Background: An epidemic of Zika virus (ZIKV) infection began in Colombia in October 2015. Previous studies have identified CNS anomalies, including microcephaly with variable degrees of neurodevelopmental delay, but studies have lacked an adequate control group for comparisons. Our aim was to compare the neurodevelopmental outcome between surviving infants born to ZIKV exposed and non-exposed women.Methods: Participating pregnant women were categorized according to symptomatology and results of RT-PCR. Maternal controls from the same geographic area were captured through the ZIKAlliance project. All infant survivors had neurodevelopmental evaluation at 12, 18, and 24 months corrected age.Findings: Compared to non-exposed controls, infants exposed in utero to ZIKV had a significantly higher proportion of cut-off scores <70 on the Bayley-III Scale at 12, 18, and 24 months for motor, language, and cognitive domains. When infants with microcephaly were excluded from the analysis, the proportion of cut-off scores <70 on the Bayley-III Scale remained higher at 18 months for motor, at 18 and 24 months for language, and at all points of assessment for cognitive development. Exposure of the fetus to ZIKV during the first trimester of pregnancy was associated with the presence of CNS anomalies and severe neurodevelopmental impairment at all points of assessment. The risk of severe neurodevelopmental impairment was higher in ZIKV exposed fetuses than non-exposed fetuses (OR 2.62, 95% CI 1.17-5.84), especially when associated with first-trimester exposure (OR 5.42, 95% CI 2.54-11.57). On the other hand, when the mediation of structural CNS lesions with neurodevelopmental involvement was introduced in the model, they were strongly associated with neurodevelopmental impairment: microcephaly at birth (OR 5.94, 95% CI 2.17-16.27), postnatal microcephaly (OR 4.90, 95% CI 2.06-11.70), and prenatal lesions of the brain parenchyma (OR 4.53, 95% CI 1.89-10.85), but ZIKV infection in the first trimester of pregnancy remained associated (OR 2.20, 95% CI 1.00-4.82).Interpretation; First-trimester exposure of the fetus to ZIKV was associated with the presence of CNS anomalies and severe neurodevelopmental impairment; exposed infants during the first-trimester without CNS anomalies still had an increased risk of severe neurodevelopmental impairment. Long-term follow-up to evaluate school performance is required.Funding Statement: This study was funded by the Colombian Ministry of Science and Innovation (Colciencias; code 110277757376), the Hospital Universitario de Santander (HUS), the Universidad Industrial de Santander (UIS) (grant 758-2017), the Colombian Association of Neonatology (ASCON), and ZIKAlliance Consortium (Global alliance for Zika virus control and prevention, funded by the European Commission Horizon 2020).Declaration of Interests: We declare no competing interests.Ethics Approval Statement: All ethics and research committees from participating centers approved this study.