IntroductionBipolar disorder has a lifetime incidence of about 0.5%-1% in both male and female individuals and presents a tremendous emotional and financial burden to affected patients and their families owing to its potential for psychosis, suicide, chronicity and recurrence.1 Clinicians and researchers have recently suggested that intervening early in the course of bi polar disorder may reduce this burden, as this strategy may have the potential to delay, lessen the severity of or even prevent full-blown disorder.2 Such an approach parallels that develop ed to identify troubled youth who are seeking help, have manifest symptoms and impaired functioning and demonstrate a substantially increased risk of psychosis onset, and for whom indicated prevention efforts might be justified.3 A recent meta-analysis confirmed that sensitivity of psychopathologic criteria for a prodromal phase of bipolar disorder was generally low. 4 Nevertheless, a pilot study of individuals in a clinical at-risk state of bipolar disorder is now available. 2 However, the predictive validity of the criteria could still be enhanced by adding reliable neurobiologic markers of the risk for bipolar disorder.There is a strong genetic component to susceptibility to bipolar disorder. The lifetime risk for bipolar affective disorder is 15%-30% in individuals with 1 first-degree relative with bipolar disorder and up to 75% in those with 2 affected first-degree relatives, and the concordance rate for monozygotic twins is around 70%. The concordance rate among monozygotic twins is higher for bipolar disorder than unipolar affective disorder, suggesting a relatively greater contribution from genetic factors in the etiology of bipolar disorder compared with schizophrenia and unipolar depression. Genetically at-risk yet healthy relatives or twins of patients with bipolar disorder are an excellent population in whom to study premorbid neurophysiologic markers of bipolar disorder.5 Examination of neurophysiologic markers of genetic Background: Although early interventions in individuals with bipolar disorder may reduce the associated personal and economic burden, the neurobiologic markers of enhanced risk are unknown. Methods: Neuroimaging studies involving individuals at enhanced genetic risk for bipolar disorder (HR) were included in a systematic review. We then performed a region of interest (ROI) analysis and a whole-brain meta-analysis combined with a formal effect-sizes meta-analysis in a subset of studies. Results: There were 37 studies included in our systematic review. The overall sample for the systematic review included 1258 controls and 996 HR individuals. No significant differences were detected between HR individuals and controls in the selected ROIs: striatum, amygdala, hippocampus, pituitary and frontal lobe. The HR group showed increased grey matter volume compared with patients with established bipolar disorder. The HR individuals showed increased neural response in the left superior frontal gyrus, medial frontal gyrus and left insula comp...