Prenatal alcohol exposure (PAE) frequently causes neurodevelopmental disorder, yet fetal alcohol spectrum disorders (FASD) are often undiagnosed. Global prevalence rates of 0.77% for FASD and European / North American rates of 2-5% highlight the need for neurologists to engage in identification, assessment, and treatment of this preventable disorder. Diagnosis remains challenging because of limitations of self-report of drinking, lack of biomarkers, and infrequency of diagnostic dysmorphic facial features. Multiple diagnostic systems and disagreement over diagnostic criteria have slowed progress in the field. PAE impacts neurodevelopment through diverse mechanisms including oxidative injury, apoptosis, modulation of gene expression, and disruption of neuronal migration / axon pathfinding. Neuroimaging reveals abnormal brain structure, cortical development, white matter microstructure, and functional connectivity. These abnormalities modify developmental trajectories and are associated with deficits in cognition, executive function, memory, vision, hearing, motor skills, behavior, and social adaptation. Trials of promising nutritional interventions and cognitive rehabilitation are underway.