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

Abstract

Background: 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. Methods: 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. Results: 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. Conclusion: 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.

A case of multiple sclerosis presenting as first-episode psychosis in a young person

“…In this case, the temporality between the improvement of psychotic symptoms and treatment of MS would suggest an association. Furthermore, it is likely that what were presumed to be negative symptoms, were more likely symptoms of fatigue and lethargy that are common in MS. Less than 1% of neuroimaging in first episode of psychosis yields clinical significance, and therefore, neuroimaging should only be performed when clinically indicated (Forbes et al, 2019). We propose that neuroimaging could be considered in the presence of apparent persistent negative symptoms in a young person, as MS is a rare but important differential diagnosis of first presentation of psychosis.…”

Recommendations for the medical work‐up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review

“…It is potentially useful to establish a baseline study in FEP, as schizophrenia has been shown to reduce cortical volume and increase ventricular size over time (Olabi et al, 2011). A recent systematic review concluded that routine brain imaging could not be recommended due to low yield and that history, neurological examination and mental status should be used to determine the likelihood of structural lesions to guide decisions about imaging (Forbes et al, 2019). The most recent NICE and Canadian guidelines specifically recommend against routine screening due to low yield and lack of cost-effectiveness (Addington et al, 2017;National Institute for Health and Care Excellence, 2008;Pringsheim et al, 2017).…”

When should we image our patients? Appropriate use of imaging in inpatient psychiatry

“…Additional factors that may influence imaging usage include ambiguous and contradictory international clinical practice guidelines and the fear of missing a potentially treatable cause of psychosis or serious neurological illness, which may result in patient harm and medicolegal risk. 2 The RANZCP guidelines currently include MRI as part of the workup for first-episode psychosis, with a caveat that disagreement exists around this recommendation. 3…”

“…3 Evidence A systematic review of 16 studies, which included 2312 individual patients, looked at the clinical utility of brain imaging with CT or MRI in first-episode psychosis and found that structural abnormalities were a possible cause of psychotic symptoms in just 0.4% of patients. 2 A further Australian study of 805 patients under the age of 50 without neurological signs over a 7-year period found the diagnostic yield of CT in the setting of psychosis to be very low. 4…”

“…Additional factors that may influence imaging usage include ambiguous and contradictory international clinical practice guidelines and the fear of missing a potentially treatable cause of psychosis or serious neurological illness, which may result in patient harm and medicolegal risk. 2 The RANZCP guidelines currently include MRI as part of the workup for first-episode psychosis, with a caveat that disagreement exists around this recommendation. 3 Evidence A systematic review of 16 studies, which included 2312 individual patients, looked at the clinical utility of brain imaging with CT or MRI in first-episode psychosis and found that structural abnormalities were a possible cause of psychotic symptoms in just 0.4% of patients.…”