Computed Tomography of the Normal Adrenal Glands

JEAN-PHILIPPE MONTAGNE,”2 HERBERT Y. KRESSEL,”3 MELVYN KOROBKIN,’ AND ALBERT A. MOSS’

CT body scans of 60 random patients without evidence of

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Results
adrenal disease were reviewed to determine the location,
In 47 of the 60 patients (78%) both adrenal glands were
size, and shape of both normal adrenal glands. Both glands
were clearly delineated in 78% of the patients evaluated. The delineated cleanly enough to perform the measurements.
length, width, and thickness of adrenal glands as measured In 13 patients (22%) both adrenal glands were either not
by computed tomography were similar to comparable mea- seen or inadequately seen to determine their size and
surements from surgical and autopsy studies. shape. The following results were obtained from mea-
sunements made on the 47 patients with excellent visual-
Initial reports [1 -3] of extnacnanial computed tomography ization of both adrenal glands.
(CT) emphasized its potential role in evaluation of the
Location
liven, pancreas, kidney, and retropenitoneal space. Only
one [3] described the CT appearance of adrenal lesions, Superiorly, the anterior margin of the night adrenal
and the authors indicated that a normal adrenal gland gland was immediately posterior to the inferior vena cava
occasionally could be seen, especially on the left. We at the level of junction of the intra- and extrahepatic
have investigated the capability of CT to image the portions (fig. 2). Its lateral margin was adjacent to the
normal adrenal gland and report the normal size, loca- postenomedial aspect of the night lobe of the liven. The
tion, and shape of both glands. Knowledge of the range separation of the gland from the liven was variable,
of normal is useful for optimal interpretation of CT scans depending on the amount of netnopenitoneal fat. Occa-
in patients with suspected adrenal pathology. sionally it was difficult to cleanly delineate the lateral
bonder of the night gland. The night crus ofthe diaphragm
is just medial to the night adrenal.
Materials and Methods The medial margin of the left adrenal gland is lateral to
The CT scans of 60 random patients who had sections the left crus of the diaphragm, but somewhat more
obtained at 1 cm intervals through the region of both adrenal anterior than the right gland (fig. 2). Its lateral margin is
glands were reviewed. None of the patients had clinical evi- posterior to the pancreatic tail and to the splenic vessels.
dence of adrenal disease. The 33 men and 27 women ranged in Most of the right adrenal gland was cephalad to the
age from 27 to 80 years (mean 56 years). An EMI 5000 body upper pole of the right kidney, whereas the left gland
scanner (matrix size 160 x 160) produced 48 of the scans; a
and the superior pole of the left kidney were usually seen
General Electric CT/T Body Scanner (matrix size 320 x 320)
on the same sections. The upper pole of the night gland
was used for the other 12.
The presence, location, size, and shape of both adrenal was either at the same level (S1%) on cephalad (34%) to
glands were evaluated. Measurements were made on the hard the upper pole of the left gland. The lower pole of both
copy recording medium routinely used in our department for glands was cephalad to the renal vessels, but the left
each scanner. The measurements were made to the nearest gland was frequently in closer apposition to the left renal
millimeter and then multipled by the appropriate minification pedicle than the night.
factor to obtain the true size. This method resulted in corrected
measurements to the nearest 0.5 cm. Shape
The length of the gland was defined as its cephalocaudal
The shape of the gland is its configuration on each
dimension and the width as the greatest linear dimension seen
cross section (fig. 3). It was determined on the section
on any single tomographic section. The thickness of the adrenal
gland was defined as its dimension perpendicular to the long
axis of the gland or one of its limbs. The greatest thickness at /t
any site was the measurement recorded. In the linear glands
this tended to occur at the anterior portion, while in the V- and
Y-shaped glands the site was usually at the junction of the
limbs. Thickness was not measured in triangular-shaped glands ,\

because a long axis could not be defined. Figure 1 shows the

methods used to measure the width and thickness of the normal Fig. 1.-Method of measuring width (W) and thickness (T) of adrenal
adrenal glands. glands.

Received September 27, 1977; accepted after revision January 27. 1978.
M. Korobkin is a James Picker Foundation Scholar in Radiological Research and the recipient of a Research Career Development Award from the
National Institutes of Health.
‘Department of Radiology, University of California School of Medicine, San Francisco, California 94143. Address reprint requests to M. Korobkin.
2Present address: Radiologie. HOpital Rousseau, 75012 Paris.
3Present address: Department of Radiology. University Hospital, University of Pennsylvania, Philadelphia, Pennsylvania 19174.
Am J Roentg.nol 130:963-966, May 1978 963 0361 -803X/78/0500 - 0963 $02.00
C 1978 American Roentgen Ray Society
 964 MONTAGNE ET AL.
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Fig. 2.-CT scan and corresponding diagram showing typical location of normal adrenal glands. P = tail of pancreas, K = left kidney. 5V = splenic
vein, SB = small bowel, C = descending colon, V = inferior vena cava.

Linear
87%
I I
V-shaped
9%
V-shaped
50%
V-shaped
32%
Triangular
9%
Fig. 3. - Most frequent shape of normal adrenal glands.
 CT OF NORMAL ADRENAL GLANDS 965

TABLE 1 TABLE 3
Length of Adrenal Glands Thickness of Adrenal Glands

Right Left Right Left

No. 5ections centimeters
No. % No. % No. % No. %

1 . 3 6 . .. . .. <1.0 ... 35 72 10 23
2 . 20 43 16 34 1.0 ... 12 26 33 77
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3 . 23 49 29 62 1.5 ... 1 2 ... ...

4 . 1 2 2 4 Note-Measurements not made in four left and one right

. Nonoverlappin triangular-shaped glands.
g adjace nt slices cit her 10 or 13 mm thick.

is considerably enlarged; this method has not been

widely used for studying the adrenals. Nuclear imaging
TABLE 2
with 31IIabeIed iodocholestrol is noninvasive, but 2-3
Width of Adrenal Glands
weeks is usually required to complete an examination
Right Left and, due to radioactive dose considerations, there is
centimeters
limited spatial resolution [6]. Adrenal arteniognaphy and
No. % No. %
venography are invasive procedures of moderate techni-
1.0 2 4 1 2
1.5
cal difficulty. Although some reports of venognaphy have
3 6 4 9
2.0 21 45 25 53 suggested a high rate of success in catheterization and
2.5 15 32 16 34 accuracy in identifying small adrenal lesions [7, 8], we
3.0 6 13 1 2 and others have had considerably less success in using
this procedure.
Using CT we were able to demonstrate the normal
where the gland was best seen. In most cases the night
adnenaj glands in 85% of the patients evaluated. Al-
gland appeared linear on slightly curvilinear. The left
though the normal adrenal gland is quite small, the
gland had more of a V on a Y shape, but occasionally
amount of fat usually present in the netnopenitoneal
appeared more squat or triangular.
space permits sharp delineation of its borders. The
Length
length, width, and thickness of the adnenals determined
by CT (tables 1-3) were remarkably similar to measure-
The length of each adrenal gland was estimated by ments reported from surgical and autopsy series [9, 10].
counting the number of transverse cross sections on There was a marked paucity of netropenitoneal fat in all
which each was visualized (table 1). The precise length 15 patients in whom the adrenal glands were not identi-
could not be measured because of the associated partial fied. In addition, inability to suspend respiration (three
volume error in estimating the cephalad and caudal patients) and streaklike artifacts due to bowel gas motion
extent of each gland. The normal adrenal gland was (two patients) contributed to the inadequate visualiza-
usually seen on two on three consecutive cross sections, tion.
corresponding to an approximate length of 2-4 cm.
Several improvements in CT scanner technology will
probably increase the frequency of demonstration of the
Width
normal adrenal glands. With scan speeds of 5 sec on
The width of each gland was determined on the section less, streaklike artifacts due to patient respiration on
in which the adrenal appeared largest during the exami- bowel gas motion (even in the absence of antipenistaltic
nation (fig. 1). About 75% of the night adrenal glands and drug) should be less common. The ability to obtain cross
80% of the left glands had a maximal width of 2.0-2.5 cm sections of thicknesses less than 1 .0 cm and to accu-
(table 2). rately position the patient for adjacent sections at inter-
vals less than 1 .0 cm will allow more ready visualization
Thickness
of small adrenal glands.
All but one of the measured glands was 1 cm thick or On occasion, it may be difficult to accurately identify
less (table 3; fig. 1). Most of the left glands were 1 .0 cm and measure the adrenal glands and distinguish them
thick, whereas most of the night glands were less than from normal adjacent structures. Depending on the
1 .0 cm. amount of retropenitoneal fat, it may be difficult to
separate the night adrenal gland from the adjacent pos-
Discussion
teromedial border of the night lobe of the liven. On the
Conventional imaging approaches to the adrenal gland left side the cephalic portion may be adjacent to the
have distinct disadvantages. Plain abdominal nadiogna- splenic vessels, while the caudal pole may be indistin-
phy is useful only if an adrenal gland is calcified. Unog- guishable from the renal vessels. Intravenous injection
raphy is helpful only if an adrenal gland is sufficiently of contrast material, especially following a bolus injec-
enlarged to displace the underyling kidney [4]. The tion [11], may occasionally be useful in identifying the
normal adrenal gland is usually not seen on nephroto- vascular structures and distinguishing them from the left
mognaphy [5]. Ultrasound can identify the gland only if it adrenal gland.
 966 MONTAGNE ET AL.

Measurements of all the parameters described may not 3. Sheedy PF II, Stephens DH, Hattery AR, Muhm JR, Hartman
be necessary or useful in all patients with suspected GW: Computed tomography of the body: initial clinical trial
adrenal pathology. Measurement of the length is severely with the EMI prototype. Am J Roentgenol 127 :23-51 1976 ,

restricted by the partial volume error that affects mea- 4. Lang EK: Roentgenographic diagnosis of suprarenal
sunements of size in the plane perpendicular to the masses. Radiology 87 :35-45, 1966
5. Fagerberg S: Roentgen examination of suprarenal glands.
scanning beam. Measurement of the width may be af-
Acta Radiol (Stockh) 49 : 21 8-226, 1958
fected by the orientation of the adrenal axis with respect
6. Hogan MJ, McRae J, Schambelan M, Biglieri EG: Location
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to the scanning plane. The range of values for adrenal of aldosterone-producing adenomas with i3IIl9iodocho
thickness was quite narrow, and initial evaluation of lesterol. N EngI J Med 294 :410-414, 1976
proven adrenal pathology in our department suggests 7. Yune HY, Klatte EC, Grim CE, Weinberger MH, Donohue
that the thickness may be the most useful of the three JP, Yum MN, Wellman HN: Radiology in primary hyperal-
measurements. dosteronism Am J Roentgenol
. 1 27 : 761-767, 1976
8. Mitty HA, Nicohis GL, Gabrilove JL: Adrenal venography:
clinical-roentgenographic correlation in 80 patients. Ra-
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