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Skotting MB, Holst AV, Munch TN. Incidental findings in MRI of the brain. Ugeskr Laeger 2024; 186:V12230770. [PMID: 38808758 DOI: 10.61409/v12230770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
This review investigates that there has been an increase in incidental brain MRI findings due to better technology and more scans. These unexpected, asymptomatic anomalies range from harmless to serious, requiring careful clinical and ethical handling. The prevalence of incidental findings with brain MRI is 4.2% and even higher when including white matter hyperintensities. There is a significant variation in this number dependent on the age of the person being scanned and the MRI quality.
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Affiliation(s)
| | - Anders Vedel Holst
- Afdeling for Hjerne- og Nervekirurgi, Københavns Universitetshospital - Rigshospitalet
| | - Tina Nørgaard Munch
- Afdeling for Hjerne- og Nervekirurgi, Københavns Universitetshospital - Rigshospitalet
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2
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Bhaskar SMM. An Equity and Justice-Informed Ethical Framework to Guide Incidental Findings in Brain Imaging Research. Clin Pract 2023; 13:116-124. [PMID: 36648851 PMCID: PMC9890311 DOI: 10.3390/clinpract13010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/24/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
The handling of incidental findings (IFs) in brain imaging studies has been a source of contention among scientists and bioethicists. A conceptual framework informed by diversity, equity, and inclusion (DEI) and distributive justice approaches, namely EUSTICE, is proposed for the ethical handling and reporting of IFs in brain imaging research. I argue that EUSTICE provides a systematic and inclusive approach to addressing the ethical conundrum around IF disclosure and managing IFs proportionately and sensitively in brain imaging research. The EUSTICE framework may have implications for the field of neurosciences or human studies broadly in guiding ethics of IFs in research.
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Affiliation(s)
- Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia; ; Tel.: +61-(02)-873-89179; Fax: +61-(02)-8738-3648
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
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3
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Oerlemans AJM, Barendregt DMH, Kooijman SC, Bunnik EM. Impact of incidental findings on young adult participants in brain imaging research: an interview study. Eur Radiol 2022; 32:3839-3845. [DOI: 10.1007/s00330-021-08474-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/25/2021] [Accepted: 11/19/2021] [Indexed: 01/02/2023]
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4
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Prevalence of incidental intracranial findings on magnetic resonance imaging: a systematic review and meta-analysis. Acta Neurochir (Wien) 2022; 164:2751-2765. [PMID: 35525892 PMCID: PMC9519720 DOI: 10.1007/s00701-022-05225-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/22/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND As the volume and fidelity of magnetic resonance imaging (MRI) of the brain increase, observation of incidental findings may also increase. We performed a systematic review and meta-analysis to determine the prevalence of various incidental findings. METHODS PubMed/MEDLINE, EMBASE and SCOPUS were searched from inception to May 24, 2021. We identified 6536 citations and included 35 reports of 34 studies, comprising 40,777 participants. A meta-analysis of proportions was performed, and age-stratified estimates for each finding were derived from age-adjusted non-linear models. RESULTS Vascular abnormalities were observed in 423/35,706 participants (9.1/1000 scans, 95%CI 5.2-14.2), ranging from 2/1000 scans (95%CI 0-7) in 1-year-olds to 16/1000 scans (95%CI 1-43) in 80-year-olds. Of these, 204/34,306 were aneurysms (3.1/1000 scans, 95%CI 1-6.3), which ranged from 0/1000 scans (95%CI 0-5) at 1 year of age to 6/1000 scans (95%CI 3-9) at 60 years. Neoplastic abnormalities were observed in 456/39,040 participants (11.9/1000 scans, 95%CI 7.5-17.2), ranging from 0.2/1000 scans (95%CI 0-10) in 1-year-olds to 34/1000 scans (95%CI 12-66) in 80-year-olds. Meningiomas were the most common, in 246/38,076 participants (5.3/1000 scans, 95%CI 2.3-9.5), ranging from 0/1000 scans (95%CI 0-2) in 1-year-olds to 17/1000 scans (95%CI 4-37) in 80-year-olds. Chiari malformations were observed in 109/27,408 participants (3.7/1000 scans, 95%CI 1.8-6.3), pineal cysts in 1176/32,170 (9/1000 scans, 95%CI 1.8-21.4) and arachnoid cysts in 414/36,367 (8.5/1000 scans, 95%CI 5.8-11.8). CONCLUSION Incidental findings are common on brain MRI and may result in substantial resource expenditure and patient anxiety but are often of little clinical significance.
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Roane JL, Mio M, Viner J, Bettridge A, Heyn C, Roifman I, Selkirk B, Kertes P, MacIntosh BJ, Thayalasuthan V, Detzler G, Endre R, Jimenez-Juan L, Henry B, Murray BJ, Goldstein BI. Incidental Findings Among Youth Participating in Multimodal Imaging Research: Characteristics of Findings and Description of a Management Approach. Front Pediatr 2022; 10:875934. [PMID: 35813368 PMCID: PMC9259791 DOI: 10.3389/fped.2022.875934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022] Open
Abstract
Research imaging in healthy and clinical youth populations yields incidental findings that require a management strategy. Our primary objective was to document the frequency and nature of incidental findings within a research group integrating multiple imaging modalities. A second objective was to describe the evolution of an approach to handling incidental findings. A case example was included to display the intricacies of some of these scenarios. Youth, ages 13-20 years, with bipolar disorder, familial risk for bipolar disorder, or healthy controls, obtained one or a combination of neuroimaging, cardio-thoracic imaging, retinal imaging, and carotid imaging. All images were systematically reviewed for incidental findings. Overall, of 223 participants (n = 102 healthy controls), 59% (n = 131) had a brain magnetic resonance imaging (MRI) incidental finding and 27% (n = 60) had at least one incidental brain finding requiring non-urgent follow-up. In addition, of 109 participants with chest/cardiac MRI and carotid ultrasound, 3% (n = 3) had chest findings, 2% (n = 2) had cardiac findings, and 1% (n = 1) had a carotid finding. Of 165 youth with retinal imaging, 1% (n = 2) had incidental findings. While the vast majority of these incidental findings were of a non-serious, non-urgent nature, there were noteworthy exceptions. Imaging research groups need a system that emphasizes the value of clinical review of research images and one that is collaborative and responsive in order to inform follow-up plans. Rating systems that have been developed and used in neuroimaging for the classification of incidental findings can be adapted for use in areas other than the brain. Regardless of severity, incidental findings may raise anxiety in youth participants and their parents. The optimal threshold is one that balances transparency with utility.
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Affiliation(s)
- Jessica L Roane
- Sunnybrook Research Institute, Toronto, ON, Canada.,Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Megan Mio
- Sunnybrook Research Institute, Toronto, ON, Canada.,Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada
| | - Jacqueline Viner
- Department of Classics, University of Toronto, Toronto, ON, Canada
| | - Ariel Bettridge
- Sunnybrook Research Institute, Toronto, ON, Canada.,Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Chinthaka Heyn
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Idan Roifman
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Beth Selkirk
- Department of Ophthalmology & Vision Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Peter Kertes
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Ophthalmology & Vision Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Ophthalmology & Visions Sciences, University of Toronto, Toronto, ON, Canada
| | - Bradley J MacIntosh
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | | | - Garry Detzler
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ruby Endre
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Laura Jimenez-Juan
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Blair Henry
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brian J Murray
- Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Benjamin I Goldstein
- Sunnybrook Research Institute, Toronto, ON, Canada.,Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Glasmacher SA, Thomas HS, Stirland L, Wilkinson T, Lumsden J, Langlands G, Waddell B, Holloway G, Thompson G, Pal S. Incidental Findings Identified on Head MRI for Investigation of Cognitive Impairment: A Retrospective Review. Dement Geriatr Cogn Disord 2019; 48:123-130. [PMID: 31805574 DOI: 10.1159/000503956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/03/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Incidental findings are common in presumed healthy volunteers but are infrequently studied in patients in a clinical context. OBJECTIVE To determine the prevalence, nature, and management implications of incidental findings on head MRI in patients presenting with cognitive symptoms, and to quantify and describe unexpected MRI abnormalities that are of uncertain relevance to the patient's cognitive symptoms. METHODS A single-centre retrospective review of patients attending a regional early-onset cognitive disorders clinic between March 2012 and October 2018. Medical records of consecutive patients who underwent head MRI were reviewed. Unexpected MRI findings were classified according to their severity and likelihood of being incidental. Markers of small vessel disease and cerebral atrophy were excluded. RESULTS Records of 694 patients were reviewed (median age 60 years, 49.9% female), of whom 514 (74.1%) underwent head MRI. 54% of the patients received a diagnosis of a neurodegenerative disorder. Overall 111 incidental findings were identified in 100 patients of whom 18 patients (3.5%, 95% CI 2.2-5.6%) had 18 incidental findings classified as requiring additional medical evaluation. 82 patients (16%, 95% CI 13.0-19.5%) had 93 incidental findings without clearly defined diagnostic consequences. 17 patients (3.3%) underwent further investigations, 14 patients (2.7%) were referred to another specialist clinic and 3 patients (0.6%) were treated surgically. Two patients had MRI findings of uncertain relevance to their cognitive symptoms, necessitating prolonged clinic follow-up. CONCLUSION Incidental findings are common in patients with cognitive impairment from this large clinic-based series; however, few required additional medical evaluation. These data could help inform discussions between clinicians and people with cognitive symptoms regarding the likelihood and potential implications of incidental imaging findings.
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Affiliation(s)
| | - Hannah Sam Thomas
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Lucy Stirland
- Division of Psychiatry, University of Edinburgh, Kennedy Tower, Royal Edinburgh Hospital, Edinburgh, United Kingdom
| | - Tim Wilkinson
- Centre for Clinical Brain Sciences, Chancellor's Building, Edinburgh, United Kingdom
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Jane Lumsden
- Centre for Clinical Brain Sciences, Chancellor's Building, Edinburgh, United Kingdom
| | - Gavin Langlands
- Centre for Clinical Brain Sciences, Chancellor's Building, Edinburgh, United Kingdom
| | - Briony Waddell
- Department of Neurology, Ninewells Hospital, Dundee, United Kingdom
| | - Guy Holloway
- Department of Old Age Psychiatry, NHS Lothian, Morningside, Royal Edinburgh Hospital, Edinburgh, United Kingdom
- Anne Rowling Regenerative Neurology Clinic, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Gerard Thompson
- Centre for Clinical Brain Sciences, Chancellor's Building, Edinburgh, United Kingdom
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, Chancellor's Building, Edinburgh, United Kingdom,
- Anne Rowling Regenerative Neurology Clinic, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom,
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Abstract
Among healthy volunteers in psychiatric brain functional magnetic resonance imaging (fMRI) research studies, the prevalence of incidentalomas can be as high as 34%, of which 10% show clinical significance. An incidentaloma is a lesion found by coincidence without clinical symptoms or suspicion. Like lesions and other types of accidental findings, it is found in healthy individuals recruited to take part in psychiatric studies. The prevalence of these accidental findings among specific psychiatric populations remains unknown. However, a precise understanding of cerebral neuroanatomy, neuroradiological expertise, and an appropriate choice of fMRI exploration sequences will increase the sensitivity of identifying these accidental findings and enable researchers to address their clinical relevance and nature. We present recommendations on how to appropriately inform patients or participants of the accidental findings. Additionally, we propose specific suggestions pertaining to the clinical research setting aimed for investigators and psychiatrists. Unlike current articles pertaining to incidentaloma, the current report provides a distinct focus on psychiatric issues and specific recommendations for studies involving psychiatric patients.
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8
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Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence. Eur J Nucl Med Mol Imaging 2019; 46:1990-2012. [PMID: 31273437 PMCID: PMC6667427 DOI: 10.1007/s00259-019-04404-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/14/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) was introduced as a hybrid SPECT/CT imaging modality two decades ago. The main advantage of SPECT/CT is the increased specificity achieved through a more precise localization and characterization of functional findings. The improved diagnostic accuracy is also associated with greater diagnostic confidence and better inter-specialty communication. METHODS This review presents a critical assessment of the relevant literature published so far on the role of SPECT/CT in a variety of clinical conditions. It also includes an update on the established evidence demonstrating both the advantages and limitations of this modality. CONCLUSIONS For the majority of applications, SPECT/CT should be a routine imaging technique, fully integrated into the clinical decision-making process, including oncology, endocrinology, orthopaedics, paediatrics, and cardiology. Large-scale prospective studies are lacking, however, on the use of SPECT/CT in certain clinical domains such as neurology and lung disorders. The review also presents data on the complementary role of SPECT/CT with other imaging modalities and a comparative analysis, where available.
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9
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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; 363:k4577. [PMID: 30467245 PMCID: PMC6249611 DOI: 10.1136/bmj.k4577] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine prevalence and types of potentially serious incidental findings on magnetic resonance imaging (MRI) in apparently asymptomatic adults, describe factors associated with potentially serious incidental findings, and summarise information on follow-up and final diagnoses. DESIGN Systematic review and meta-analyses. DATA SOURCES Citation searches of relevant articles and authors' files in Medline and Embase (from inception to 25 April 2017). REVIEW METHODS Eligible studies included prevalence and types of incidental findings detected among apparently asymptomatic adults undergoing MRI of the brain, thorax, abdomen, or brain and body. Data on study population and methods, prevalence and types of incidental findings, and final diagnoses were extracted. Pooled prevalence was estimated by random effects meta-analysis, and heterogeneity by τ2 statistics. MAIN OUTCOME MEASURES Prevalence of potentially serious incidental findings on MRI of the brain, thorax, abdomen, and brain and body. RESULTS Of 5905 retrieved studies, 32 (0.5%) met the inclusion criteria (n=27 643 participants). Pooled prevalence of potentially serious incidental findings was 3.9% (95% confidence interval 0.4% to 27.1%) on brain and body MRI, 1.4% (1.0% to 2.1%) on brain MRI, 1.3% (0.2% to 8.1%) on thoracic MRI, and 1.9% (0.3% to 12.0%) on abdominal MRI. Pooled prevalence rose after including incidental findings of uncertain potential seriousness (12.8% (3.9% to 34.3%), 1.7% (1.1% to 2.6%), 3.0% (0.8% to 11.3%), and 4.5% (1.5% to 12.9%), respectively). There was generally substantial heterogeneity among included studies. About half the potentially serious incidental findings were suspected malignancies (brain, 0.6% (95% confidence interval 0.4% to 0.9%); thorax, 0.6% (0.1% to 3.1%); abdomen, 1.3% (0.2% to 9.3%); brain and body, 2.3% (0.3% to 15.4%)). There were few informative data on potential sources of between-study variation or factors associated with potentially serious incidental findings. Limited data suggested that relatively few potentially serious incidental findings had serious final diagnoses (48/234, 20.5%). CONCLUSIONS A substantial proportion of apparently asymptomatic adults will have potentially serious incidental findings on MRI, but little is known of their health consequences. Systematic, long term follow-up studies are needed to better inform on these consequences and the implications for policies on feedback of potentially serious incidental findings. SYSTEMATIC REVIEW REGISTRATION Prospero CRD42016029472.
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Affiliation(s)
- Lorna M Gibson
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
| | - Laura Paul
- Department of Clinical Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cathie L M Sudlow
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh BioQuarter, Edinburgh EH16 4UX, UK
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10
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Griffiths P, Mooney C, Bradburn M, Jarvis D. Should we perform in utero MRI on a fetus at increased risk of a brain abnormality if ultrasonography is normal or shows non-specific findings? Clin Radiol 2018; 73:123-134. [DOI: 10.1016/j.crad.2017.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 06/29/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
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Takashima K, Takimoto Y, Nakazawa E, Hayashi Y, Tsuchiya A, Fujita M, Akabayashi A. Discovery and informing research participants of incidental findings detected in brain magnetic resonance imaging studies: Review and multi-institutional study. Brain Behav 2017; 7:e00676. [PMID: 28523219 PMCID: PMC5434182 DOI: 10.1002/brb3.676] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/01/2017] [Accepted: 02/10/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Brain imaging studies using magnetic resonance imaging (MRI) sometimes reveal incidental findings (IFs) that might be relevant to some of the health issues in research participants. Although professional communities have discussed how to manage these IFs, there is no global consensus on the concrete handling procedures including how to inform participants of IFs. METHODS First, this study reviewed previous studies for the number of IFs discovered in brain imaging studies using MEDLINE. Second, a multi-institutional study determined the number of IF discoveries and evaluated the method of informing participants at multiple institutions, which participated in a national brain science project in Japan. RESULTS Both the review and multi-institutional study showed that IFs with a high urgency level were discovered in 0-2.0% of participants, including healthy volunteers, and that the rate of IF discovery in general was higher in studies conducted in elderly population. Moreover, multi-institutional study suggested the criteria used to judge whether or not to inform participants of IFs may differ by institution. CONCLUSIONS Our results suggest that in order to ensure informing the participants of high urgency IFs, physicians who are capable of interpreting brain images clinically should review all brain images, and the establishment of a support system is required for brain imaging studies at nonmedical institutions. Since the method of informing participants of IFs might affect their understanding and acceptance of IFs, which are related to managing risks of false "clean bill of health" or psychological impacts of informing IFs, further research focusing on communication of IFs is needed.
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Affiliation(s)
- Kyoko Takashima
- Department of Public Policy Institute of Medical Science the University of Tokyo Tokyo Japan
| | - Yoshiyuki Takimoto
- Department of Biomedical Ethics Graduate School of Medicine the University of Tokyo Tokyo Japan
| | - Eisuke Nakazawa
- Department of Biomedical Ethics Graduate School of Medicine the University of Tokyo Tokyo Japan
| | - Yoshinori Hayashi
- Department of Philosophy College of Letters Ritsumeikan University Kyoto Japan
| | - Atsushi Tsuchiya
- Graduate School of Integrated Arts and Sciences Tokushima University Tokushima Japan
| | - Misao Fujita
- Uehiro Research Division for iPS Cell Ethics Center for iPS Cell Research and Application (CiRA) Kyoto University Kyoto Japan
| | - Akira Akabayashi
- Department of Biomedical Ethics Graduate School of Medicine the University of Tokyo Tokyo Japan
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12
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Bunnik EM, van Bodegom L, Pinxten W, de Beaufort ID, Vernooij MW. Ethical framework for the detection, management and communication of incidental findings in imaging studies, building on an interview study of researchers' practices and perspectives. BMC Med Ethics 2017; 18:10. [PMID: 28166795 PMCID: PMC5294804 DOI: 10.1186/s12910-017-0168-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 01/19/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND As thousands of healthy research participants are being included in small and large imaging studies, it is essential that dilemmas raised by the detection of incidental findings are adequately handled. Current ethical guidance indicates that pathways for dealing with incidental findings should be in place, but does not specify what such pathways should look like. Building on an interview study of researchers' practices and perspectives, we identified key considerations for the set-up of pathways for the detection, management and communication of incidental findings in imaging research. METHODS We conducted an interview study with a purposive sample of researchers (n = 20) at research facilities across the Netherlands. Based on a qualitative analysis of these interviews and on existing guidelines found in the literature, we developed a prototype ethical framework, which was critically assessed and fine-tuned during a two-day international expert meeting with bioethicists and representatives from large population-based imaging studies from the United Kingdom, Germany, Sweden and Belgium (n = 14). RESULTS Practices and policies for the handling of incidental findings vary strongly across the Netherlands, ranging from no review of research scans and limited feedback to research participants, to routine review of scans and the arrangement of clinical follow-up. Respondents felt that researchers do not have a duty to actively look for incidental findings, but they do have a duty to act on findings, when detected. The principle of reciprocity featured prominently in our interviews and expert meeting. CONCLUSION We present an ethical framework that may guide researchers and research ethics committees in the design and/or evaluation of appropriate pathways for the handling of incidental findings in imaging studies. The framework consists of seven steps: anticipation of findings, information provision and informed consent, scan acquisition, review of scans, consultation on detected abnormalities, communication of the finding, and further clinical management and follow-up of the research participant. Each of these steps represents a key decision to be made by researchers, which should be justified not only with reference to costs and/or logistical considerations, but also with reference to researchers' moral obligations and the principle of reciprocity.
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Affiliation(s)
- Eline M. Bunnik
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Lisa van Bodegom
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Wim Pinxten
- Department of Morphology, Hasselt University, Agoralaan Gebouw D, BE 3590 Diepenbeek, Belgium
| | - Inez D. de Beaufort
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Meike W. Vernooij
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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13
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Johnston JC, Wester K, Sartwelle TP. Neurological Fallacies Leading to Malpractice: A Case Studies Approach. Neurol Clin 2016; 34:747-73. [PMID: 27445252 DOI: 10.1016/j.ncl.2016.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.
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Affiliation(s)
- James C Johnston
- Legal Medicine Consultants, 1150 N Loop 1604 West, Suite 108-625, San Antonio, TX 78248, USA.
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen 5021, Norway
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14
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Morello-Frosch R, Varshavsky J, Liboiron M, Brown P, Brody JG. Communicating results in post-Belmont era biomonitoring studies: lessons from genetics and neuroimaging research. ENVIRONMENTAL RESEARCH 2015; 136:363-72. [PMID: 25460657 PMCID: PMC4262542 DOI: 10.1016/j.envres.2014.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/28/2014] [Accepted: 10/01/2014] [Indexed: 05/04/2023]
Abstract
BACKGROUND Biomonitoring is a critical tool to assess the effects of chemicals on health, as scientists seek to better characterize life-course exposures from diverse environments. This trend, coupled with increased institutional support for community-engaged environmental health research, challenge established ethical norms related to biomonitoring results communication and data sharing between scientists, study participants, and their wider communities. METHODS Through a literature review, participant observation at workshops, and interviews, we examine ethical tensions related to reporting individual data from chemical biomonitoring studies by drawing relevant lessons from the genetics and neuroimaging fields. RESULTS In all three fields ethical debates about whether/how to report-back results to study participants are precipitated by two trends. First, changes in analytical methods have made more data accessible to stakeholders. For biomonitoring, improved techniques enable detection of more chemicals at lower levels, and diverse groups of scientists and health advocates now conduct exposure studies. Similarly, innovations in genetics have catalyzed large-scale projects and broadened the scope of who has access to genetic information. Second, increasing public interest in personal medical information has compelled imaging researchers to address demands by participants to know their personal data, despite uncertainties about their clinical significance. Four ethical arenas relevant to biomonitoring results communication emerged from our review: tensions between participants' right-to-know their personal results versus their ability or right-to-act to protect their health; whether and how to report incidental findings; informed consent in biobanking; and open-access data sharing. CONCLUSION Ethically engaging participants in biomonitoring studies requires consideration of several issues, including scientific uncertainty about health implications and exposure sources, the ability of participants to follow up on potentially problematic results, tensions between individual and community research protections, governance and consent regarding secondary use of tissue samples, and privacy challenges in open access data sharing.
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Affiliation(s)
- Rachel Morello-Frosch
- University of California Berkeley, School of Public Health and Department of Environmental Science, Policy and Management, 130 Mulford Hall, Berkeley, CA 94720-3114, USA.
| | - Julia Varshavsky
- University of California Berkeley, School of Public Health, 50 University Hall, #7360, Berkeley, CA 94720-7360, USA.
| | - Max Liboiron
- Memorial University of Newfoundland and Labrador, Department of Sociology, St. John's, NL, Canada A1C 5S7.
| | - Phil Brown
- Northeastern University, Social Science Environmental Health Research Institute, Department of Sociology and Anthropology and Department of Health Sciences, 360 Huntington Avenue, 500 Holmes Hall, Boston, MA 02115, USA.
| | - Julia G Brody
- Silent Spring Institute, 29 Crafts St, Newton, MA 02458, USA.
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15
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Hoffmann M. Two basic ethical problems of incidental findings in population-based, non-intervening magnetic resonance imaging (MRI) research. J Eval Clin Pract 2013; 19:427-32. [PMID: 23692223 DOI: 10.1111/jep.12036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 11/27/2022]
Abstract
Population-based magnetic resonance imaging (MRI) generates many beneficial consequences for future generations of patients. But there are also some unintended implications for present patients and research subjects. The most important of these implications is the occurrence of incidental findings. In what follows, I will explicate two basic ethical problems concerning incidental findings. I will first argue that the main cause of these two problems lies in the conflicted nature of the medical researcher's role. I will then clarify the two problems, which involves appealing to two basic ethical requirements. The first problem originates from specific empirical conditions of epidemiological MRI research, which indicate shortcomings in the process of obtaining informed consent. The second problem is due to a conflict between obligations of beneficence for the research subjects and the researcher's duty to produce valid and generalizable study results. Finally, I will develop some preliminary perspectives for the solution of these problems.
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Affiliation(s)
- Martin Hoffmann
- Department of Philosophy, University of Hamburg, Hamburg, Germany.
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16
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The Relation Between Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Acquired During Operations Enduring Freedom and Iraqi Freedom. J Head Trauma Rehabil 2013; 28:1-12. [DOI: 10.1097/htr.0b013e318256d3d3] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Khandanpour N, Hoggard N, Connolly DJA. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol 2012; 68:245-50. [PMID: 22959259 DOI: 10.1016/j.crad.2012.07.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 11/18/2022]
Abstract
AIM To investigate whether imaging is associated with early detection of the organic causes of the first episode of psychosis (FEP). MATERIALS AND METHODS Individuals with FEP but no neurological signs referred to a tertiary centre for cerebral magnetic resonance imaging (MRI) or computed tomography (CT) were reviewed retrospectively. Two groups were evaluated with either CT or MRI; the two groups were independent and no individual underwent both CT and MRI. RESULTS One hundred and twelve consecutive cerebral MRI and 204 consecutive CT examinations were identified. Three (2.7%) individuals had brain lesions [brain tumour and human immunodeficiency virus (HIV) encephalopathy] potentially accountable for the psychosis at MRI. Seventy patients (62.5%) had incidental brain lesions, such as cerebral atrophy, small vessel ischaemic changes, unruptured Circle of Willis aneurysm, cavernoma, and arachnoid cysts at MRI. Three patients (1.5%) had focal brain lesions (primary or secondary tumours) potentially accountable for the psychosis at CT. One hundred and thirty-three patients (65.2%) had incidental brain lesions unrelated to the psychosis on CT scan. There was no significant difference between MRI and CT imaging in detecting organic disease potentially responsible for FEP (p < 0.001). CONCLUSION Routine MRI or CT imaging of the brain is unlikely to reveal disease leading to a significant change in management. MRI was comparable with CT in terms of diagnosis of both pathological and incidental cerebral lesions. Therefore, routine brain structural imaging of FEP in patients without focal neurology may not be routinely required and if imaging is requested then CT may function equally as well as MRI as the first-line investigation.
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Affiliation(s)
- N Khandanpour
- Academic Unit of Radiology, Royal Hallamshire Hospital, University of Sheffield, UK
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18
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Craven IJ, Griffiths PD, Bhattacharyya D, Grunewald RA, Hodgson T, Connolly DJA, Coley SC, Batty R, Romanowski CAJ, Hoggard N. 3.0 T MRI of 2000 consecutive patients with localisation-related epilepsy. Br J Radiol 2012; 85:1236-42. [PMID: 22573303 DOI: 10.1259/bjr/30177037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Clinical guidelines suggest that all patients diagnosed with localised seizures should be investigated with MRI to identify any epileptogenic structural lesions, as these patients may benefit from surgical resection. There is growing impetus to use higher field strength scanners to image such patients, as some evidence suggests that they improve detection rates. We set out to review the detection rate of radiological abnormalities found by imaging patients with localised seizures using a high-resolution 3.0 T epilepsy protocol. METHODS Data were reviewed from 2000 consecutive adult patients with localisation-related epilepsy referred between January 2005 and February 2011, and imaged at 3.0 T using a standard epilepsy protocol. RESULTS An abnormality likely to be related to seizure activity was identified in 403/2000 (20.2%) patients, with mesial temporal sclerosis diagnosed in 211 patients. 313/2000 (15.6%) had lesions potentially amenable to surgery. Abnormalities thought unrelated to seizure activity were found in 324/2000 (16.1%), with 8.9% having evidence of ischaemic disease. CONCLUSIONS Since the introduction of the then National Institute for Clinical Excellence guidelines in 2004, the detection rate of significant pathology using a dedicated 3.0 T epilepsy protocol has not fallen, despite the increased numbers of patients being imaged. This is the largest study of epilepsy imaging at 3.0 T to date and highlights the detection rates of significant pathology in a clinical setting using a high-strength magnet. The prevalence of ischaemic disease in this population is significantly higher than first thought, and may not be incidental, as is often reported.
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Affiliation(s)
- I J Craven
- Department of Radiology, Royal Hallamshire Hospital, Sheffield, UK.
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19
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20
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Apold VS, Downie J. Bad news about bad news: the disclosure of risks to insurability in research consent processes. Account Res 2011; 18:31-44. [PMID: 21287413 DOI: 10.1080/08989621.2011.542681] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
One of the phenomena associated with research is "incidental findings," that is, unexpected findings made during the research, and outside the scope of the research, which have potential health importance. One underappreciated risk of incidental findings is the potential loss of the research subject's insurability; or if a research subject fails to disclose incidental findings when applying for insurance, the insurance contract may be voidable by the insurer. In this article, we seek to explain the insurability risks associated with incidental findings and to make recommendations for how researchers and research ethics committees should address the issue of disclosure of these risks.
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Affiliation(s)
- Victoria Smith Apold
- Faculties of Law and Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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21
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Booth TC, Jackson A, Wardlaw JM, Taylor SA, Waldman AD. Incidental findings found in "healthy" volunteers during imaging performed for research: current legal and ethical implications. Br J Radiol 2010; 83:456-65. [PMID: 20335427 DOI: 10.1259/bjr/15877332] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Incidental findings found in "healthy" volunteers during research imaging are common and have important implications for study design and performance, particularly in the areas of informed consent, subjects' rights, clinical image analysis and disclosure. In this study, we aimed to determine current practice and regulations concerning information that should be given to research subjects when obtaining consent, reporting of research images, who should be informed about any incidental findings and the method of disclosure. We reviewed all UK, European and international humanitarian, legal and ethical agencies' guidance. We found that the guidance on what constitutes incidental pathology, how to recognise it and what to do about it is inconsistent between agencies, difficult to find and less complete in the UK than elsewhere. Where given, guidance states that volunteers should be informed during the consent process about how research images will be managed, whether a mechanism exists for identifying incidental findings, arrangements for their disclosure, the potential benefit or harm and therapeutic options. The effects of incidentally discovered pathology on the individual can be complex and far-reaching. Radiologist involvement in analysis of research images varies widely; many incidental findings might therefore go unrecognised. In conclusion, guidance on the management of research imaging is inconsistent, limited and does not address the interests of volunteers. Improved standards to guide management of research images and incidental findings are urgently required.
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Affiliation(s)
- T C Booth
- Royal Free Hospital NHS Trust, Department of Radiology, Pond Street, London, UK.
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22
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Deslauriers C, Bell E, Palmour N, Pike B, Doyon J, Racine E. Perspectives of Canadian Researchers on Ethics Review of Neuroimaging Research. J Empir Res Hum Res Ethics 2010; 5:49-66. [DOI: 10.1525/jer.2010.5.1.49] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current and potential uses of neuroimaging in healthcare and beyond have spurred discussion about the ethical issues related to neuroimaging and neuroimaging research. This study examined the perspectives of neuroimagers on ethical issues in their research and on the ethics review process. One hundred neuroimagers from 13 Canadian neuroscience centers completed an online survey and 35 semi-structured interviews were conducted. Neuroimagers felt that most ethical and social issues identified in the literature were dealt with adequately, well, and even very well by research ethics boards (REBs), but some issues such as incidental findings and transfer of knowledge were problematic. Neuroimagers reported a range of practical problems in the ethics review process. We aimed to gather perspectives from REB on the ethics review process, but insufficient participation by REBs prevented us from reporting their perspectives. Given shortcomings identified by neuroimagers as well as longstanding issues in Canadian ethics governance, we believe that substantial challenges exist in Canadian research ethics governance that jeopardize trust, communication, and the overall soundness of research ethics governance. Neuroimagers and REBs should consider their shared responsibilities in developing guidance to handle issues such as incidental findings, risk assessment, and knowledge transfer.
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Affiliation(s)
- C. Deslauriers
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal
| | - E. Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal
| | - N. Palmour
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal
| | | | | | - E. Racine
- Institut de recherches cliniques de Montréal, Université de Montréal and McGill University
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Morris Z, Whiteley WN, Longstreth WT, Weber F, Lee YC, Tsushima Y, Alphs H, Ladd SC, Warlow C, Wardlaw JM, Al-Shahi Salman R. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009; 339:b3016. [PMID: 19687093 PMCID: PMC2728201 DOI: 10.1136/bmj.b3016] [Citation(s) in RCA: 505] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2009] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To quantify the prevalence of incidental findings on magnetic resonance imaging (MRI) of the brain. DESIGN Systematic review and meta-analysis of observational studies. DATA SOURCES Ovid Medline (1950 to May 2008), Embase (1980 to May 2008), and bibliographies of relevant articles. Review methods Two reviewers sought and assessed studies of people without neurological symptoms who underwent MRI of the brain with or without intravenous contrast for research purposes or for occupational, clinical, or commercial screening. MAIN OUTCOME MEASURES Overall disease specific and age specific prevalence of incidental brain findings, calculated by meta-analysis of pooled proportions using DerSimonian-Laird weights in a random effects model. RESULTS In 16 studies, 135 of 19 559 people had neoplastic incidental brain findings (prevalence 0.70%, 95% confidence interval 0.47% to 0.98%), and prevalence increased with age (chi(2) for linear trend, P=0.003). In 15 studies, 375 of 15 559 people had non-neoplastic incidental brain findings (prevalence 2.0%, 1.1% to 3.1%, excluding white matter hyperintensities, silent infarcts, and microbleeds). The number of asymptomatic people needed to scan to detect any incidental brain finding was 37. The prevalence of incidental brain findings was higher in studies using high resolution MRI sequences than in those using standard resolution sequences (4.3% v 1.7%, P<0.001). The prevalence of neoplastic incidental brain findings increased with age. CONCLUSIONS Incidental findings on brain MRI are common, prevalence increases with age, and detection is more likely using high resolution MRI sequences than standard resolution sequences. These findings deserve to be mentioned when obtaining informed consent for brain MRI in research and clinical practice but are not sufficient to justify screening healthy asymptomatic people.
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Affiliation(s)
- Zoe Morris
- Division of Clinical Neurosciences, Western General Hospital, Edinburgh
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