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4D image sequence of the fetus demonstrated changing from mouthing expression to grimacing expression.
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To produce a new scoring system for fetal neurobehavior based on prenatal assessment by 3D/4D sonography. We identified severely brain damaged infants and those with optimal neurological findings and compared fetal with neonatal findings.
The new scoring system was retrospectively applied in a group of 100 low-risk pregnancies. After delivery, post...
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Citations
... Specifically, it seeks to address two core questions: (1) How can AI-enhanced 4D ultrasound improve the detection of fetal anomalies and neurodevelopmental patterns linked to long-term health risks? [35,36] (2) What are the challenges and opportunities in integrating these advanced technologies into routine prenatal care to ensure equitable and effective implementation? [37,38] By addressing these critical gaps in current diagnostic methods and harnessing state-of-the-art technology, this study contributes to the evolution of personalized prenatal care and the optimization of maternal-fetal health outcomes [39,40]. ...
... These dynamic visualizations provide critical insights into neurodevelopmental and motor functions, which are essential indicators of fetal health [29,31]. Beyond movement analysis, the enhanced spatial and temporal resolution of 4D ultrasound enables precise detection of structural anomalies, including facial clefts, limb deformities, and cardiac defects [30,35]. Early identification of such conditions allows for timely interventions, improving pregnancy outcomes [36]. ...
... The integration of artificial intelligence (AI) with 4D ultrasound enhances its diagnostic capabilities by enabling advanced data analysis, which surpasses the limits of human interpretation [42,43]. AI-powered applications such as the Kurjak Antenatal Neurodevelopmental Test (KANET) leverage real-time imaging to detect subtle motor and facial irregularities, which may signal neurodevelopmental disorders like cerebral palsy or autism spectrum disorders [35,39]. By combining imaging with epigenetic data, AI uncovers the complex interplay between genetic predispositions and environmental exposures during gestation [48]. ...
Introduction
The fetal origins of adult disease, widely known as Barker’s Hypothesis, suggest that adverse fetal environments significantly impact the risk of developing chronic diseases, such as diabetes and cardiovascular conditions, in adulthood. Recent advancements in 4D ultrasound (4D US) and artificial intelligence (AI) technologies offer a promising avenue for improving prenatal diagnostics and validating this hypothesis. These innovations provide detailed insights into fetal behavior and neurodevelopment, linking early developmental markers to long-term health outcomes.
Content
This study synthesizes contemporary developments in AI-enhanced 4D US, focusing on their roles in detecting fetal anomalies, assessing neurodevelopmental markers, and evaluating congenital heart defects. The integration of AI with 4D US allows for real-time, high-resolution visualization of fetal anatomy and behavior, surpassing the diagnostic precision of traditional methods. Despite these advancements, challenges such as algorithmic bias, data diversity, and real-world validation persist and require further exploration.
Summary
Findings demonstrate that AI-driven 4D US improves diagnostic sensitivity and accuracy, enabling earlier detection of fetal abnormalities and optimization of clinical workflows. By providing a more comprehensive understanding of fetal programming, these technologies substantiate the links between early-life conditions and adult health outcomes, as proposed by Barker’s Hypothesis.
Outlook
The integration of AI and 4D US has the potential to revolutionize prenatal care, paving the way for personalized maternal-fetal healthcare. Future research should focus on addressing current limitations, including ethical concerns and accessibility challenges, to promote equitable implementation. Such advancements could significantly reduce the global burden of chronic diseases and foster healthier generations.
... As the fetus develops, these muscles prepare for actions like sucking, swallowing, and initial facial expressions. By the third trimester, the muscles have formed well enough to allow limited facial movements visible in ultrasound scans, indicating readiness for neonatal life [4,6,[14][15][16][17][18][19][20][21][22][23][24][25][26]. ...
... Conditions like Horner's Syndrome cause asymmetrical features, including ptosis and constricted pupils, which can diminish expressive clarity. 4D ultrasound technology has revolutionized fetal diagnostics by enabling real-time, detailed analysis of facial expressions like smiling, squinting, and frowning (Figures 2-5 and 7) [1,[15][16][17][18][19][20][21][22][23][24][25][26][70][71][72][73][74][75][76]. This non-invasive method allows clinicians to detect potential abnormalities in cranial nerves or the autonomic system, providing early indications of conditions like Bell's Palsy or Ramsay Hunt Syndrome. ...
... AI has enhanced diagnostic precision by automating the detection of subtle movement patterns, uncovering irregularities missed by human observation (Figures 8-10) [63][64][65][66][67][68][69]. When paired with prenatal MRI, 4D ultrasound provides a comprehensive approach to understanding cranial nerve development and associated disorders [15][16][17][18][19][20][21][22][23][24][25][26][70][71][72][73][74][75][76]. These technologies improve diagnostic accuracy, enabling earlier interventions and better neonatal outcomes. ...
The development of facial musculature and expressions in the human fetus represents a critical intersection of developmental biology, neurology, and evolutionary anthropology, offering insights into early neurological and social development. Fetal facial expressions, shaped by Cranial Nerve VII, reflect evolutionary adaptations for nonverbal communication and exhibit minimal asymmetry in universal expressions. Advancements in 4D ultrasound imaging and artificial intelligence (AI) have introduced innovative methods for analyzing these movements, revealing their potential as diagnostic tools for neurodevelopmental disorders like Bell’s Palsy and Ramsay Hunt Syndrome before birth. These technologies promise early interventions that could significantly improve neonatal outcomes. By integrating imaging, AI, and longitudinal studies, researchers propose a multidisciplinary approach to establish diagnostic criteria for fetal facial movements. However, translating these advancements into clinical practice requires addressing ethical and practical challenges, refining imaging and AI methodologies, and fostering interdisciplinary collaboration. The review highlights the universality of fetal expressions while emphasizing the importance of distinguishing typical variability from pathological markers. In conclusion, these findings suggest transformative potential for maternal-fetal medicine, paving the way for proactive strategies to manage neurodevelopmental risks. Focused research is essential to fully harness these innovations and establish a new frontier in perinatal science.
... Facial features can provide valuable insights into fetal development, genetic conditions, and potential congenital anomalies [1,2]. Current manual analysis of fetal facial profiles is time-consuming and relies heavily on the expertise of healthcare providers [42][43][44]. ...
Artificial intelligence has emerged as a transformative technology in the field of healthcare, offering significant advancements in various medical disciplines, including obstetrics. The integration of artificial intelligence into 3D/4D ultrasound analysis of fetal facial profiles presents numerous benefits. By leveraging machine learning and deep learning algorithms, AI can assist in the accurate and efficient interpretation of complex 3D/4D ultrasound data, enabling healthcare providers to make more informed decisions and deliver better prenatal care. One such innovation that has significantly improved the analysis of fetal facial profiles is the integration of artificial intelligence (AI) in 3D/4D ultrasound imaging. In conclusion, the integration of artificial intelligence in the analysis of 3D/4D ultrasound data for fetal facial profiles offers numerous benefits, including improved accuracy, consistency, and efficiency in prenatal diagnosis and care.
... The introduction of the Kurjak Antenatal Neurodevelopmental Test (KANET) has significantly impacted clinical practice, particularly in prenatal care and fetal neurology (1)(2)(3)(4)(5)(6)(7)(8). According to our opinion, the key aspects of its signifi cance and importance are (1): ...
... KANET has enabled healthcare providers to detect potential neurodevelopmental disorders much earlier than by traditional methods. By using four-dimensional ultrasound (4D US) to assess fetal behavior and movements, KANET off ers a window into the developing fetal nervous system, allowing clinicians to identify abnormalities that could indicate future neurological issues (1)(2)(3)(4)(5)(6)(7)(8). This early detection is crucial for timely intervention and management (7). ...
... In summary, the introduction of KANET into clinical practice has been a groundbreaking development in prenatal medicine. It has enhanced the ability of clinicians to detect and understand neurodevelopmental issues early in life, off ering signifi cant potential for early intervention and better outcomes for aff ected individuals (1)(2)(3)(4)(5)(6)(7)(8)(9). ...
The Kurjak Antenatal Neurodevelopmental Test (KANET) has revolutionized prenatal care and fetal neurology by providing a non-invasive method to assess fetal neurodevelopment using fourdimensional ultrasound (4D US). Over the past ten years, KANET has been widely implemented across various clinical settings, enabling the early detection of neurodevelopmental disorders. This early identifi cation is crucial for timely intervention and improved long-term outcomes. KANET standardizes the assessment of fetal neurological function, off ering a structured and objective approach that enhances our understanding of fetal behavior and its implications for postnatal development. While KANET demonstrates high specifi city and a low false-negative rate, its sensitivity in detecting specifi c conditions like cerebral palsy (CP) remains limited. The test’s widespread use has not only informed clinical management strategies but also promoted further research into prenatal neurodevelopment and potential prenatal interventions. Recent studies highlight diff erences in fetal behavior in pregnancies complicated by gestational diabetes, suggesting the potential for KANET to inform future neurodevelopmental outcomes. Continued research and refi nement of KANET are essential to enhance its predictive accuracy and ensure comprehensive postnatal follow-up.
... The new scoring system for prenatal neurological assessment of the fetus proposed by Kurjak et al. will give some new possibilities to detect fetuses at high neurological risk, although it is obvious that the dynamic and complicated process of functional CNS development is not easy to investigate. 116 Although there were attempts to standardize the KANET with some modifications and after its critical appraisal, it should be stated that there is still a long way to go before its routine use in everyday clinical practice. 85 ...
There is also a continuity of fetal and neonatal movements, which are important indicators of developmental processes of the brain.
The aim of the paper is to present neurological prenatal and postnatal assessment of behavior, which is affected by the continuity
of general and other movements from prenatal to postnatal life.
A prenatal neurological test has been developed using four-dimensional ultrasound (4D US) to assess isolated head anteflexion,
eye blinking, facial and mouth movements, leg, hand and finger movements, cranial sutures, and general movement (GM) gestalt
perception, all included in the Kurjak antenatal neurodevelopmental test (KANET). Neurological assessment should be continued
postnatally as clinical investigation and assessment of Prechtl’s GMs. Continuity of assessments relates to the continuity of fetal
to neonatal movements, understanding which gives clinicians the opportunity for earlier detection of neurological disability.
The diagnosis of cerebral palsy (CP) as the most severe neurological disability is retrospective, and it is exceptionally made before
the age of 6 months in only the most severely affected infants; the specificity of the diagnosis will improve as the child ages and
the nature of the disability evolves.
Interest in the diagnosis of neurological impairment among experts using 4D US has recently shifted toward the prenatal
period. Are we approaching the era of the development of diagnostic tests to detect nonreassuring fetal neurological status in
its intrauterine life to intervene at appropriate times in order to decrease the CP rate? It is questionable if the KANET test could
be the tool to achieve this desire.
Keywords: Brain, Cerebral palsy, Four-dimensional ultrasound, Fetus, Neonate, Neurological impairment
... [1][2][3][4][18][19][20][21][22][23]35 KANET was the first method that managed to assess the fetus neurologically by using 4D ultrasound in a similar way that we would assess a neonate postnatally. [36][37][38][39] or sometime after birth, and exactly how severely will it affect it, and when exactly will the problem be diagnosed, as it is mostly diagnosed after birth and sometimes long after birth. [4][5][6] The main reason why almost all cases of neurological impairment are diagnosed after birth is that there is no standardized method of assessing the fetus neurologically in utero. ...
... Kurjak antenatal neurodevelopmental test (KANET) is a structured way of assessing fetal behavior with 4D ultrasound, in a similar way that a neonate is assessed after birth KANET aims to define normal fetal behavior for each stage of pregnancy and, on the other hand, to identify abnormal conditions that could be related to neurologic impairment. 36,76 KANET has a general part that includes fetal GM and the general part that includes parameters modified by the neonatal assessment, the so-called Amiel-Tison Neurological Assessment at Term (ATNAT) signs. 37,40 The following parameters are included in the KANET test: isolated head anteflexion, overlapping cranial sutures, head circumference, isolated eye blinking, facial alterations, mouth opening (yawning or mouthing), isolated hand and leg movements and thumb position, and gestalt perception of GMs (overall perception of the body and limb movements with their qualitative assessment). ...
... 47 In many systematic reviews, abnormal fidgety GMs are considered a reliable predictor of CP. 48,49 Currently, a combination of GMs, the HINE, and neonatal MRI is the gold standard for the diagnosis of CP in high-risk infants and can be used to accurately predict CP before 5 months' CA. 43,48 sIgns o F postnAtAl neurologIcAl Assessment used prenAtAlly Kurjak et al. by using 4D US and introducing the KANET was at that time convinced that 4D US compared to two-dimensional (2D) US, opened up a new field of fetal neurology by the introduction of a standardized and comprehensive method to evaluate the fetal neurological condition objectively and reproducibly by observation of fetal behavior and GMs. 50,51 However, from the postnatal neurological assessment, one can learn that making a neurological diagnosis based only on the assessment of motoric function or even the evaluation of GMs is almost impossible because much more should be learned from neuroimaging and electrophysiological and other diagnostic means. 52,53 By postnatal clinical neurologic assessment, clinicians are evaluating many more components like cognitive function, cranial nerves, motor strength, sensation, reflexes, coordination, gait, emotion, learning, self-control, and memory 52,53 . ...
Assessment of the structure and function of the brain was enabled by the development of ultrasound (US) technology, which may
depict how complicated developmental processes of the brain structure in utero can result in complex behavior of embryo and
fetus. Extrauterine life is the continuation of intrauterine life, and transposing our knowledge of brain structure and function from
prenatal to postnatal life is an important approach to making the distinction between normal and abnormal brain development and
the early diagnosis of various structural or functional brain abnormalities. The invention of four-dimensional US (4D US) enabled
the introduction of the Kurjak Antenatal Neurodevelopmental Test (KANET), which opened up a new field of fetal neurology. The
KANET is a standardized and comprehensive method to evaluate fetal neurological condition objectively and reproducibly by
observation of fetal behavior and general movements (GMs). Based on the existing investigation, if the KANET score is normal,
then there is a high probability that the development of the infant will be normal, with a very low probability that the child with
developmental delay would have been missed, while the prediction is more complicated if the score is abnormal or borderline.
Keywords: Brain, Four-dimensional, Fetal behavior, Function, Neonate, Structure, Ultrasound
... 30 In 2008, the Zagreb group was the first to introduce the KANET for the assessment of the neurological status of the fetus, aiming to the detection of the fetal brain and neurodevelopmental alterations due to in utero brain impairment. 76,77 In order to develop the new scoring system, they identified severely brain-damaged neonates and neonates with good neurological conditions and then compared the neonatal findings with corresponding findings in utero 76,77 In the group of 100 low-risk pregnancies, they retrospectively applied KANET. After delivery, postnatal neurological assessment (ATNAT) was performed, and all neonates assessed as normal reached a score between 14 and 20, assumed to be the score of optimal neurological development. ...
... 30 In 2008, the Zagreb group was the first to introduce the KANET for the assessment of the neurological status of the fetus, aiming to the detection of the fetal brain and neurodevelopmental alterations due to in utero brain impairment. 76,77 In order to develop the new scoring system, they identified severely brain-damaged neonates and neonates with good neurological conditions and then compared the neonatal findings with corresponding findings in utero 76,77 In the group of 100 low-risk pregnancies, they retrospectively applied KANET. After delivery, postnatal neurological assessment (ATNAT) was performed, and all neonates assessed as normal reached a score between 14 and 20, assumed to be the score of optimal neurological development. ...
... Based on this, a neurological scoring system has been proposed. 76,77 All normal fetuses reached a score from 14 to 20. A total of 10 fetuses who were postnatally described as mildly or moderately abnormal achieved a prenatal score of 5-13, while another ten fetuses postnatally assigned as neurologically abnormal had a prenatal score of 0-5. ...
Understanding the structure and function of the fetal nervous system has been the dream of physicians for centuries. The
pioneering efforts of Ian Donald in obstetric ultrasound (US) in the latter part of the 20th century have permitted this dream
to become a reality. The initial contribution of obstetric US focused on normal and abnormal structures. Initially, anencephaly
was described and followed by increasingly subtle central nervous system (CNS) abnormalities such as agenesis of the corpus
callosum. The current and evolving challenge for investigators in obstetric US is to have similar success with the understanding of
fetal neurological function. There are many functional neurological abnormalities, such as cerebral palsy (CP), whose causes are
poorly understood. There are also an escalating number of results illustrating that a large presence of neurological problems, such
as minimal cerebral dysfunction, schizophrenia, epilepsy, or autism, upshot at least in part from prenatal neurodevelopmental
problems. Clinical and epidemiological studies have revealed that CP most often results from prenatal rather than perinatal or
postnatal causes. Currently, although momentous advances in prenatal and perinatal care, there are no means to identify or expect
the development of these disorders. Therefore, the development of diagnostic strategies to avoid and condense the saddle of
perinatal brain damage has to turn into one of the most imperative tasks of contemporary perinatal medicine. The application
of the new neurobehavioral test Kurjak’s antenatal neurobehavioral test (KANET) might improve our understanding of prenatal
neurodevelopmental events and possibly antenatal detection of CP and other neurological diseases.
... Kurjak antenatal neurodevelopmental test (KANET) for fetal neurobehavior was introduced for prenatal assessment by the use of three-dimensional or four-dimensional sonography [30]. In this prenatal assessment, the characteristics and significance of normal and abnormal fetal isolated leg movements and general movements were investigated. ...
The fetus movements play an important role in fetal well-being. With the continuous advancement of real-time scanning machines, it is feasible to observe the fetus movement in detail. The characteristics of fetal lower limb movements in prenatal examination have not been systematically investigated. This review proposes the patterns of fetal lower limb movements, the maternal influence on fetal lower limb movements, and the application of fetal lower limb movements for the diagnosis of prenatal diseases. A systematic search of literature on the lower limb movements of the fetus in uterus was performed in the databases, namely, Web of Science and Scopus. Thirty-four publications were selected. This review demonstrates that isolated fetal lower limb movements are rare and always accompanied with the movements of other body segments. Detection of the presence of fetal leg movements seems to be of no diagnostic value for fetuses with prenatal diseases. The isolated lower limb movement was statistically significant different between fetuses of low- and high-risk pregnant women. The coordinated movements of the fetal lower limbs and other parts should be considered when analyzing fetal movements in the future study.
... Finally, the increased yawning frequencies found in the second born twin, known to be prone to higher neonatal morbidity [47,60], is consistent with the hypothesis that yawning behavior might be affected by perinatal clinical conditions [35,61]. This seems to confirm that analysis of yawning is a promising tool for neurobehavioral assessment, potentially allowing clinicians and researchers to identify at-risk infants through early observation, both during the fetal and neonatal periods [62,63]. Overall, our results are consistent with the hypothesis that yawning frequencies in preterm neonates are modulated by two separate cholinergic-related factors-respectively, hunger and sleep-related factors-as well as by a possibly ACTH-mediated stress-related condition (i.e. ...
Yawning is a long neglected behavioral pattern, but it has recently gained an increasing interdisciplinary attention for its theoretical implications as well as for its potential use as a clinical marker, with particular regard to perinatal neurobehavioral assessment. The present study investigated the factors affecting yawning frequencies in hospitalized preterm neonates (N = 58), in order to distinguish the effects of hunger and sleep-related modulations and to examine the possible impact of demographic and clinical variables on yawning frequencies. Results showed that preterm neonates yawned more often before than after feeding, and this modulation was not explained by the amount of time spent in quiet sleep in the two conditions. Moreover, second born twins, known to be more prone to neonatal mortality and morbidity, showed increased yawning rates compared to first born twins. Overall, our results are consistent with the hypothesis that yawning frequencies in preterm neonates are modulated by separate mechanisms, related e.g. to hunger, vigilance and stress. These findings, although preliminary and based only on behavioral data, might indicate that several distinct neuropharmacological pathways that have been found to be involved in yawn modulation in adults are already observable in preterm neonates.
