How to Perform Parathyroid 4D CT: Tips and Traps for Technique and Interpretation

Published Online:

The radiologist’s ability to detect a candidate lesion and differentiate it from mimics can be increased with appreciation of the typical contrast enhancement characteristics and morphologic features of parathyroid adenomas.

Parathyroid four-dimensional (4D) computed tomography (CT) is an imaging technique for preoperative localization of parathyroid adenomas that involves multidetector CT image acquisition during two or more contrast enhancement phases. Four-dimensional CT offers an alternative or additional tool in the evaluation of primary hyperparathyroidism. The purpose of this article is to describe the 4D CT technique and provide a practical guide to the radiologist for imaging interpretation. The article will discuss the rationale for imaging, approach to interpretation, imaging findings, and pitfalls.

© RSNA, 2014


  • 1. Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 2006;140(6):932–940; discussion 940–941. Crossref, MedlineGoogle Scholar
  • 2. Ruda JM, Hollenbeak CS, Stack BC Jr. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg 2005;132(3):359–372. Crossref, MedlineGoogle Scholar
  • 3. Ghandur-Mnaymneh L, Kimura N. The parathyroid adenoma. A histopathologic definition with a study of 172 cases of primary hyperparathyroidism. Am J Pathol 1984;115(1):70–83. MedlineGoogle Scholar
  • 4. Silverberg SJ, Shane E, Jacobs TP, Siris E, Bilezikian JP. A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med 1999;341(17):1249–1255. Crossref, MedlineGoogle Scholar
  • 5. Sackett WR, Barraclough B, Reeve TS, Delbridge LW. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Arch Surg 2002;137(9):1055–1059. Crossref, MedlineGoogle Scholar
  • 6. van Dalen A, Smit CP, van Vroonhoven TJ, Burger H, de Lange EE. Minimally invasive surgery for solitary parathyroid adenomas in patients with primary hyperparathyroidism: role of US with supplemental CT. Radiology 2001;220(3):631–639. LinkGoogle Scholar
  • 7. Beland MD, Mayo-Smith WW, Grand DJ, Machan JT, Monchik JM. Dynamic MDCT for localization of occult parathyroid adenomas in 26 patients with primary hyperparathyroidism. AJR Am J Roentgenol 2011;196(1):61–65. Crossref, MedlineGoogle Scholar
  • 8. Untch BR, Adam MA, Scheri RP, et al. Surgeon-performed ultrasound is superior to 99Tc-sestamibi scanning to localize parathyroid adenomas in patients with primary hyperparathyroidism: results in 516 patients over 10 years. J Am Coll Surg 2011;212(4):522–529; discussion 529–531. Crossref, MedlineGoogle Scholar
  • 9. Civelek AC, Ozalp E, Donovan P, Udelsman R. Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. Surgery 2002;131(2):149–157. Crossref, MedlineGoogle Scholar
  • 10. Wang TS, Cheung K, Farrokhyar F, Roman SA, Sosa JA. Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism. Surgery 2011;150(6):1286–1294. Crossref, MedlineGoogle Scholar
  • 11. Lubitz CC, Stephen AE, Hodin RA, Pandharipande P. Preoperative localization strategies for primary hyperparathyroidism: an economic analysis. Ann Surg Oncol 2012;19(13):4202–4209. Crossref, MedlineGoogle Scholar
  • 12. Gafton AR, Glastonbury CM, Eastwood JD, Hoang JK. Parathyroid lesions: characterization with dual-phase arterial and venous enhanced CT of the neck. AJNR Am J Neuroradiol 2012;33(5):949–952. Crossref, MedlineGoogle Scholar
  • 13. Doppman JL, Hammond WG, Melson GL, Evens RG, Ketcham AS. Staining of parathyroid adenomas by selective arteriography. Radiology 1969;92(3):527–530. LinkGoogle Scholar
  • 14. Lubitz CC, Hunter GJ, Hamberg LM, et al. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Surgery 2010;148(6):1129–1137; discussion 1137–1138. Crossref, MedlineGoogle Scholar
  • 15. Mortenson MM, Evans DB, Lee JE, et al. Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography. J Am Coll Surg 2008;206(5):888–895; discussion 895–896. Crossref, MedlineGoogle Scholar
  • 16. Starker LF, Mahajan A, Björklund P, Sze G, Udelsman R, Carling T. 4D parathyroid CT as the initial localization study for patients with de novo primary hyperparathyroidism. Ann Surg Oncol 2011;18(6):1723–1728. Crossref, MedlineGoogle Scholar
  • 17. Hunter GJ, Schellingerhout D, Vu TH, Perrier ND, Hamberg LM. Accuracy of four-dimensional CT for the localization of abnormal parathyroid glands in patients with primary hyperparathyroidism. Radiology 2012;264(3):789–795. LinkGoogle Scholar
  • 18. Kutler DI, Moquete R, Kazam E, Kuhel WI. Parathyroid localization with modified 4D-computed tomography and ultrasonography for patients with primary hyperparathyroidism. Laryngoscope 2011;121(6):1219–1224. Crossref, MedlineGoogle Scholar
  • 19. Welling RD, Olson JA Jr, Kranz PG, Eastwood JD, Hoang JK. Bilateral retropharyngeal parathyroid hyperplasia detected with 4D multidetector row CT. AJNR Am J Neuroradiol 2011;32(5):E80–E82. Crossref, MedlineGoogle Scholar
  • 20. Perrier ND, Edeiken B, Nunez R, et al. A novel nomenclature to classify parathyroid adenomas. World J Surg 2009;33(3):412–416. Crossref, MedlineGoogle Scholar
  • 21. Randall GJ, Zald PB, Cohen JI, Hamilton BE. Contrast-enhanced MDCT characteristics of parathyroid adenomas. AJR Am J Roentgenol 2009;193(2):W139–W143. Crossref, MedlineGoogle Scholar
  • 22. Lumachi F, Zucchetta P, Varotto S, Polistina F, Favia G, D’Amico D. Noninvasive localization procedures in ectopic hyperfunctioning parathyroid tumors. Endocr Relat Cancer 1999;6(1):123–125. Crossref, MedlineGoogle Scholar
  • 23. Abboud B, Sleilaty G, Ayoub S, et al. Intrathyroid parathyroid adenoma in primary hyperparathyroidism: can it be predicted preoperatively? World J Surg 2007;31(4):817–823. Crossref, MedlineGoogle Scholar
  • 24. Goodman A, Politz D, Lopez J, Norman J. Intrathyroid parathyroid adenoma: incidence and location—the case against thyroid lobectomy. Otolaryngol Head Neck Surg 2011;144(6):867–871. Crossref, MedlineGoogle Scholar
  • 25. Nguyen XV, Roy Choudhury K, Eastwood JD, et al. Incidental thyroid nodules on CT: evaluation of 2 risk-categorization methods for work-up of nodules. AJNR Am J Neuroradiol 2013;34(9):1812–1817. Crossref, MedlineGoogle Scholar
  • 26. Carlson D. Parathyroid pathology: hyperparathyroidism and parathyroid tumors. Arch Pathol Lab Med 2010;134(11):1639–1644. Crossref, MedlineGoogle Scholar
  • 27. Sackett WR, Reeve TS, Barraclough B, Delbridge L. Thyrothymic thyroid rests: incidence and relationship to the thyroid gland. J Am Coll Surg 2002;195(5):635–640. Crossref, MedlineGoogle Scholar
  • 28. Bahl M, Muzaffar M, Vij G, Sosa JA, Choudhury KR, Hoang JK. Prevalence of the polar vessel sign in parathyroid adenomas on the arterial phase of 4D CT. AJNR Am J Neuroradiol 2013 Aug 14. [Epub ahead of print] MedlineGoogle Scholar
  • 29. Mahajan A, Starker LF, Ghita M, Udelsman R, Brink JA, Carling T. Parathyroid four-dimensional computed tomography: evaluation of radiation dose exposure during preoperative localization of parathyroid tumors in primary hyperparathyroidism. World J Surg 2012;36(6):1335–1339. Crossref, MedlineGoogle Scholar
  • 30. Madorin CA, Owen R, Coakley B, et al. Comparison of radiation exposure and cost between dynamic computed tomography and sestamibi scintigraphy for preoperative localization of parathyroid lesions. JAMA Surg 2013;148(6):500–503. Crossref, MedlineGoogle Scholar
  • 31. National Cancer Institute SEER. Data 1983 to 2009. Accessed December 2012. Google Scholar
  • 32. Mittman N, Desiraju B, Meyer KB, Chattopadhyay J, Avram MM. Treatment of secondary hyperparathyroidism in ESRD: a 2-year, single-center crossover study. Kidney Int Suppl 2010 (117):S33–S36. Crossref, MedlineGoogle Scholar

Article History

Received December 20, 2012; revision requested January 30, 2013; revision received February 13; accepted March 19; final version accepted April 30.
Published online: Jan 2014
Published in print: Jan 2014