When a person presents with psychosis without a past history of a mental disorder, that is, a first-episode psychosis, a medical workup is essential because it is possible that the psychotic symptoms are caused not by schizophrenia but by another brain or systemic illness. This is very important so that a serious, even potentially treatable, underlying illness is not missed. What exactly this medical workup should consist of is discussed on another page on this website.
Frequently, clinicians order a magnetic resonance imaging (MRI) scan of the brain as part of this workup. Is this appropriate? Should we routinely order an MRI of the brain in patients who present with first-episode psychosis?
What do Practice Guidelines say?
The American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia (final draft, December 2019) recommends “Brain imaging (CT or MRI, with MRI being preferred), if indicated based on neurological exam or history“.
The Royal Australian and New Zealand College of Psychiatrists’ clinical practice guidelines for the management of schizophrenia and related disorders (Galletly et al., 2016) also recommend an MRI of the brain in patients with first-episode psychosis but note that “Expert opinion is divided about whether MRI scan of the brain is necessary for all people with first-episode psychosis.”
OK. And, what if there is no particular indication in the history or neurological examination to suggest that an MRI of the brain is needed? The APA’s guideline says in a footnote that, “In the absence of such indications, decisions about imaging should consider that the yield of routine brain imaging is low, with less than 1% of studies showing potentially serious incidental findings or abnormalities that would influence treatment.”
How useful is an MRI of the brain in first-episode psychosis?
Many papers have looked at the question of how useful brain imaging is in patients with first-episode psychosis (Forbes et al., 2019; Cunqueiro et al., 2019; Falkenberg et al., 2017; Khandanpour et al., 2013; Strahl et al., 2010; Albon et al., 2008).
The most recent review of relevant studies, as of July 2020, reviewed 16 studies including over 2300 patients (Forbes et al., 2019). Note: the majority of these studies used CT scans rather than MRIs. The review found that:
1. Structural abnormalities in the brain were commonly found.
2. BUT the great majority of these did not require any intervention (range 0% to 61% with a median of 3.5%). Examples of structural findings that did not lead to any change in the treatment were—arachnoid cysts, cerebral atrophy, mild ventricular atrophy, white matter hyperintensity, etc
3. Also, these structural abnormalities were almost never thought to be the cause of the psychosis (range 0% to 3% with a median of 0%). Examples of structural findings that led to some change in the treatment plan but were not thought to be the cause of the psychosis were—old infarcts, small vessel ischemic changes, etc.
What clinical features suggest that brain imaging is needed?
A possible need for brain imaging is suggested by the presence of the following clinical features (not an exhaustive list):
In the history
– Older age when first-episode psychosis occurs
– Concern for seizures
– Chronic headaches
– Severe, acute headache
– Unexplained nausea and vomiting
– Impaired consciousness
– Unexplained lethargy
– Presence of delirium
– Unexplained change in personality
– Rapid progression of working memory deficits (over less than three months; Graus et al., 2016)
– Recent onset of cognitive impairment
On the physical examination
– Focal neurological signs
– Cognitive impairment
– If headaches, nausea, and vomiting are present, the patient may have increased intracranial pressure due to a variety of reasons.
– If rapidly progressing (over less than three months) working memory deficits are present along with impaired consciousness, lethargy, or personality change, this may suggest autoimmune encephalitis (Graus et al. 2016).
Here are just a few examples of the kinds of things that may be seen in patients with first-episode psychosis:
– Basal ganglia changes that are found in Huntington’s disease
1. If imaging of the brain is needed in a patient with first-episode psychosis, an MRI should be preferred over a CT scan. This is because an MRI has much greater sensitivity for picking up brain pathology and because an MRI avoids exposure to ionizing radiation (Forbes and Stuckey, 2020).
2. An MRI of the brain should at least be considered in all patients with first-episode psychosis.
3. But, in patients 50-years-old or younger with no neurological signs or cognitive impairment, and none of the clinical characteristics discussed above, an MRI of the brain is probably not needed.
4. In situations where it is unclear whether or not a brain MRI is indicated, we should remember, as the APA guideline notes, that an MRI of the brain is a low-risk procedure and that a negative finding can be reassuring to patients and their families.
5. Even if an MRI of the brain is ordered, the APA’s guideline notes that “… it is rarely necessary to delay other treatment or hospitalization while awaiting imaging results.”
American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia (final draft, December 2019)
Cunqueiro A, Durango A, Fein DM, Ye K, Scheinfeld MH. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol. 2019 Feb;49(2):240-244. doi: 10.1007/s00247-018-4265-y. Epub 2018 Oct 5. PMID: 30291381.
Falkenberg I, Benetti S, Raffin M, Wuyts P, Pettersson-Yeo W, Dazzan P, Morgan KD, Murray RM, Marques TR, David AS, Jarosz J, Simmons A, Williams S, McGuire P. Clinical utility of magnetic resonance imaging in first-episode psychosis. Br J Psychiatry. 2017 Oct;211(4):231-237. doi: 10.1192/bjp.bp.116.195834. Epub 2017 May 4. PMID: 28473319.
Forbes M, Stefler D, Velakoulis D, Stuckey S, Trudel JF, Eyre H, Boyd M, Kisely S. The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review. Aust N Z J Psychiatry. 2019 Nov;53(11):1093-1104. doi: 10.1177/0004867419848035. Epub 2019 May 22. PMID: 31113237.
Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, Kulkarni J, McGorry P, Nielssen O, Tran N. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry. 2016 May;50(5):410-72. doi: 10.1177/0004867416641195. PMID: 27106681.
Khandanpour N, Hoggard N, Connolly DJ. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol. 2013 Mar;68(3):245-50. doi: 10.1016/j.crad.2012.07.010. Epub 2012 Sep 5. PMID: 22959259.
References not used on this page
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Andrea S, Papirny M, Raedler T. Brain Imaging in Adolescents and Young Adults With First-Episode Psychosis: A Retrospective Cohort Study. J Clin Psychiatry. 2019 Nov 5;80(6):18m12665. doi: 10.4088/JCP.18m12665. PMID: 31721483.
Forbes M, Somasundaram A, Jagadheesan K, Stuckey S. When should we image our patients? Appropriate use of imaging in inpatient psychiatry. Australas Psychiatry. 2020 Jun 25:1039856220934313. doi: 10.1177/1039856220934313. Epub ahead of print. PMID: 32586111.
Gibson LM, Paul L, Chappell FM, Macleod M, Whiteley WN, Al-Shahi Salman R, Wardlaw JM, Sudlow CLM. Potentially serious incidental findings on brain and body magnetic resonance imaging of apparently asymptomatic adults: systematic review and meta-analysis. BMJ. 2018 Nov 22;363:k4577. doi: 10.1136/bmj.k4577. PMID: 30467245; PMCID: PMC6249611.
González-Vivas C, Soldevila-Matías P, Sparano O, García-Martí G, Martí-Bonmatí L, Crespo-Facorro B, Aleman A, Sanjuan J. Longitudinal studies of functional magnetic resonance imaging in first-episode psychosis: A systematic review. Eur Psychiatry. 2019 Jun;59:60-69. doi: 10.1016/j.eurpsy.2019.04.009.
Epub 2019 May 7. PMID: 31075523.
Graus F, Titulaer MJ, Balu R, Benseler S, Bien CG, Cellucci T, Cortese I, Dale RC, Gelfand JM, Geschwind M, Glaser CA, Honnorat J, Höftberger R, Iizuka T, Irani SR, Lancaster E, Leypoldt F, Prüss H, Rae-Grant A, Reindl M, Rosenfeld MR, Rostásy K, Saiz A, Venkatesan A, Vincent A, Wandinger KP, Waters P, Dalmau J. A clinical approach to diagnosis of autoimmune encephalitis. Lancet Neurol. 2016 Apr;15(4):391-404. doi: 10.1016/S1474-4422(15)00401-9. Epub 2016 Feb 20. PMID: 26906964; PMCID: PMC5066574.
Kasinathan J, Baker RJ, Perkes IE. A case for imaging in high-risk psychosis: insular pathology in first episode psychosis. Aust N Z J Psychiatry. 2017 Oct;51(10):1057-1058. doi: 10.1177/0004867417700279. Epub 2017 Mar 28. PMID: 28349711.
Strahl B, Cheung YK, Stuckey SL. Diagnostic yield of computed tomography of the brain in first episode psychosis. J Med Imaging Radiat Oncol. 2010 Oct;54(5):431-4. doi: 10.1111/j.1754-9485.2010.02196.x. PMID: 20958941.
van den Noort M, Bosch P, Lim S, Litscher D, Litscher G. Magnetic resonance imaging in first-episode psychosis. Br J Psychiatry. 2017 Oct;211(4):250. doi: 10.1192/bjp.211.4.250. PMID: 28970305.
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