Diagnostic Imaging Pathways - Hyperaldosteronism (Primary Suspected)
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This pathway provides guidance on the imaging of adult patients with biochemically confirmed primary hyperaldosteronism.
Date reviewed: October 2017
Date of next review: October 2020
Published: February 2018
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Adrenal Adenoma Image 1a, b and c (Computed Tomography): There is a 12mm sized rounded hypodense mass lesion noted in the right adrenal gland. There is marked contrast wash-out demonstrated in the lesion which is in keeping with adenoma. |
| 1b |  |
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| 1c |  |
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| 1d |  |
Image 1d (Adrenal Vein Sampling): A sample is taken from the left adrenal vein for analysis and comparison to that from the right renal vein. |
| 2a |  |
Adrenocortical Adenoma Image 2a: Adrenalectomy specimen showing a typical adrenocortical adenoma forming a circumscribed and encapsulated mass with a homogenous yellow cut surface. Note the residual adrenal parenchyma at the periphery of the lesion (arrow). |
| 2b |  |
Image 2b (H&E, x2.5) and 2c (H&E, x10): Histological section showing the pushing border between the adenoma and the surrounding parenchyma (arrows) At higher power, the cells form sheets and nests and exhibit uniform nuclei and clear cytoplasm due to their high lipid content.
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| 2c |  |
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Teaching Points
Teaching Points
- Indications for screening of suspected hyperaldosteronism
- Hypokalaemic hypertension
- Resistance / Refractory hypertension
- Presence of an incidentally detected adrenal mass
- Family history of hypertension
- Biochemical confirmation of primary hyperaldosteronism must be confirmed prior to imaging
- CT of the adrenals is the initial imaging modality for localisation of biochemically proven primary hyperaldosteronism
- Adrenal vein sampling should be undertaken to assess for a surgical remedial cause of primary hyperaldosteronism
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Primary Hyperaldosteronism
- The incidence of hyperaldosteronism as a cause for hypertension is believed to be more common than previously thought. 2-10% of patients with hypertension have hyperaldosteronism 1-3
- Imaging is used for localisation of a biochemically proven abnormality 1, 4, 5
- The most important distinction to be made is between the two most common causes of primary hyperaldosteronism 1, 4, 6
- Aldosterone producing adenoma (APA) - one third of cases of primary hyperaldosteronism
- Bilateral adrenal hyperplasia or idiopathic hyperaldosteronism (IHA) - two thirds of cases of primary hyperaldosteronism
- Aldosterone producing adenoma is treated surgically and bilateral adrenal hyperplasia is treated medically 1, 4
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Screening for Primary Hyperaldosteronism
- Plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA) is regarded as the screening test of choice for primary hyperaldosteronism (PA) 1,2
- Biochemical diagnosis of primary hyperaldosteronism must be established prior to performing imaging studies to avoid unnecessary surgery because 3% to 7% of patients over the age of 50 have non-functioning adrenal nodules ("incidentalomas") 7
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Confirmatory Testing
- A number of further tests are available to confirm the diagnosis of primary hyperaldosteronism. These include 8
- Normal saline infusion – most commonly used
- Fludrocortisone suppression test
- Oral sodium loading
- In clinical practice however, a properly performed plasma aldosterone:renin concentration (PAC / PRA) particularly in the absence of medications likely to cause false results (such as B-blockers and diuretics) is normally sufficient to make the diagnosis
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Computed Tomography (CT)
- Initial imaging modality of choice for localisation of biochemically proven primary hyperaldosteronism 1, 4
- Computed Tomography has been shown to have a sensitivity of 50-60% in the detection of adenoma 9-11
- Magnetic Resonance Imaging has been shown to have a comparable sensitivity of 70% in detecting adenoma, with a specificity of 100% 12
- Advantages - non-invasive, can be used in the assessment of adrenal incidentalomas and is useful in mapping the position of veins prior to adrenal vein sampling 13
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Adrenal Vein Sampling (AVS)
- Most reliable method to localise the lesion resulting in primary hyperaldosteronism, and will dictate further management 2, 9, 10, 13-15
- Concordance between computed tomography and adrenal vein sampling for the assessment of primary hyperaldosteronism is poor 2, 13
- Adrenal vein sampling is a sensitive test to differentiate aldosterone-producing adenoma (APA) from bilateral hyperplasia 10, 14, 15
- The aldosterone to cortisol ratio in both adrenal veins is compared. If one side has a concentration more than 2 times the other side, then APA is diagnosed; bilateral adrenal hyperplasia is the diagnosis by default 15
- When successful, AVS unequivocally establishes the presence or absence of unilateral aldosterone production, thus clarifying the choice of therapy - medical or surgical 1
- Disadvantages - invasive, highly operator-dependent, not widely available and carries a finite risk of venous thrombosis, adrenal haemorrhage, and adrenal insufficiency 2
References
References
Date of literature search: September 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Thakkar RB, Oparil S. Primary aldosteronism: a practical approach to diagnosis and treatment. J Clin Hypertens (Greenwich). 2001;3(3):189-95. (Review article). View the reference
- Buffolo F, Monticone S, Williams TA, Rossato D, Burrello J, Tetti M, et al. Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary? International Journal of Molecular Sciences. 2017;18(4):848. (Review article). View the reference
- Gordon RD, Stowasser M, Tunny TJ, Klemm SA, Rutherford JC. High incidence of primary aldosteronism in 199 patients referred with hypertension. Clin Exp Pharmacol Physiol. 1994;21(4):315-8. (Level II evidence). View the reference
- Ganguly A. Primary aldosteronism. N Engl J Med. 1998;339(25):1828-34. (Review article). View the reference
- Stowasser M, Gordon RD. Primary Aldosteronism: Changing Definitions and New Concepts of Physiology and Pathophysiology Both Inside and Outside the Kidney. Physiol Rev. 2016;96(4):1327-84. (Review article). View the reference
- Iacobone M, Citton M, Viel G, Rossi GP, Nitti D. Approach to the surgical management of primary aldosteronism. Gland Surg. 2015;4(1):69-81. (Review article). View the reference
- Bornstein SR, Stratakis CA, Chrousos GP. Adrenocortical tumors: recent advances in basic concepts and clinical management. Ann Intern Med. 1999;130(9):759-71. (Review article). View the reference
- Schirpenbach C, Reincke M. Screening for primary aldosteronism. Best Pract Res Clin Endocrinol Metab. 2006;20(3):369-84. (Review article). View the reference
- Doppman JL, Gill JR, Jr., Miller DL, Chang R, Gupta R, Friedman TC, et al. Distinction between hyperaldosteronism due to bilateral hyperplasia and unilateral aldosteronoma: reliability of CT. Radiology. 1992;184(3):677-82. (Level II evidence). View the reference
- Harper R, Ferrett CG, McKnight JA, McIlrath EM, Russell CF, Sheridan B, et al. Accuracy of CT scanning and adrenal vein sampling in the pre-operative localization of aldosterone-secreting adrenal adenomas QJM: An International Journal of Medicine. 1999;92(11):643-50. (Level III evidence) View the reference
- Dunnick NR, Leight GS, Jr., Roubidoux MA, Leder RA, Paulson E, Kurylo L. CT in the diagnosis of primary aldosteronism: sensitivity in 29 patients. AJR Am J Roentgenol. 1993;160(2):321-4. (Level III evidence). View the reference
- Sohaib SA, Peppercorn PD, Allan C, Monson JP, Grossman AB, Besser GM, et al. Primary hyperaldosteronism (Conn syndrome): MR imaging findings. Radiology. 2000;214(2):527-31. (Level IV evidence). View the reference
- Kempers MJ, Lenders JW, van Outheusden L, van der Wilt GJ, Schultze Kool LJ, Hermus AR, et al. Systematic review: diagnostic procedures to differentiate unilateral from bilateral adrenal abnormality in primary aldosteronism. Ann Intern Med. 2009;151(5):329-37. (Review article). View the reference
- Magill SB, Raff H, Shaker JL, Brickner RC, Knechtges TE, Kehoe ME, et al Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism. J Clin Endocrinol Metab. 2001;86(3):1066-71. (Level III evidence). View the reference
- Mayo-Smith WW, Boland GW, Noto RB, Lee MJ. State-of-the-art adrenal imaging. Radiographics. 2001;21(4):995-1012. (Review article). View the reference
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