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Purpose  A retrospective study was performed to study the effect of fetal surgery on brain development measured by MRI in fetuses with myelomeningocele (MMC).    Methods  MRI scans of 12 MMC fetuses before and after surgery were compared to 24 age-matched controls without central nervous system abnormalities. An automated super-resolution reconstruction technique generated isotropic brain volumes to mitigate 2D MRI fetal motion artefact. Unmyelinated white matter, cerebellum and ventricles were automatically segmented, and cerebral volume, shape and cortical folding were thereafter quantified. Biometric measures were calculated for cerebellar herniation level (CHL), clivus-supraocciput angle (CSO), transverse cerebellar diameter (TCD) and ventricular width (VW). Shape index (SI), a mathematical marker of gyrification, was derived. We compared cerebral volume, surface area and SI before and after MMC fetal surgery versus controls. We additionally identified any relationship between these outcomes and biometric measurements.    Results  MMC ventricular volume/week (mm 3 /week) increased after fetal surgery (median: 3699, interquartile range (IQR): 1651–5395) compared to controls (median: 648, IQR: 371–896);  P  = 0.015. The MMC SI is higher pre-operatively in all cerebral lobes in comparison to that in controls. Change in SI/week in MMC fetuses was higher in the left temporal lobe (median: 0.039, IQR: 0.021–0.054), left parietal lobe (median: 0.032, IQR: 0.023–0.039) and right occipital lobe (median: 0.027, IQR: 0.019–0.040) versus controls ( P  = 0.002 to 0.005). Ventricular volume (mm 3 ) and VW (mm) ( r  = 0.64), cerebellar volume and TCD ( r  = 0.56) were moderately correlated.    Conclusions  Following fetal myelomeningocele repair, brain volume, shape and SI were significantly different from normal in most cerebral layers. Morphological brain changes after fetal surgery are not limited to hindbrain herniation reversal. These findings may have neurocognitive outcome implications and require further evaluation.    Supplementary Information  The online version contains supplementary material available at 10.1007/s00234-021-02725-8.

Cortical spectral matching and shape and volume analysis of the fetal brain pre- and post-fetal surgery for spina bifida: a retrospective study