‘‘Zebra pattern’’ in necrotizing enterocolitis Eduardo Kaiser Ururahy Nunes Fonseca , Marco Philipe Teles Reis Ponte, Yoshino Tamaki Sameshima Imaging Department, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Sa˜o Paulo 05652-901, Brazil Necrotizing enterocolitis (NEC) is a potentially fatal and relatively common condition in neonates. Although its pathophysiology is still not completely known, it has a clear predominance in preterm babies and almost 10% of the cases occur in term neonates, notably those with con- genital cardiomyopathies [1]. Patients with NEC have intestinal mucosal damage that progresses to bowel inflammation and ultimately to ischemia, necrosis, and perforation [1–3]. Traditionally, these babies are evaluated through abdominal plain X-ray in which the findings of pneu- matosis intestinalis, portal venous air, and pneumoperi- toneum are considered highly suggestive of NEC in a compatible clinical scenario [1–3]. Also, the presence of free intraperitoneal air indicates intestinal perforation, leading to surgical approach. Despite that plethora of possible findings, abdominal X-rays usually show just the late consequences of NEC natural history. Ultrasound has been increasingly used in this disease as it can not only depict all X-ray findings but also reflect the whole natural history [2–4] and even assess for prognosis [4]. Ultrasound with color Doppler shows an excellent correlation with the pathophysiologic phases of bowel suffering stages in NEC [2]: in early stages, there is a marked thickening of bowel wall with hyperemia. In this stage, thickening of the valvulae conniventes leads to the so-called ‘‘zebra pattern’’ (Fig. 1), due to the similarity of the thickened valvulae conniventes (hyperechoic) and their interspaces (hypoe- choic) with zebra stripes (Fig. 2). Color Doppler shows hyperemia in the valvulae conniventes better depicting this pattern and also underlying pathophysiology stage of wall thickening and hyperemia. Although colorful, this Doppler pattern is also referred to as zebra pattern. It is important to note that the gray-scale ‘‘zebra pat- tern’’ is a nonspecific finding that can be seen in other causes of diffuse bowel edema in neonates, even in the absence of inflammation or ischemia [2, 3]. Correspondence to: Eduardo Kaiser Ururahy Nunes Fonseca; email: edukaiser_unf@hotmail.com ª Springer Science+Business Media New York 2017 Abdominal Radiology Abdom Radiol (2017) DOI: 10.1007/s00261-017-1191-7