Neuroimaging of central diabetes insipidus—when, how and findings

Abstract

Central or neurogenic diabetes insipidus (CDI) is due to deficient synthesis or secretion of antidiuretic hormone (ADH), also known as arginine vasopressin peptide (AVP). It is clinically characterised by polydipsia and polyuria (urine output > 30 mL/kg/day) of dilute urine (< 250 mOsm/L). It is the result of a defect in one of more sites involving the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei of the hypothalamus, median eminence of the hypothalamus, infundibulum or the posterior pituitary gland. A focused MRI pituitary gland or sella protocol is essential. There are several neuroimaging correlates and causes of CDI, illustrated in this review. The most common causes are benign or malignant neoplasms of the hypothalamic-pituitary axis (25%), surgery (20%), head trauma (16%) or familial causes (10%). No cause is identified in up to 30% of cases. Knowledge of the anatomy and physiology of the hypothalamo-neurohypophyseal axis is crucial when evaluating a patient with CDI. Establishing the aetiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. The aim of the pictorial review is to illustrate the wide variety of causes of CDI on neuroimaging, highlight the optimal MRI protocol and to revise the detailed neuroanatomy and neurophysiology required to interpret these studies.

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Abbreviations

CDI:

Central diabetes insipidus

HPA:

Hypothalamic pituitary axis

PPBS:

Posterior pituitary bright spot

ADH:

Antidiuretic hormone

AVP:

Arginine vasopressin peptide

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Key points

• Central or neurogenic diabetes insipidus (CDI) occurs when there is a defect in one of more sites involving the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei of the hypothalamus, median eminence of the hypothalamus, infundibulum or the posterior pituitary gland resulting in deficient synthesis or secretion of antidiuretic hormone (ADH).

• A focussed pituitary MRI pituitary gland and sella protocol is essential in all patients without a clear aetiology.

• Common causes found on MRI include neurosurgery, head trauma, craniopharyngioma, germinoma, langerhans cell histiocytosis and congenital structural abnormalities.

• In patients over 50 years with acute onset of CDI, pituitary metastases should be considered and appropriate investigations including chest radiograph should be performed.

• There are several neuroimaging correlates and causes of CDI, illustrated in this review.

• A cause for CDI cannot be established in 12.2% of paediatric and 30% of adult cases despite biochemical and radiological evaluation

• When initial imaging is normal, serial follow-up imaging should be performed before a diagnosis of idiopathic CDI can be made. Current literature suggests at least a follow-up MRI after 6 months and a duration of follow-up of 3 years. Larger studies are required to inform evidence-based guidelines for follow-up of CDI.

• The aim of the pictorial review is to illustrate the wide variety of causes of CDI on neuroimaging, highlight the optimal MRI protocol and to revise the detailed neuroanatomy and neurophysiology required to interpret these studies.

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Adams, N.C., Farrell, T.P., O’Shea, A. et al. Neuroimaging of central diabetes insipidus—when, how and findings. Neuroradiology 60, 995–1012 (2018). https://doi.org/10.1007/s00234-018-2072-7

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Keywords

  • Central diabetes insipidus
  • Hypothalamic-neurohypophyseal axis
  • Hypothalamic pituitary axis
  • Magnetic resonance imaging
  • Posterior pituitary bright spot