Key points How common are neuroradiological abnormalities in first episode psychosis? Findings In this systematic review and meta-analysis, we found that approximately 6% of patients with first-episode psychosis had an abnormality that required a change in clinical treatment. The number of patients needed to scan for 1 clinically relevant abnormality was estimated to be 18. Meaning These findings support the routine use of magnetic resonance imaging as part of the initial evaluation in patients presenting with a first episode of psychosis. |
Early diagnosis of secondary psychosis , where a psychotic disorder is caused by another medical condition, is an indispensable but complex diagnostic task in psychiatry. Because several causes of secondary psychosis result in structural brain abnormalities, many psychiatrists consider brain imaging essential during the evaluation phase.
Magnetic resonance imaging (MRI) is a safe and well-tolerated technique that has high sensitivity for detecting intracranial abnormalities. Since its introduction more than 40 years ago, structural MRI has become increasingly available and scanning costs have progressively decreased. However, there is no consensus on whether MRI should be a mandatory part of the clinical evaluation of patients presenting with first episode psychosis (FEP). Some guidelines recommend scanning all patients with first episode psychosis (FEP), while others recommend that MRI be limited to cases where a secondary cause is suspected.
Most radiological abnormalities in patients with FEP are incidental and do not require any clinical action. However, a minority of abnormalities lead to a change in a patient’s clinical care. A barrier to resolving the debate over the routine use of MRI in the evaluation of first episode psychosis (FEP) has been uncertainty about the prevalence of clinically relevant abnormalities, with estimates ranging from 0% 7 to more than 10 %.
Beyond the guidelines for individual clinical management, there is also the issue of population health. In otherwise healthy individuals, white matter hyperintensities reliably predict later cognitive decline, increased cerebrovascular risk, and increased mortality in epidemiologic studies suggesting that the presence of neuroradiologic abnormalities may be an indicator of health. neurological.
We sought to clarify the prevalence of intracranial abnormalities in FEP by performing the first meta-analysis of such studies to our knowledge. We also sought to establish the prevalence of clinically relevant abnormalities that led to a change in diagnosis or management. Additionally, we examined the influence of study, patient, and imaging characteristics on the outcome.
Importance
People who present with first episode psychosis (FEP) may have a secondary ("organic") etiology to their symptoms that can be identified by neuroimaging. Because failure to detect such cases at an early stage can have serious clinical consequences, it has been suggested that brain magnetic resonance imaging (MRI) should be mandatory for all patients presenting with first episode psychosis (FEP). . However, this remains a controversial issue, in part because the prevalence of clinically relevant MRI abnormalities in this group is unclear.
Aim
To derive a meta-analytic estimate of the prevalence of clinically relevant neuroradiological abnormalities in first episode psychosis (FEP).
Data sources
The electronic databases Ovid, MEDLINE, PubMed, Embase, PsychINFO, and Global Health were searched through July 2021. References and citations of included articles and review articles were also searched.
Study selection
Magnetic resonance imaging studies of patients with FEP were included if they reported the frequency of intracranial radiological abnormalities.
Data extraction and synthesis
Independent extraction was performed by 3 investigators and a random effects meta-analysis of pooled proportions was calculated. Moderators were evaluated using subgroup and meta-regression analyses.
Heterogeneity was assessed using the I 2 index. The robustness of the results was assessed by sensitivity analysis. Publication bias was assessed using funnel plots and Egger tests.
Main results and measures
Proportion of patients with a clinically relevant radiological abnormality (defined as a change in clinical management or diagnosis); number of patients needed to scan to detect 1 such abnormality (number needed to assess [NNA]).
Results
Twelve independent studies (13 samples) comprising 1613 patients with first episode psychosis (FEP) were included. Of these patients, 26.4% (95% CI, 16.3%-37.9%; ANN of 4) had an intracranial radiological abnormality and 5.9% (95% CI, 3.2%-9 .0%) had a clinically relevant abnormality, yielding an NNA of 18. There were high degrees of heterogeneity between studies for these outcomes, 95% to 73%, respectively.
The most common type of clinically relevant finding was white matter alterations , with a prevalence of 0.9% (95% CI, 0-2.8%), followed by cysts, with a prevalence of 0.5%. (95% CI, 0-1.4%).
Conclusions and relevance
The estimated prevalence of a radiological abnormality on MRI in patients with FEP was 26%, while that of a clinically relevant abnormality was 6%. FEP patients had a significantly higher prevalence of overall radiological abnormalities, as well as clinically relevant abnormalities compared to healthy controls, after removal of one outlier. White matter abnormalities, predominantly small hyperintensities, were the most common finding overall and the most common clinically relevant finding. The NNA to detect 1 clinically relevant abnormality was 18.
This systematic review and meta-analysis found that around 6% of patients presenting with psychosis have a clinically relevant radiological abnormality on MRI, with a corresponding NNA of 18.
These findings provide a rationale for the use of MRI in the clinical evaluation of all patients presenting with psychosis. As the availability of MRI increases and its costs decrease, it becomes increasingly difficult to justify MRI not being a mandatory part of the clinical evaluation of FEP.
Because the consequences of failing to detect these abnormalities can be serious, these findings support the use of MRI as part of the initial clinical evaluation of all patients with first-episode psychosis (FEP).
