Chance et al (2002) described volumetric measurement of the amygdala and found few differences between normal and schizophrenia post-mortem samples. This fails to confirm published magnetic resonance imaging (MRI) data on hundreds of individuals which have been systematically reviewed and analysed (Wright et al, 2000). Chance et al (2002) report mean absolute volumes (643 mm3 for nine men and 612 mm3 for nine women) that are much smaller than those reported in MRI studies. They go on to speculate on the reasons for this discrepancy and point to ‘limitations’ in both MRI and meta-analysis. The authors are right to highlight the problem of anatomical definition of the amygdala in vivo and how other imaging parameters may obscure (or reveal) laterality effects and differences between subject groups. However, they are wrong to blame meta-analysis. Systematic review and meta-analysis of MRI data is a powerful means of quantifying the precise effects that are the subject of speculation by Chance and colleagues.
We have recently carried out just such a review of the normal human amygdala (Brierley et al, 2002). Some 39 studies and 51 data-sets met our inclusion criteria, allowing comparison of 1491 amygdala pairs. The weighted mean volumes (95% CI) for the left and right amygdala were 1726.7 mm3 (35.1) and 1691.7 mm3 (37.2), respectively. The range was from 1050 to 3880 mm3. This variance is clearly worrying. We were able to examine systematically some of the causes of this and found that most imaging parameters, such as slice thickness and plane of orientation, were not particularly influential. Study size had a weak but significant effect, with larger studies tending to give smaller volumes. Anatomical definition was the most important variable. Studies which employed the Watson criteria (Watson et al, 1992) gave significantly larger volumes than the remainder. Gender differences persisted (male greater than female) even in studies which attempted to control for intracranial volume. Laterality effects were not significant.
The ease of obtaining high-resolution anatomical brain images afforded by modern MRI on large samples of individuals across the life span means that MRI should be taken as the gold standard on regional volumetrics rather than post-mortem samples with all their attendant deficiencies. However, in order to exploit the advantages of MRI, researchers must pay particular attention to reliability of anatomical definitions. We have proposed that Watson's criteria be adopted generally and have recommended some minor improvements (Brierley et al, 2002).
- © 2002 Royal College of Psychiatrists
We agree with David et al that the key problem, which we have highlighted, in in vivo MRI studies of the amygdala, is anatomical definition. The ability to define anatomical boundaries at the cellular level means that post-mortem samples set the gold standard for anatomical delineation. Indeed, the generally smaller volumes of the amygdala (uncorrected for tissue shrinkage in Chance et al, 2002) reported in post-mortem studies are indicative of more conservative estimates when the precise boundaries can be seen. This is consistent with Brierley et al's (2002) conclusion in their meta-analysis that anatomical definition is the most prominent contributor to variance in MRI volume estimates of the amygdala.
Our criticism is not of meta-analysis per se, but of the inclusion of some studies, which owing to low scan resolution use only very approximate anatomical definitions. Particularly problematic in schizophrenia is the use of landmarks, which may be systematically shifted with respect to the boundary of the amygdala, owing to other changes in the temporal lobe. While MRI studies have the obvious advantages of an in vivo assessment and larger sample size, post-mortem studies are also important as a check on the possibility of systematic bias which may enter the MRI literature (Walker et al, 2002).
We agree with the importance of consensus criteria for anatomical definitions which take full advantage of the improvements in up-to-date MRI visualisation. Our paper concludes with some references to studies attempting to tackle this issue for the amygdala, to which the paper of Brierley et al (2002) should be added.