D sonography in the assessment of fetal functional neurodevelopment and behavioural paterns. Ultrasound Rev Obstet Gynecol 2005;5:1–15. DOI: 10.3109/14767058.2010.534830
  26. Kurjak A, Pooh R, Tikvica A, et al. Assesment of fetal neurobehavior by 3D/4D ultrasound. Fetal Neurol 2009:222–250. DOI: 10.5005/jp/books/10305_7
  27. Lebit DF, Vladareanu PD. The role of 4D ultrasound in the assessment of fetal behaviour. Maedica (Bucur) 2011;6(2):120–127.
  28. Merz E, Abramowicz JS. 3D/4D ultrasound in prenatal diagnosis: is it time for routine use? Clin Obstet Gynecol 2012;55(1):336–351. DOI: 10.1097/GRF.0b013e3182446ef7
  29. Kurjak A, Vecek N, Hafner T, et al. Prenatal diagnosis: what does four-dimensional ultrasound add? J Perinat Med 2002;30(1):57–62. DOI: 10.1515/JPM.2002.008
  30. Kurjak A, Vecek N, Kupesic S, et al., Four-dimensional ultrasound: how much does it improve perinatal practice? In: Carrera JM, Chervenak FA, Kurjak A, eds. Controversies in perinatal medicine, studies on the fetus as a patient. Parthenon Publishing: New York; 2003;222.
  31. Andonotopo W, Stanojevic M, Kurjak A, et al. Assessment of fetal behavior and general movements by four-dimensional sonography. Ultrasound Rev Obstet Gynecol 2004;4(2): 103–108. DOI: 10.1080/14722240400016895
  32. Kurjak A, Carrera J, Medic M, et al. The antenatal development of fetal behavioral patterns assessed by four-dimensional sonography. J Matern Fetal Neonatal Med 2005;17(6):401–416. DOI: 10.1080/14767050400029657
  33. Kurjak A, Miskovic B, Andonotopo W, et al. How useful is 3D and 4D ultrasound in perinatal medicine? J Perinat Med 2007;35(1):10–27. DOI: 10.1515/JPM.2007.002
  34. Kurjak A, Tikvica A, Stanojevic M, et al. The assessment of fetal neurobehavior by three-dimensional and four-dimensional ultrasound. J Matern Fetal Neonatal Med 2008;21(10):675–684. DOI: 10.1080/14767050802212166
  35. Morokuma S, Fukushima K, Yumoto Y, et al. Simplified ultrasound screening for fetal brain function based on behavioral pattern. Early Hum Dev 2007;83(3):177–181. DOI: 10.1016/j.earlhumdev.2006.05.012
  36. Kurjak A, Miskovic B, Stanojevic M, et al. New scoring system for fetal neurobehavior assessed by three- and four-dimensional sonography. J Perinat Med 2008;36(1):73–81. DOI: 10.1515/JPM.2008.007
  37. Gosselin J, Gahagan S, Amiel-Tison C. The Amiel-Tison Neurological Assessment at term: conceptual and methodological continuity in the course of follow-up. Ment Retard Dev Disabil Res Rev 2005;11(1):34–51. DOI: 10.1002/mrdd.20049
  38. Amiel-Tison C, Gosselin J, Kurjak A. Neurosonography in the second half of fetal life: a neonatologist's point of view. J Perinat Med 2006;34(6):437–446. DOI: 10.1515/JPM.2006.088
  39. Tomasovic S, Predojevic M. 4D Ultrasound - medical devices for recent advances on the etiology of cerebral palsy. Acta Inform Med 2011;19(4):228–234. DOI: 10.5455/aim.2011.19.228-234
  40. 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.
  41. Stanojevic M, Kurjak A, Salihagić-Kadić A, et al. Neurobehavioral continuity from fetus to neonate. J Perinat Med 2011;39(2):171–177. DOI: 10.1515/jpm.2011.004
  42. Kurjak A, Andonotopo W, Hafner T, et al. Normal standards for fetal neurobehavioral developments–longitudinal quantification by four-dimensional sonography. J Perinat Med 2006;34(1):56–65. DOI: 10.1515/JPM.2006.007
  43. Stanojevic M, Talic A, Miskovic B, et al. An attempt to standardize Kurjak's antenatal neurodevelopmental test: Osaka Consensus Statement. Donald School J Ultrasound Obstet Gynecol 2011;5(4):317–329.
  44. Pooh RK, Pooh K, Fetal VM. Donald School J Ultrasound Obstet Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: Gynecol 2007;1:40–46.
  45. Kurjak A, Ahmed B, Abo-Yaquab S, et al. An attempt to introduce neurological test for fetus based on 3D and 4D sonography. Donald School J Ultrasound Obstet Gynecol 2008;2(4):29–34. DOI: 10.5005/jp-journals-10009-1076
  46. Kuno A, Akiyama M, Yamashiro C, et al. Three-dimensional sonographic assessment of fetal behavior in the early second trimester of pregnancy. J Ultrasound Med 2001;20(12):1271–1275. DOI: 10.7863/jum.2001.20.12.1271
  47. Koyanagi T, Horimoto N, Maeda H, et al. Abnormal behavioral patterns in the human fetus at term: correlation with lesion sites in the central nervous system after birth. J Child Neurol 1993;8(1):19–26. DOI: 10.1177/088307389300800103
  48. 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
  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. Andonotopo W, Kurjak A, Kosuta MI. Behavior of an anencephalic fetus studied by 4D sonography. J Matern Fetal Neonatal Med 2005;17(2):165–168. DOI: 10.1080/14767050400028717
  51. 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
  52. 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
  53. 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
  54. 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
  55. 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
  56. Horimoto N, Koyanagi T, Maeda H, et al. Can brain impairment be detected by in utero behavioural patterns? Arch Dis Child 1993;69(1 Spec No):3–8. DOI: 10.1136/adc.69.1_spec_no.3
  57. Prechtl HF, Einspieler C. Is neurological assessment of the fetus possible? Eur J Obstet Gynecol Reprod Biol 1997;75(1):81–84. DOI: 10.1016/s0301-2115(97)00197-8
  58. Nijhuis JG, Prechtl HF, Martin CB Jr, et al. Are there behavioural states in the human fetus? Early Hum Dev 1982;6(2):177–195. DOI: 10.1016/0378-3782(82)90106-2
  59. Honemeyer U, Kurjak A. The use of KANET test to assess fetal CNS function. First 100 cases. Uruguay: 10th World Congress of Perinatal Medicine; 8-11 November 2011. Poster presentation P209.
  60. Vladareanu R, Lebit D, Constantinescu S. Ultrasound assessment of fetal neurobehavior in high-risk pregnancies. Donald School J Ultrasound Obstet Gynecol; 2012;6:132–147. DOI: 10.5005/jp-journals-10009-1235
  61. 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
  62. 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
  63. Kurjak A, Predojevic M, Salihagic-Kadic A. Fetal brain function: lessons learned and future challenges of 4D sonography. Donald School J Ultrasound Obstet Gynecol 2010;5(2):85–92. DOI: 10.5005/jp-journals-10009-1182
  64. Greenwood C, Newman S, Impey L, et al. Cerebral palsy and clinical negligence litigation: a cohort study. BJOG 2003;110(1):6–11.
  65. Strijbis EM, Oudman I, van Essen P, et al. Cerebral palsy and the application of the international criteria for acute intrapartum hypoxia. Obstet Gynecol 2006;107(6):1357–1365. DOI: 10.1097/01.AOG.0000220544.21316.80
  66. de Vries JI, Fong BF. Changes in fetal motility as a result of congenital disorders: an overview. Ultrasound Obstet Gynecol 2007;29(5):590–599. DOI: 10.1002/uog.3917
  67. de Vries JI, Fong BF. Normal fetal motility: an overview. Ultrasound Obstet Gynecol 2006;27(6):701–711. DOI: 10.1002/uog.2740
  68. Rosier-van Dunné FM, van Wezel-Meijler G, Bakker MP, et al. General movements in the perinatal period and its relation to echogenicity changes in the brain. Early Hum Dev 2010;86(2):83–86. DOI: 10.1016/j.earlhumdev.2010.01.023
  69. Hata T, Kanenishi K, Akiyama M, et al. Real-time 3-D sonographic observation of fetal facial expression. J Obstet Gynaecol Res 2005;31(4):337–340. DOI: 10.1111/j.1447-0756.2005.00298.x
  70. Kozuma S, Baba K, Okai T, et al. Dynamic observation of the fetal face by three-dimensional ultrasound. Ultrasound Obstet Gynecol 1999;13(4):283–284.
  71. Kurjak A, Azumendi G, Andonotopo W, et al. Three- and four-dimensional ultrasonography for the structural and functional evaluation of the fetal face. Am J Obstet Gynecol 2007;196(1):16–28. DOI: 10.1016/j.ajog.2006.06.090
  72. Predojević M, Talić A, Stanojević M, et al. Assessment of motoric and hemodynamic parameters in growth restricted fetuses - case study. J Matern Fetal Neonatal Med 2014;27(3):247–251. DOI: 10.3109/14767058.2013.807241
  73. 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
  74. Stanojevic M, Antsaklis P, Salihadic-Kadic A et al. Is Kurjak antenatal neurodevelopmental test ready for routine clinical application? Bucharest Consensus Statement. Donald School J Ultrasound Obstet Gynecol 2015;9(3):260–265. DOI: 10.5005/jp-journals-10009-1412
  75. Spencer-Smith MM, Spittle AJ, Doyle LW, et al. Long-term benefits of home-based preventive care for preterm infants: a randomized trial. Pediatrics 2012;130(6):1094–1101. DOI: 10.1542/peds.2012-0426
  76. Neto RM, Kurjak A. Recent results of the clinical application of KANET test. Donald School J Ultrasound Obstet Gynecol 2015;9(4):420–425.
  77. Hanaoka U, Hata T, Kanenishi 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
  78. 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
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.