This study aimed at (a) identifying causative mechanisms of clinical features in carriers of karyotypically balanced chromosomal rearrangements (BCRs), and (b) disclosing the mechanisms of formation of these chromosomal rearrangements. Forty-five BCRs - 29 translocations, 10 inversions and six complex rearrangements, detected in patients with intellectual disability, developmental delay and/or congenital malformations were investigated. Thirty-one rearrangements were de novo, three were familial and segregated with the clinical phenotype, and 11 BCRs were inherited from phenotypically normal parents. Initially, the breakpoints of the rearrangements were mapped by using fluorescence in situ hybridization (FISH), and the presence of cryptic genomic imbalances was investigated by array comparative genomic hybridization (a-CGH). Breakpoint-containing segments were narrowed down to approximately 100 pb - 1 kb, by using NGS-based mate-pair-sequencing (MPS). In order to investigate breakpoint junctions at the nucleotide level, breakpoint segments delimited by MPS were Sanger sequenced. De novo microimbalances on the rearranged chromosomes were detected by aCGH in 12 out of the 45 patients investigated (27%). MPS of 27 BCRs expanded the number of breakpoints, previously detected by karyotyping and aCGH, from 114 to 156 (breakpoint resolution < 2 kb, in most cases). The number of breakpoints/BCR ranged from 2 to 20. The 156 breakpoints resulted in 86 balanced and 32 unbalanced sample-specific structural variations (SVs). In 12 out of the 45 patients investigated by aCGH, microimbalaces on the rearranged chromosomes were responsible or likely contributed to the clinical features observed in the carriers. In five of these 12 rearrangements, truncated known disease genes or their regulatory regions also contributed to the clinical phenotype. MPS analysis revealed four out of the 33 rearrangements not associated with microimbalaces, truncated known disease genes, thus explaining clinical features of carriers. Another balanced rearrangement might have truncated the regulatory region of a dosage sensitive gene, thus disturbing gene expression and leading to the clinical features of the carrier. A karyotypically balanced translocation t(2;22)(p13;q12.2) associated with variable learning disabilities and dysmorphisms, was detected in six individuals in a three-generation family. Combined a-CGH, FISH and MPS revealed a ten-break complex rearrangement, also involving chromosome 5. As the consequence of the segregation of the derivative chromosomes der(2), der(5) and der(22), different microimbalances were present in affected and clinically normal family members, thus contributing to the clinical variability. Although, historically, BCRs inherited from phenotypically normal parents have not been considered as causally associated with clinical features of carriers, cryptic microimbalances on the rearranged chromosome have been reported that explained the clinical features of the affected carriers. In 11 such inherited BCRs ascertained through affected individuals, which were investigated in this work by using aCGH, no microimbalances were detected on the chromosomes involved. However, aCGH analysis in an affected girl, who carried an inv(12)mat, detected a likely pathogenic 8.7 Mb deletion on chromosome 8. This deleted chromosome derived from another maternal balanced rearrangement, not related to the inversion. In order to investigate mechanisms of BCR formation, breakpoint junctions, mapped at intervals of approximately 1 kb by MPS, were narrowed down to the nucleotide level by Sanger sequencing. Fifty-one breakpoint junctions (BPJs) from 17 BCRs (nine translocations, three inversions and five complex rearrangements) were sequenced. The occurrence of blunt fusions or <10 bp deletions, insertions or duplications in the majority of the 51 BPJs, and the absence of homology or the presence of just 2 bp to 4 bp microhomology indicated non-homologous end joining (NHEJ). In three of the four most complex BCRs (17 to 20 breaks) indicated chromothripsis as the mechanism underlying their formation. This study illustrates the importance of combining copy number variation analysis by microarray and breakpoint mapping by MPS, to determine the structure of karyotypically balanced chromosomal rearrangements, and to unravel their clinical impact. Mapping the breakpoint-junctions by MPS, followed by Sanger sequencing, was fundamental to determine the mechanism of formation of these rearrangements