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      The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review

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          Australian and US guidelines recommend routine brain imaging, either computed tomography or magnetic resonance imaging, to exclude structural lesions in presentations for first-episode psychosis. The aim of this review was to examine the evidence for the appropriateness and clinical utility of this recommendation by assessing the frequency of abnormal radiological findings in computed tomography and magnetic resonance imaging scans among patients with first-episode psychosis.


          PubMed and Embase database were searched from inception to April 2018 using appropriate MeSH or Emtree terms. Studies were included in the review if they reported data on computed tomography or magnetic resonance imaging scan findings of individuals with first-episode psychosis. No restriction on the geographical location of the study or the age of participants was applied. We calculated the percentage of abnormal radiological findings in each study, separately by the two diagnostic methods.


          There were 16 suitable studies published between 1988 and 2017, reporting data on an overall 2312 patients with first-episode psychosis. Most were observational studies with a retrospective design and the majority examined patients with computed tomography. While structural abnormalities were a relatively common finding, these rarely required clinical intervention (range across studies: 0–60.7%; median: 3.5%) and were very rarely the cause of the psychotic symptoms (range: 0–3.3%; median: 0%). Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis.


          There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking, mental status and neurological examination. If intracranial pathology is suspected clinically, a magnetic resonance imaging or computed tomography scan should be performed depending on the clinical signs, the acuity and the suspected pathology. National guidelines should reflect evidence-based data.

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          Most cited references23

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          Incidental findings on brain magnetic resonance imaging from 1000 asymptomatic volunteers.

          Previous reports have discussed incidental disease found on brain magnetic resonance imaging (MRI) scans that had been requested for an unrelated clinical concern or symptom, resulting in a selection bias for disease. However, the prevalence of unexpected abnormalities has not been studied in a healthy population. To evaluate the prevalence of incidental findings on brain MRI scans obtained for a healthy, asymptomatic population without selection bias. Retrospective analysis of brain MRI scans obtained between May 17, 1996, and July 25, 1997, from 1000 volunteers who participated as control subjects for various research protocols at the National Institutes of Health. All participants (age range, 3-83 years; 54.6% male) were determined to be healthy and asymptomatic by physician examination and participant history. Prevalence of abnormalities on brain MRI by category of finding (no referral necessary, routine referral, urgent referral [within 1 week of study], and immediate referral [within 1 to several days of study]). Eighty-two percent of the MRI results were normal. Of the 18% demonstrating incidental abnormal findings, 15.1% required no referral; 1.8%, routine referral; 1.1%, urgent referral; and 0%, immediate referral. In subjects grouped for urgent referral, 2 confirmed primary brain tumors (and a possible but unconfirmed third) were found, demonstrating a prevalence of at least 0.2%. Asymptomatic subjects present with a variety of abnormalities, providing valuable information on disease prevalence in a presumed healthy population. A small percentage of these findings require urgent medical attention and/or additional studies.
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            Structural neuroimaging across early-stage psychosis: Aberrations in neurobiological trajectories and implications for the staging model.

            This review critically examines the structural neuroimaging evidence in psychotic illness, with a focus on longitudinal imaging across the first-episode psychosis and ultra-high-risk of psychosis illness stages.
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              Forty years of structural imaging in psychosis: promises and truth.

              Since the first study published in the Lancet in 1976, structural neuroimaging has been used in psychosis with the promise of imminent clinical utility. The actual impact of structural neuroimaging in psychosis is still unclear.

                Author and article information

                Australian & New Zealand Journal of Psychiatry
                Aust N Z J Psychiatry
                SAGE Publications
                November 2019
                May 22 2019
                November 2019
                : 53
                : 11
                : 1093-1104
                [1 ]Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
                [2 ]Department of Epidemiology and Public Health, University College London, London, UK
                [3 ]Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
                [4 ]Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, VIC, Australia
                [5 ]Monash Imaging, Diagnostic Neuroradiology and MRI, Monash Health, Clayton, VIC, Australia
                [6 ]Department of Imaging, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
                [7 ]Department of Psychiatry, University of Sherbrooke, Sherbrooke, QC, Canada
                [8 ]Innovation Institute, Texas Medical Centre, Houston, TX, USA
                [9 ]School of Medicine, University of Queensland, Brisbane, QLD, Australia
                © 2019




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