CASE REPORTA 30-year-old woman, gravida 2 para 1, was referred to our fetal magnetic resonance imaging (MRI) service at week 24 of a monochorionic twin pregnancy, because 4 h earlier a transabdominal ultrasound examination had demonstrated absence of cardiac activity in the smaller twin and no brain lesions in the survivor. There was a history of twin-to-twin transfusion syndrome. No serological signs of maternal-fetal infections had been reported. A transabdominal ultrasound examination that had been performed 44 h earlier had shown the twins alive and with normal intracranial anatomy. Based on our experience of fetal MRI detection of ischemic lesions in survivors of monochorionic twin pregnancies 1 , in our institution pregnant women carrying the diagnosis of cotwin death usually undergo fetal brain MRI as early as possible, followed by a second examination 2-3 weeks later. The woman gave written consent to undergo prenatal MRI at our institution.MRI was performed at 1.5 Tesla, using an abdominal phase-array coil, with 4-mm thick multiplanar single-shot fast spin-echo (ss-FSE) T2-weighted sections (TR/TE = 3000/180 ms, field of view = 320 mm, matrix = 256 × 256) and with 6-mm thick multiplanar diffusion-weighted imaging (DWI) sections (TR/TE = 1000/90 ms, field of view = 360 mm, matrix = 128 × 128, b-factor max = 600 mm 2 /s, three axis diffusion sensitized gradient directions, acquisition time = 7 s, during maternal apnea). Apparent diffusion coefficient (ADC) maps were calculated. While ss-FSE T2-weighted images were uninformative, the ADC value was markedly reduced compared to normal (0.4 µm 2 /ms; normal fetal brain value = 1.9 µm 2 /ms (Righini et al. 2 )) within the deep frontal white matter of both hemispheres, especially on coronal sections (Figure 1). At the 14-day follow-up MRI study, ss-FSE T2-weighted images showed extensive malacic areas bilaterally in the periventricular frontal white matter, with disruption of the anterior portion of the corpus callosum and of the septum pellucidum, and with a cyst at the level of the septum pellucidum remnants. The medial frontal cortex was partially involved at the level of the pericallosum gyrus bilaterally. On the same occasion, ultrasound imaging showed large hypoechogenic areas within the medial and anterior portions of both cerebral hemispheres (Figure 2).Normal vaginal delivery occurred at 35 weeks of gestation. Neonatal neurological examination showed mild hypotonia but no seizures were noted. MRI confirmed the prenatal imaging findings.