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It should be no surprise that a visit to a doctor can reveal something is wrong. After all, most who define themselves as unwell expect a medical explanation based on the best available diagnostic technology. Unfortunately, the increasing use of imaging technologies is leading clinicians to identify abnormalities that have nothing to do with the presenting problem, and no one knows quite what to do with them, particularly when it comes to insurance.
Incidental findings from brain magnetic resonance imaging (MRI) that need further evaluation occur in about 3% of middle-aged and elderly populations - that’s one for every 37 scans.1 The majority are without clinical consequences, but 0.7% of scans show tumours, mostly benign menigiomas that can be managed with routine annual imaging.2 It takes 2,000 scans to find one clinically silent low-grade glioma.3
But early treatment of these cancers improves outcomes. A tumour may be present but silent for a decade or more and do well if removed early. This success has led to calls for a screening program that would identify all the other incidental findings, each with its own problems.4
Cerebrovascular abnormalities are by far the largest category but present greater management challenges. Identifying one aneurysm requires 286 scans. Aneurysms have a 1.3% risk of rupture per year but treatment with coiling carries a 4.7% risk of death or disability.5 Similar risk/benefit questions arise in arteriovenous malformations and cerebral cavernous malformations.6
Silent strokes, or excessive white matter changes, should prompt cardiovascular risk review and alert the underwriter to the impact of these problems. Whether the identification and management of these otherwise asymptomatic lesions makes any difference to outcomes is not clear.7
The detection of unexpected serious problems on MRI screening is fortuitous and usually good news because providing the appropriate treatment early improves the prognosis. For many there will be difficult decisions to make. It is imperative that anyone undergoing MRI investigations is aware of this possibility before the scan is performed. This is especially the case in research settings and the growing market for direct to consumer investigations. The ways in which findings are shared is also important, to ensure that joint decision making about management can take place, often in the face of significant uncertainty and anxiety.8
For the insurer, the situation is usually more straightforward. It is important to wait until all relevant investigations and the treatment plan is complete. The vast majority of non-specific findings (e.g. minor white matter changes) are of little consequence, whilst the insurance risk of those specifically diagnosed can be assessed case by case each on its own merits.
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