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DOI: 10.1148/rg.274065150
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Right arrow Genitourinary Radiology

Role of Radiology in the Management of Primary Aldosteronism1

Shilpan M. Patel, BSc (Hon), MRCP, Ravi K. Lingam, BSc (Hon), MRCP, FRCR, Tina I. Beaconsfield, MSc, FRCRI, Tan L. Tran, FRCS (Eng), DMRD, FRCR, and Beata Brown, MRCP

1 From the Departments of Radiology (S.M.P., R.K.L., T.I.B., T.L.T.) and Endocrinology (B.B.), Central Middlesex and Northwick Park Hospitals, North West London Hospitals (NWLH) Trust, Watford Rd, Harrow HA1 3UJ, England. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received August 11, 2006; revision requested September 11 and received November 27; accepted December 4. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Diagram illustrates the renin-angiotensin-aldosterone axis. Physiologic release of aldosterone occurs if there is a reduction in the effective circulating volume (eg, hemorrhage). Aldosterone works by increasing sodium retention in the distal renal tubules, which in turn promotes water absorption and causes isotonic expansion of the effective circulating volume. Aldosterone is also a potent vasoconstrictor. Both of these mechanisms serve to increase blood pressure (BP). This increase is detected by cells of the juxtaglomerular apparatus, which suppress renin production as part of a negative feedback mechanism. In primary aldosteronism, this negative feedback mechanism is overridden by the pathologic excess of aldosterone, which occurs in the absence of an appropriate stimulus.

 

Figure 2A
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  		Figure 2a.  Left (a) and right (b) adrenal venograms demonstrate the normal ordered branching pattern of veins within the adrenal glands.

 

Figure 2B
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  		Figure 2b.  Left (a) and right (b) adrenal venograms demonstrate the normal ordered branching pattern of veins within the adrenal glands.

 

Figure 3
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  		Figure 3.  Adrenal adenoma in a 52-year-old man. Adrenal venogram demonstrates a left adrenal adenoma (arrow), a finding that was biochemically confirmed with AVS.

 

Figure 4A
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  		Figure 4a.  APA. (a) Unenhanced CT scan obtained in a 30-year-old woman with primary aldosteronism shows a 5-cm low-attenuation (– 16 HU) right adrenal mass (arrow), a finding that is in keeping with an APA. The left adrenal gland is normal (arrowhead). (b) T1-weighted MR image obtained in a 45-year-old woman with primary aldosteronism shows an APA of the medial limb of the right adrenal gland (arrow). The lateral limb of the right adrenal gland and the left adrenal gland (arrowhead) appear normal. Both patients underwent surgery, with postoperative histologic analysis leading to the diagnosis of APA.

 

Figure 4B
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  		Figure 4b.  APA. (a) Unenhanced CT scan obtained in a 30-year-old woman with primary aldosteronism shows a 5-cm low-attenuation (– 16 HU) right adrenal mass (arrow), a finding that is in keeping with an APA. The left adrenal gland is normal (arrowhead). (b) T1-weighted MR image obtained in a 45-year-old woman with primary aldosteronism shows an APA of the medial limb of the right adrenal gland (arrow). The lateral limb of the right adrenal gland and the left adrenal gland (arrowhead) appear normal. Both patients underwent surgery, with postoperative histologic analysis leading to the diagnosis of APA.

 

Figure 5
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  		Figure 5.  Diagram illustrates width measurements of the body (1) and limbs (2, 3) of the adrenal gland (Reprinted, with permission, from reference 48).

 

Figure 6A
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  		Figure 6a.  BAH in a 55-year-old woman. Unenhanced CT scans (a, b) and T1-weighted MR image (c) demonstrate bilateral smooth enlargement of the adrenal glands (arrows). BAH was diagnosed with AVS.

 

Figure 6B
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  		Figure 6b.  BAH in a 55-year-old woman. Unenhanced CT scans (a, b) and T1-weighted MR image (c) demonstrate bilateral smooth enlargement of the adrenal glands (arrows). BAH was diagnosed with AVS.

 

Figure 6C
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  		Figure 6c.  BAH in a 55-year-old woman. Unenhanced CT scans (a, b) and T1-weighted MR image (c) demonstrate bilateral smooth enlargement of the adrenal glands (arrows). BAH was diagnosed with AVS.

 

Figure 7
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  		Figure 7.  Diagram illustrates an algorithm proposed by Lingam et al (38) for diagnosing BAH. Although all cases were correctly managed in their study, the sample size was small, and it was suggested that a larger study would be necessary to validate the algorithm.

 

Figure 8A
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  		Figure 8a.  APA in a 66-year-old woman. Adrenal scintigrams obtained immediately (a), 7 days (b), and 11 days (c) after the administration of NP-59 with the patient prone demonstrate unilateral increased uptake, a finding that was surgically confirmed to represent a left-sided APA. It is worth noting that this study was performed after a long dexamethasone-suppressed period, so that the timing of appearances of unilateral abnormalities does not conform to the interpretative convention outlined by Gross et al (49,50). (Case courtesy of Adil Al-Nahhas, MBBS, FRCP, Hammersmith Hospital, London, England.)

 

Figure 8B
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  		Figure 8b.  APA in a 66-year-old woman. Adrenal scintigrams obtained immediately (a), 7 days (b), and 11 days (c) after the administration of NP-59 with the patient prone demonstrate unilateral increased uptake, a finding that was surgically confirmed to represent a left-sided APA. It is worth noting that this study was performed after a long dexamethasone-suppressed period, so that the timing of appearances of unilateral abnormalities does not conform to the interpretative convention outlined by Gross et al (49,50). (Case courtesy of Adil Al-Nahhas, MBBS, FRCP, Hammersmith Hospital, London, England.)

 

Figure 8C
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  		Figure 8c.  APA in a 66-year-old woman. Adrenal scintigrams obtained immediately (a), 7 days (b), and 11 days (c) after the administration of NP-59 with the patient prone demonstrate unilateral increased uptake, a finding that was surgically confirmed to represent a left-sided APA. It is worth noting that this study was performed after a long dexamethasone-suppressed period, so that the timing of appearances of unilateral abnormalities does not conform to the interpretative convention outlined by Gross et al (49,50). (Case courtesy of Adil Al-Nahhas, MBBS, FRCP, Hammersmith Hospital, London, England.)

 

Figure 9
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  		Figure 9.  Diagram illustrates a proposed algorithm for differentiating APA from BAH in patients with primary aldosteronism. The algorithm has not yet been tested for efficacy.

 




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