Approach to the Patient With Primary Aldosteronism: Role of Molecular Imaging

A common yet underdiagnosed cause of secondary hypertension, primary aldosteronism (PA) is characterized by excess aldosterone production, causing hypertension with increased risk of cardio-renal-metabolic complications. Accurate and timely localization of the source of aldosterone excess is crucial for management, in the form of curative adrenalectomy for unilateral aldosterone-producing adenoma or medical management for bilateral adrenal hyperplasia. The current diagnostic algorithm involves adrenal vein sampling (AVS) as the current "gold standard" in determining lateralization of aldosterone secretion, but its technical challenges present significant barriers to timely diagnosis and treatment. Recent technological advancements have contributed to the evolution of molecular imaging modalities such as 11C-metomidate positron emission tomography-computed tomography (11C-MTO PET-CT). Improved molecular imaging modalities hold significant potential to complement existing diagnostic pathways and refine treatment strategies for PA. This review evaluates different case scenarios comparing the utility of AVS with 11C-MTO PET-CT, suggesting a practical approach for its interpretation and highlighting the clinical decision-making process.