Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32 https://doi.org/10.24869/psyd.2023.

27 Original paper
© Medicinska naklada, Zagreb & School of Medicine, University of Zagreb & Pro mente, Zagreb, Croatia

COMPARISON OF INCIDENTAL FINDINGS OF BRAIN

MAGNETIC RESONANCE IMAGING OF SCHIZOPHRENIA
PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS
AND HEALTHY CONTROLS
Olga Bayar Kapici1, Yaşar Kapici2 & Atilla Tekin3
1
Adıyaman Training and Research Hospital, Department of Radiology, Adıyaman, Turkey
2
Kahta State Hospital, Psychiatry Outpatient Clinic, Adıyaman, Turkey
3
Adıyaman University, Faculty of Medicine, Department of Psychiatry, Adıyaman, Turkey

received: 20.12.2022; revised: 30.1.2023; accepted: 8.2.2023

SUMMARY
Background: It has been emphasized for a long time that neurodevelopmental and neurodegenerative processes play an
important role in the etiology of schizophrenia.
Subjects and methods: In this study, brain magnetic resonance imaging (MRI) of 97 patients with schizophrenia (SCH), 42 first-
episode psychosis (FEP) patients, and 70 healthy controls (HC) were analyzed, and abnormal findings on brain MRI were recorded.
Participant's age, gender, and brain MRI findings were recorded retrospectively. Fazekas grades evaluated the distribution of white
matter hyperintensities in the brain.
Results: The mean ages of FEP, SCH, and HC were 24.8±6.3, 36.9±11.5, and 36±10.5, respectively. Generalized cerebral
atrophy was higher in SCH and HC than in FEP groups, and frontoparietal atrophy was higher in the SCH group than in HC and
FEP groups (p<0.001). The percentage of Fazekas Grade-1 was higher in the SCH group than HC and FEP groups (p=0.006).
Additionally, the cavum veli interpositi (CVI) rate was higher in FEP and SCH groups than in the HC group (p=0.042).
Conclusion: Although there was no significant age difference between the SCH and HC groups, the higher prevalence of
generalized cerebral atrophy in the SCH group may indicate the neurodegenerative process of schizophrenia. The fact that CVI, a
congenital brain anomaly, was detected more frequently in the FEP and SCH groups may suggest that schizophrenia may be
associated with neurodevelopmental process.

Key words: schizophrenia - first-episode psychosis - brain magnetic resonance imaging

* * * * *

INTRODUCTION such as stress. It is thought that the disappearance of

synaptic connections compensating for the disorder as
Schizophrenia is a chronic mental illness that a result of pruning is responsible for the symptoms
affects 1% of the population. Schizophrenia is often (Fatani et al. 2017).
characterized by a prodromal period (social withdra- Although schizophrenia is thought to result from an
wal, depressive symptoms, obsessive and compulsive impairment in early development, neuronal maturation
symptoms) and subsequent psychotic exacerbations processes that occur during adolescence reveal
(delusions-halucinations and disorganized behavior or psychosis. It is known that the human brain reaches
speech). Although the etiology of schizophrenia is not approximately the adult brain size in primary school
yet known, it is thought that brain abnormalities years, and this growth occurs from gray matter, not
ultimately play a role in the development of schizo- white matter. In addition, specific regulation of neural
phrenia (McCutcheon et al. 2020). connections and remarkable shrinkage of cerebral
The neurodevelopmental theory proposes that structures also occur in early cerebral maturation. The
schizophrenia results from a structural deficiency in delay between an early lesion and the onset of the
the early life stages of development. These develop- disease is explained by genetic changes in some
mental stages are; neuronal precursors, glial prolife- maturation mechanisms, such as cortical pruning that
ration and migration, axonal and dendritic prolife- occurs at puberty (Walker et al. 2004).
ration, myelination of axons, programmed cell death, Postmortem studies have reported limbic and tem-
and synaptic pruning. A widely accepted model pro- poral lobe abnormalities, including the amygdala-hip-
poses that a neurodevelopmental defect leads to chan- pocampal complex and parahippocampal gyrus, and an
ges in morphology and cell architecture, resulting in a enlargement of the temporal horn of the lateral ven-
deficit in the modulatory capacity of neurons. How- tricles. Most of these findings were lateralized to the
ever, it is thought that this neurodevelopmental defect left side of the brain, leading to speculation that
leads to significant symptoms in adolescence and early schizophrenia might be an anomaly of brain develop-
adulthood when triggered by environmental factors ment (Shenton et al. 2001).

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 Olga Bayar Kapici, Yaşar Kapici & Atilla Tekin: COMPARISON OF INCIDENTAL FINDINGS OF BRAIN MAGNETIC RESONANCE
IMAGING OF SCHIZOPHRENIA PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS AND HEALTHY CONTROLS
Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32

On FLAIR axial images of Brain MRG: A: Fazekas Grade 0 B: Fazekas Grade I C: Fazekas Grade II
Figure 1. Illustration of Normal Brain MRI and Fazekas Grade I and Grade II

The magnetic resonance imaging (MRI) study SUBJECTS AND METHODS

conducted in 1984 illuminated the understanding of
brain abnormalities in patients with schizophrenia. Study Design
Subsequent brain MRI studies have shown enlarged Brain MRIs of patients followed up with the diag-
lateral ventricles and specific gray matter volume nosis of schizophrenia and first-episode psychosis in the
reductions, particularly in the superior temporal gyrus Psychiatry Clinic of Hospital between 01/01/2018 and
and medial temporal lobe brain regions (amygdala, 01/01/2022 were retrospectively analyzed. The Local
hippocampus, and parahippocampal gyrus). Decreases Ethics Committee approved this research (Date of
in the size of the cortical sulcus and the volume of the Decision: 18/01/2022, Number of Meetings:1, Number
frontal and parietal lobes have also been reported of Decisions: 2022/1-21).
(McCarley et al. 1999).
Brain MRI should be performed to exclude
Study Group
neurological diseases in patients with schizophrenia or
patients with psychotic symptoms. In this study, we Ninety-seven patients with schizophrenia, 42 pa-
aim to compare the findings detected incidentally on tients with first-episode psychosis without treatment,
brain MRI in patients with schizophrenia (SCH) and and 70 healthy controls were included. Among the pa-
patients with first-episode psychosis (FEP) with the tients with a diagnosis of schizophrenia, those with mi-
healthy control (HC) group. graine (n=4), vitamin B12 deficiency (n=11), hypo-

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 Olga Bayar Kapici, Yaşar Kapici & Atilla Tekin: COMPARISON OF INCIDENTAL FINDINGS OF BRAIN MAGNETIC RESONANCE
IMAGING OF SCHIZOPHRENIA PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS AND HEALTHY CONTROLS
Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32

thyroidism (n=2), diabetes mellitus (n=4), hypertension Statistical Analysis

(n=3), operated brain tumor (n=1), mental retardation
(n=3), iron deficiency anemia (n=2), alcohol or sub- Continuous variables were given as mean ± standard
stance abuse (n=4) were excluded from the study. People deviation. Categorical variables were given as percenta-
without psychiatric diagnoses were selected as healthy ges (%). Kurtosis and skewness values and the Kolmo-
controls based on their statements and medical records. gorov-Smirnov test were used to determine whether con-
tinuous variables were normally distributed. One-way
Anova test and Tamhane test were used to compare the
Brain MRI Examination mean ages of SCH, FEP, and HC groups. The Chi-square
The MRI examination was obtained from the Philips test and Fischer’s Exact test were used to compare cate-
Achieva MR device (Philips Medical Systems, Best, gorical variables. IBM SPSS Statistics v.26 (IBM SPSS
Netherlands) with a 1.5 Tesla magnetic field strength Inc., Chicago, IL, USA) was used to perform statistical
using a head coil. The evaluation was performed on brain analysis, p values < 0.05 being considered significant.
MRI T1-weighted axial, T2-weighted axial, FLAIR axial,
and T2-weighted coronal and T1-weighted sagittal RESULTS
images. Brain MRI findings, age, and gender informa-
tion were recorded retrospectively. According to the The mean ages of FEP, SCH, and HC were 24.8±6.3,
region of atrophy on brain MRI, atrophy was divided 36.9±11.5, and 36±10.5, respectively. There was a signifi-
into four classes: generalized cerebral, frontal, fronto- cant difference in age between the groups (p<0.001).
parietal, and cerebrocerebellar. Fazekas scale was used According to the Post-hoc Tamhane test, the mean ages
to assess the level of brain aging. Fazekas scale was of SCH and HC groups were higher than the mean age of
made according to WMH. Fazekas grade 0 (absence), 1 the FEP group (p<0.001 and p<0.001, respectively). There
(punctate foci), 2 (beginning confluence of loci), or 3 was no difference in age between the SCH and HC groups
(large confluent areas) (Scheltens et al. 1993). The (p=0.944). 48.6% of HC, 66.7% of FEP, and 70.1% of
appearance of Fazekas grade 0, grade1, and grade 2 on SCH were male, and there was a significant difference
brain MRI is shown in figure 1. The appearance of the between the groups in terms of gender distribution
cavum septum pellucidum, cavum vergae, and cavum (p=0.015). Post-hoc analysis showed that the percentage of
veli interpositi on brain MRI are given in figure 2. males was higher in FEP and SCH groups than HC group.

On T2- weighted axial images of Brain MRG: A: Cavum Septum Pellucidum B: Cavum Vergae C: Cavum Veli Interpositi
Figure 2. Cavum Septum Pellucidum, Cavum Vergae and Cavum Veli Interpositi

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 Olga Bayar Kapici, Yaşar Kapici & Atilla Tekin: COMPARISON OF INCIDENTAL FINDINGS OF BRAIN MAGNETIC RESONANCE
IMAGING OF SCHIZOPHRENIA PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS AND HEALTHY CONTROLS
Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32

Table-1. Comparison of incidental MRI findings between first episode psychotic patients and chronic schizophrenic
patients and healthy controls
HC (n=70) FEP (n=42) SCH (n=97) χ2 p
N/% N/% N/%
Atrophy 33.686 <0.001
Generalized Cerebral 5 / 7.1a,b 0 / 0b 15 / 15.5a
Frontal 0/0 1 / 2.4 5 / 5.2
Frontoparietal 0 / 0a 0 / 0a 12 / 12.4b
Cerebrocerebellar 0/0 0/0 2 / 2.1
Fazekas 0.006
Grade 1 1 / 1.4a 1 / 2.4a 13 / 13.4b
Grade 2 0/0 0/0 2 / 2.1
Cavum septum pellucidum 2 / 2.9 4 / 9.5 8 / 8.2 0.236
Cavum vergae 1 / 1.4 1 / 2.4 5 / 5.2 0.483
Cavum veli interpositi 1 / 1.4 a 5 / 11.9 b 8 / 8.2 a,b 0.042
Ethmoidal thickening 27 / 38.6 20 / 47.6 46 / 47.4 1.497 0.473
Maxillary thickening 9 / 12.9 10 / 23.8 22 / 22.7 3.074 0.215
Sphenoid thickening 5 / 7.1 2 / 4.8 7 / 7.2 0.878
Frontal thickening 5 / 7.1 2 / 4.8 6 / 6.2 0.935
Retention cyst 12 / 17.1 7 / 16.7 20 / 20.6 0.461 0.794
Septal Deviation 20 / 28.6 11 / 26.2 37 / 38.1 2.662 0.264
Sinus Polyp 0/0 1 / 2.4 0/0 0.201
Adenoid Hypertrophy 2 / 2.9 4 / 9.5 3 / 3.1 0.192
Concha Bullosa 0/0 0/0 1/1 N/A
Ranula Cyst 0/0 0/0 1/1 N/A
Tornwalt's Cyst 2 / 2.9 0/0 1/1 0.593
Nonspesific Gliotic foci 10 / 14.3 6 / 14.3 22 / 22.7 0.425
Gliosis 0/0 0/0 5 / 5.2 0.083
Encephalomalacia 0/0 0/0 3 / 3.1 0.306
Mastoiditis 1 / 1.4 1 / 2.4 1/1 0.783
Mega cisterna Magna 4 / 5.7 2 / 4.8 7 / 7.2 0.870
Scalp Lesion 0/0 1 / 2.4 0/0 0.201
Vertebral artery dolichoectasia 1 / 1.4 0/0 7 / 7.2 0.083
Venticular Asymmetry 2 / 2.9 1 / 2.4 1/1 0.544
Partial empty sella 0/0 1 / 2.4 2 / 2.1 0.436
Vertebral artery hypoplasia 0/0 0/0 1/1 N/A
Ferromagnetic Artifact 0/0 0/0 1/1 N/A
Mesial temporal sclerosis 0/0 0/0 2 / 2.1 0.688
Hydrocephalus 0/0 0/0 1/1 N/A
Dyke Davidoff Masson 0/0 0/0 1/1 N/A
Arachnoid Cyst 2 /2.9 0/0 0/0 0.473
Chi-square test was used; p values < 0.05 being considered significant

The frequency of incidental MRI findings of the DISCUSSION

groups was compared in Table 1. Accordingly, genera-
lized cerebral atrophy was higher in SCH and HC than The striking results we obtained in this study are as
in FEP groups, and frontoparietal atrophy was higher follows: i.) Generalized cerebral, frontal, and fronto-
in the SCH group than in HC and FEP groups parietal atrophies were significantly higher in the SCH
(p<0.001). The percentage of Grade-1 Fazekas was group than in FEP and HC, ii.) Fazekas grade 1 was
higher in the SCH group than HC and FEP groups significantly higher in the SCH group than in FEP and
(p=0.006). Additionally, the percentage of cavum veli HC, iii.) Cavum veli interpositi was significantly higher
interpositi was higher in FEP and SCH groups than HC in FEP and SCH groups than HC iv.) Encephalomalacia
group (p=0.042). and gliosis were found only in the SCH group.

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 Olga Bayar Kapici, Yaşar Kapici & Atilla Tekin: COMPARISON OF INCIDENTAL FINDINGS OF BRAIN MAGNETIC RESONANCE
IMAGING OF SCHIZOPHRENIA PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS AND HEALTHY CONTROLS
Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32

Although it is known that Emil Kraepelin, who first (Tubbs et al. 2011). The velum interpositum is formed
described schizophrenia, talked about cellular damage by the superposition of two layers of the tela choroidea
in the cortical brain in patients with schizophrenia, the of the third ventricle between the internal cerebral veins
first findings of ventricular enlargement in patients with and the posterior medial choroidal artery. The velum
schizophrenia were obtained from pneumoencephalo- interpositum is a space containing cerebrospinal fluid,
graphic studies in the 1920s (DeLisi et al. 2022). When and the expansion of this space is called CVI. It is an
Smith et al. performed brain MRI for the first time on incidental finding on brain MRI and does not cause any
patients with schizophrenia in 1984, it became possible complications. However, studies have associated CVI
to understand the brain abnormalities of people with with psychosis, mental retardation, hydrocephalus, and
schizophrenia (Smith et al. 1984). White and gray epilepsy (De Leucio & Dossani 2022). CVI was found
matter changes, superior temporal gyrus, temporal and more frequently than HC in both FEP and SCH groups
frontal lobe axonal connections, and uncinate and fornix in this study.
abnormalities have been reported in schizophrenia CSP is a space located between the leaflets of the
(Shenton et al. 2001). While some studies on schizo- septum pellucidum located below the anterior part of
phrenia reported a reduction in brain volume, some the corpus callosum and above the fornix, and it
studies did not find a difference with healthy controls. regresses after birth. However, it can be seen in 10%
The difficulties of taking the head/brain size data, which of adults (Galarza et al. 2004). CSP has been reported
is affected by many reasons such as age, gender, and more frequently in schizophrenia in many studies
nutrition, as an objective criterion, has reduced the (DeLisi et al. 1993, Degreef et al. 1992, Nopoulos et
importance of total brain volume (Ward et al. 1996). al. 1997). We did not find a significant difference
However, brain atrophy, characterized by enlargement between the groups in terms of CSP frequency.
of the cerebral sulci and ventricles, is a commonly Although the frequency of CSP was higher in the SCH
acceptable finding in schizophrenia. and FEP groups. We think that increasing the sample
In this study, the mean age of the FEP group was size may make this difference statistically significant.
lower than that of HC and SCH, and the FEP group If the CSP continues posteriorly, crosses the fornix and
included a diagnostically heterogeneous disease group extends into the foramen of Monro, it is called CV. CV
(short psychotic episode, schizophreniform disorder, is seen in less than 1% of adults. It is emphasized that
psychotic depression, schizophrenia, schizoaffective CV is more common in patients with schizophrenia
disorder, bipolar disorder, psychosis not otherwise (Degreef et al. 1992).
specified). This may explain the differences in the Encephalomalacia is defined as the loss of brain
distribution of brain abnormalities. tissue due to cerebral injury, ischemia, or trauma.
White matter hyperintensities (WMH), also known Encephalomalacia has been associated with neuro-
as leukoaraiosis, are characterized by a bright appea- logical and neuropsychiatric diseases. Encephalo-
rance on T2-weighted and FLAIR images of brain MRI. malacia is often accompanied by gliosis resulting from
Although WMH is considered an incidental finding injury-induced glial cell proliferation (Das et al. 2018).
mainly in the elderly, it is thought to be associated with
impairment in attention, processing, and executive func- Limitations
tions. It is thought that WMH develops due to hypoxic
damage, hypoperfusion and atherosclerosis. While This study has some limitations. The absence of
Zanetti et al. found no difference in WMH between information for disease severity and disease duration
first-episode psychosis and healthy controls (Zanetti et resulted in the inability to perform correlation analysis.
al. 2008), Persaud et al. found focal signal intensities Another limitation of the study is the follow-up of FEP
higher in SCH patients than in bipolar disorder patients patients after the first-episode. The fact that the mean
and healthy controls (Persaud et al. 1997). Lubman et al. age of the FEP group is smaller than the other two
found more frequent WMH in schizophrenia patients groups can be considered as a limitation.
than healthy subjects (Lubman et al. 2002). Our study
found that the Fazekas grades determined by the WMH CONCLUSION
shape were higher in the SCH group than the FEP and
HC group. Atherosclerosis is thought to be in the Although schizophrenia is accepted as a psychiatric
pathophysiology of WMH. According to the literature, disorder, it should be evaluated as a neuropsychiatric
atherosclerosis is also more common in schizophrenia disorder because of the frequent neurodevelopmental or
than healthy population (Davidson 2002). In future neuroanatomical pathologies in schizophrenia. Although
studies, comparison of Fazekas scale with lipid para- brain MRI has no place in the diagnosis of schizo-
meters and carotis intima media thickness can be phrenia, brain MRI is often used in the differential diag-
performed to evaluate atherosclerosis. nosis and exclusion of additional pathologies. This
Anterior midline intracranial cysts such as cavum study is valuable because it shows that both neurodeve-
veli interpositi (CVI), cavum septum pellucidum (CSP), lopmental abnormalities and acquired pathologies are
and cavum vergae (CV) are diagnosed with brain MRI more common in schizophrenia.

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 Olga Bayar Kapici, Yaşar Kapici & Atilla Tekin: COMPARISON OF INCIDENTAL FINDINGS OF BRAIN MAGNETIC RESONANCE
IMAGING OF SCHIZOPHRENIA PATIENTS, FIRST-EPISODE PSYCHOSIS PATIENTS AND HEALTHY CONTROLS
Psychiatria Danubina, 2023; Vol. 35, No. 1, pp 27-32

9. Lubman DI, Velakoulis D, McGorry PD, Smith DJ,

Acknowledgements: None. Brewer W, Stuart G et al.: Incidental radiological findings
on brain magnetic resonance imaging in first‐episode
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Correspondence:
Olga Bayar Kapici, MD
Adıyaman Training and Research Hospital, Department of Radiology
02040, Adıyaman, Turkey
E-mail: olgasahbayar@gmail.com

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