Adrenal incidentaloma is a tumour or mass of adrenal gland discovered accidentally while imaging the abdomen for other condition using CT or MRI scans. These masses are commonly seen in asymptomatic persons with no signs of adrenal disease. Adrenal incidentalomas are more frequent in elderly population; the vast majority are not hormone-secreting, benign adenomas.
Epidemiology
Cross-sectional abdominal images are likely to reveal adrenal incidentaloma. Between 1 to 5% of all CT scans that are done for non-abdominal reveal an adrenal mass and majority of them are AIs. This ranges between 2% to 9% of AIs had autopsies conducted.
Anatomy
Pathophysiology
Pathophysiology of adrenal incidentalomas encompasses benign as well as malignant neoplasms with diverse hormonal activities. From the incidentals noted during examination, there is clinical management based on size, hormonal activity, and appearances on imaging with periodic scans or other investigations to determine the next course of action.
Etiology
Congenital Adrenal Hyperplasia (CAH): In some cases, non-classic CAH adrenal hyperplasia may present as an incidentaloma. They do not appear to be related to clinical levels of hyperandrogenemia but can be seen in conjunction with mild androgen excess.
Infection or Hemorrhage: Adrenal masses may be due to infection such as tuberculosis, histoplasmosis, or by haemorrhage, this is in cases of trauma, sepsis, or on patients on anticoagulant therapy.
Aldosterone-Secreting Adenoma (Conn’s Syndrome):
This is a rare cause of primary hyperaldosteronism.
Adrenal gland metastases occur frequently from lung, breast, kidney, or melanoma cancers of the body. It is seen most frequently in patients with an underlying known primary malignancy.
Genetics
Prognostic Factors
Size of the Incidentaloma:
Mass Size >4 cm: larger masses have higher chances of being malignant, with most guidelines recommending surgery if the size exceeds 4-6 cm.
Mass Size <4 cm: while smaller lesions are usually benign, follow-up examinations are usually advised to check for growth.
Growth Rate: A change in size of over 1-cm in six to twelve months can therefore suggest malignancy.
Hormonal activity:
Benign lesion is usually do not increase in size or increase very slowly Most of the benign skin lesions are therefore unlikely to become malignant.
Hormonal Activity Cortisol Secretion (Cushing’s Syndrome): Incidentalomas themselves may be hypersecretory and cause subclinical or clinical Cushing’s disease.
Aldosterone Secretion (Conn’s Syndrome): About half of adrenal masses produce aldosterone hormone causing primary hyperaldosteronism.
Clinical History
Age Group:
The typical age group in which adrenal incidentalomas are more commonly found is between 40 and 60. However, the prevalence increases significantly with advancing age, particularly in individuals over 60 years.
Physical Examination
General assessment
Endocrine examination
Abdominal examination
Age group
Associated comorbidity
Subclinical Cushing’s Syndrome
Pheochromocytoma
Aldosteronoma
Hyperlipidemia
Hypertension
Associated activity
Acuity of presentation
Age Group: The average age when the incidence of adrenal incidentalomas is higher is between 40 and 60 years. But there is a progressive increase in the prevalence with increasing age especially persons above 60.
Acute Presentation: This incidentaloma can be discovered during a routine imaging investigation for trauma or acute abdomen pain, for example. Occasionally it may be an incidentaloma that can be hormonally functioning to cause an acute event such as adrenal haemorrhage, acute cushing’s disease or pheochromocytoma crisis. For such reasons, immediate treatment is necessary, and more so, if there are indications of hormonal overproduction, pheochromocytoma and cortisol producing tumor.
Chronic Presentation: Most of the time, adrenal incidentalomas are discovered during cross-sectional imaging performed for nonadrenal diseases, and none of the imaging studies initially point to adrenal pathology. These cases typically require stepwise evaluation rather than emergent management of hormonal activity and have the potential for malignancy.
Differential Diagnoses
Non-functioning Adrenal Adenoma (Benign)
Adrenocortical Carcinoma (ACC)
Pheochromocytoma
Adrenal Metastasis
Adrenal Myelolipoma
Cushing’s Syndrome (Cortisol-producing Adenoma)
Aldosterone-producing Adenoma (Conn’s Syndrome)
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment Paradigm:
Initial Evaluation Imaging Characteristics: The appearance is indicated on imaging (CT, MRI) and should assess a difference between a benign and malignant mass.
Fatty masses with homogeneity should be regarded as benign adenomas, however, irregular or enlarging masses are suspect of malignancy.
Size:
Mass measuring less than 4 cm are generally benign.
Mass measuring more than 4-6 cm is generally believed to be malignant.
Hormonal Evaluation: It is also important to do some tests to see if the tumor is hormone secreting.
Key tests include:
Cortisol: Screening for Cushing’s syndrome.
Aldosterone: For screening of primary hyperaldosteronism in hypertensive patients and as an adjunct to biochemical testing in primary aldosteronism diagnosis.
Catecholamines: Exclude pheochromocytoma with metanephrine measurements.
Sex Hormones: Some of the rare tumors may produce androgens or estrogens.
Management Based on Hormonal Activity
Non-Functioning Tumors:
Small, non-functioning masses (<4 cm) with benign imaging characteristics are often managed by having periodic imaging and clinical follow-ups to monitor for growth.
Repeat imaging at 6-12 months and then annually for 2-5 years is advised if growth is not noted.
Functional Tumors:
Cushing’s Syndrome: Adrenalectomy is usually recommended if the mass is producing cortisol.
Pheochromocytoma: Surgical resection should be performed only after adequate medical preparation with alpha-blockade.
Aldosterone-producing tumors (Conn’s Syndrome): The treatment of choice is adrenalectomy, especially in patients with unilateral disease.
Stress Management: If the adrenal incidentaloma is functional, for example causing excess cortisol production such as in subclinical Cushing’s syndrome, then the patient should reduce stressful activities. Some stress relieving strategies that can be recommended include, the mindfulness, relaxation and improving sleep.
Diet and Exercise: Daily food choices and exercise regimen should be kept healthy especially when the adrenal incidentalomas related to metabolic syndrome, such as hypertension, obesity, or glucose intolerance.
Monitoring and Medical Environment: Incidentaloma requires monitoring by checkups with imaging and laboratory tests to evaluate the size, function, or development of complications.
Exposure to Endocrine Disruptors: Reducing the contact with hormone disruptor agents like some pesticides, plastics, and chemicals can also reduce other risks attributed to hormone imbalance.
The procedure is most used for functioning or benign adrenal tumors and larger tumors 4-6 cm with benign features.
Less postoperative pain, recovery time, and scarring,
The procedure involves making three or four small incisions, usually on either side of the abdomen, in which a camera and instruments are used by the surgeon to remove the adrenal gland.
Open Adrenalectomy:
Usually recommended for large tumors greater than 6 cm, suspected malignancy, and in cases where laparoscopic access is not possible.
It invasively requires a larger incision. Due to this, it enables better visualization and access to the adrenal gland. Sometimes this is performed with the help of a flank, an anterior or posterior approach.
Patient History and Physical Examination: Evaluate signs associated with hypercortisolism, hyper aldosteronism or pheochromocytoma. Imaging Studies: Normally, CT or MRI defines the size, density, and the enhancement of the adrenal mass.
Hormonal Evaluation
Biochemical Screening:
Cortisol: Screen for Cushing’s syndrome by undergoing a 24-hour free urine cortisol test or a late-night salivary cortisol test.
Aldosterone and Renin: Screening for; the first condition that you should look out for is primary hyperaldosteronism particularly in patients who have been diagnosed with hypertension.
Risk Assessment Size and Imaging Characteristics: Only adrenal masses > 4 cm or those with imaging characteristics highly suggestive, presumably malignant, should be considered malignant.
Malignancy Criteria: Assess through size, shape and high density on the imaging.
Management Decisions
Hormone-Secreting Adenomas: If functional, management depends on the hormone involved (e.g., medical therapy for Cushing or adrenalectomy for aldosterone-producing neoplasm).
Non-Functioning Adenomas: If the mass is non-aggressive (generally small and not hormone producing) management may entail periodic follow up by imaging and hormonal assays.
Surgical Intervention
Indications for Surgery: Usually advised for patients with large tumors greater than 4 cm in size, any tumors that have typical features of malignancy or tumours that secrete hormones.
Type of Surgery: Laparoscopic adrenalectomy is done where there is a resectable tumor in the adrenals.
Adrenal incidentaloma is a tumour or mass of adrenal gland discovered accidentally while imaging the abdomen for other condition using CT or MRI scans. These masses are commonly seen in asymptomatic persons with no signs of adrenal disease. Adrenal incidentalomas are more frequent in elderly population; the vast majority are not hormone-secreting, benign adenomas.
Cross-sectional abdominal images are likely to reveal adrenal incidentaloma. Between 1 to 5% of all CT scans that are done for non-abdominal reveal an adrenal mass and majority of them are AIs. This ranges between 2% to 9% of AIs had autopsies conducted.
Pathophysiology of adrenal incidentalomas encompasses benign as well as malignant neoplasms with diverse hormonal activities. From the incidentals noted during examination, there is clinical management based on size, hormonal activity, and appearances on imaging with periodic scans or other investigations to determine the next course of action.
Congenital Adrenal Hyperplasia (CAH): In some cases, non-classic CAH adrenal hyperplasia may present as an incidentaloma. They do not appear to be related to clinical levels of hyperandrogenemia but can be seen in conjunction with mild androgen excess.
Infection or Hemorrhage: Adrenal masses may be due to infection such as tuberculosis, histoplasmosis, or by haemorrhage, this is in cases of trauma, sepsis, or on patients on anticoagulant therapy.
Aldosterone-Secreting Adenoma (Conn’s Syndrome):
This is a rare cause of primary hyperaldosteronism.
Adrenal gland metastases occur frequently from lung, breast, kidney, or melanoma cancers of the body. It is seen most frequently in patients with an underlying known primary malignancy.
Size of the Incidentaloma:
Mass Size >4 cm: larger masses have higher chances of being malignant, with most guidelines recommending surgery if the size exceeds 4-6 cm.
Mass Size <4 cm: while smaller lesions are usually benign, follow-up examinations are usually advised to check for growth.
Growth Rate: A change in size of over 1-cm in six to twelve months can therefore suggest malignancy.
Hormonal activity:
Benign lesion is usually do not increase in size or increase very slowly Most of the benign skin lesions are therefore unlikely to become malignant.
Hormonal Activity Cortisol Secretion (Cushing’s Syndrome): Incidentalomas themselves may be hypersecretory and cause subclinical or clinical Cushing’s disease.
Aldosterone Secretion (Conn’s Syndrome): About half of adrenal masses produce aldosterone hormone causing primary hyperaldosteronism.
Age Group:
The typical age group in which adrenal incidentalomas are more commonly found is between 40 and 60. However, the prevalence increases significantly with advancing age, particularly in individuals over 60 years.
General assessment
Endocrine examination
Abdominal examination
Subclinical Cushing’s Syndrome
Pheochromocytoma
Aldosteronoma
Hyperlipidemia
Hypertension
Age Group: The average age when the incidence of adrenal incidentalomas is higher is between 40 and 60 years. But there is a progressive increase in the prevalence with increasing age especially persons above 60.
Acute Presentation: This incidentaloma can be discovered during a routine imaging investigation for trauma or acute abdomen pain, for example. Occasionally it may be an incidentaloma that can be hormonally functioning to cause an acute event such as adrenal haemorrhage, acute cushing’s disease or pheochromocytoma crisis. For such reasons, immediate treatment is necessary, and more so, if there are indications of hormonal overproduction, pheochromocytoma and cortisol producing tumor.
Chronic Presentation: Most of the time, adrenal incidentalomas are discovered during cross-sectional imaging performed for nonadrenal diseases, and none of the imaging studies initially point to adrenal pathology. These cases typically require stepwise evaluation rather than emergent management of hormonal activity and have the potential for malignancy.
Non-functioning Adrenal Adenoma (Benign)
Adrenocortical Carcinoma (ACC)
Pheochromocytoma
Adrenal Metastasis
Adrenal Myelolipoma
Cushing’s Syndrome (Cortisol-producing Adenoma)
Aldosterone-producing Adenoma (Conn’s Syndrome)
Treatment Paradigm:
Initial Evaluation Imaging Characteristics: The appearance is indicated on imaging (CT, MRI) and should assess a difference between a benign and malignant mass.
Fatty masses with homogeneity should be regarded as benign adenomas, however, irregular or enlarging masses are suspect of malignancy.
Size:
Mass measuring less than 4 cm are generally benign.
Mass measuring more than 4-6 cm is generally believed to be malignant.
Hormonal Evaluation: It is also important to do some tests to see if the tumor is hormone secreting.
Key tests include:
Cortisol: Screening for Cushing’s syndrome.
Aldosterone: For screening of primary hyperaldosteronism in hypertensive patients and as an adjunct to biochemical testing in primary aldosteronism diagnosis.
Catecholamines: Exclude pheochromocytoma with metanephrine measurements.
Sex Hormones: Some of the rare tumors may produce androgens or estrogens.
Management Based on Hormonal Activity
Non-Functioning Tumors:
Small, non-functioning masses (<4 cm) with benign imaging characteristics are often managed by having periodic imaging and clinical follow-ups to monitor for growth.
Repeat imaging at 6-12 months and then annually for 2-5 years is advised if growth is not noted.
Functional Tumors:
Cushing’s Syndrome: Adrenalectomy is usually recommended if the mass is producing cortisol.
Pheochromocytoma: Surgical resection should be performed only after adequate medical preparation with alpha-blockade.
Aldosterone-producing tumors (Conn’s Syndrome): The treatment of choice is adrenalectomy, especially in patients with unilateral disease.
Endocrinology, Metabolism
Stress Management: If the adrenal incidentaloma is functional, for example causing excess cortisol production such as in subclinical Cushing’s syndrome, then the patient should reduce stressful activities. Some stress relieving strategies that can be recommended include, the mindfulness, relaxation and improving sleep.
Diet and Exercise: Daily food choices and exercise regimen should be kept healthy especially when the adrenal incidentalomas related to metabolic syndrome, such as hypertension, obesity, or glucose intolerance.
Monitoring and Medical Environment: Incidentaloma requires monitoring by checkups with imaging and laboratory tests to evaluate the size, function, or development of complications.
Exposure to Endocrine Disruptors: Reducing the contact with hormone disruptor agents like some pesticides, plastics, and chemicals can also reduce other risks attributed to hormone imbalance.
Endocrinology, Metabolism
Endocrinology
Laparoscopic Adrenalectomy
The procedure is most used for functioning or benign adrenal tumors and larger tumors 4-6 cm with benign features.
Less postoperative pain, recovery time, and scarring,
The procedure involves making three or four small incisions, usually on either side of the abdomen, in which a camera and instruments are used by the surgeon to remove the adrenal gland.
Open Adrenalectomy:
Usually recommended for large tumors greater than 6 cm, suspected malignancy, and in cases where laparoscopic access is not possible.
It invasively requires a larger incision. Due to this, it enables better visualization and access to the adrenal gland. Sometimes this is performed with the help of a flank, an anterior or posterior approach.
Endocrinology, Metabolism
Initial Evaluation:
Patient History and Physical Examination: Evaluate signs associated with hypercortisolism, hyper aldosteronism or pheochromocytoma. Imaging Studies: Normally, CT or MRI defines the size, density, and the enhancement of the adrenal mass.
Hormonal Evaluation
Biochemical Screening:
Cortisol: Screen for Cushing’s syndrome by undergoing a 24-hour free urine cortisol test or a late-night salivary cortisol test.
Aldosterone and Renin: Screening for; the first condition that you should look out for is primary hyperaldosteronism particularly in patients who have been diagnosed with hypertension.
Risk Assessment Size and Imaging Characteristics: Only adrenal masses > 4 cm or those with imaging characteristics highly suggestive, presumably malignant, should be considered malignant.
Malignancy Criteria: Assess through size, shape and high density on the imaging.
Management Decisions
Hormone-Secreting Adenomas: If functional, management depends on the hormone involved (e.g., medical therapy for Cushing or adrenalectomy for aldosterone-producing neoplasm).
Non-Functioning Adenomas: If the mass is non-aggressive (generally small and not hormone producing) management may entail periodic follow up by imaging and hormonal assays.
Surgical Intervention
Indications for Surgery: Usually advised for patients with large tumors greater than 4 cm in size, any tumors that have typical features of malignancy or tumours that secrete hormones.
Type of Surgery: Laparoscopic adrenalectomy is done where there is a resectable tumor in the adrenals.
Adrenal incidentaloma is a tumour or mass of adrenal gland discovered accidentally while imaging the abdomen for other condition using CT or MRI scans. These masses are commonly seen in asymptomatic persons with no signs of adrenal disease. Adrenal incidentalomas are more frequent in elderly population; the vast majority are not hormone-secreting, benign adenomas.
Cross-sectional abdominal images are likely to reveal adrenal incidentaloma. Between 1 to 5% of all CT scans that are done for non-abdominal reveal an adrenal mass and majority of them are AIs. This ranges between 2% to 9% of AIs had autopsies conducted.
Pathophysiology of adrenal incidentalomas encompasses benign as well as malignant neoplasms with diverse hormonal activities. From the incidentals noted during examination, there is clinical management based on size, hormonal activity, and appearances on imaging with periodic scans or other investigations to determine the next course of action.
Congenital Adrenal Hyperplasia (CAH): In some cases, non-classic CAH adrenal hyperplasia may present as an incidentaloma. They do not appear to be related to clinical levels of hyperandrogenemia but can be seen in conjunction with mild androgen excess.
Infection or Hemorrhage: Adrenal masses may be due to infection such as tuberculosis, histoplasmosis, or by haemorrhage, this is in cases of trauma, sepsis, or on patients on anticoagulant therapy.
Aldosterone-Secreting Adenoma (Conn’s Syndrome):
This is a rare cause of primary hyperaldosteronism.
Adrenal gland metastases occur frequently from lung, breast, kidney, or melanoma cancers of the body. It is seen most frequently in patients with an underlying known primary malignancy.
Size of the Incidentaloma:
Mass Size >4 cm: larger masses have higher chances of being malignant, with most guidelines recommending surgery if the size exceeds 4-6 cm.
Mass Size <4 cm: while smaller lesions are usually benign, follow-up examinations are usually advised to check for growth.
Growth Rate: A change in size of over 1-cm in six to twelve months can therefore suggest malignancy.
Hormonal activity:
Benign lesion is usually do not increase in size or increase very slowly Most of the benign skin lesions are therefore unlikely to become malignant.
Hormonal Activity Cortisol Secretion (Cushing’s Syndrome): Incidentalomas themselves may be hypersecretory and cause subclinical or clinical Cushing’s disease.
Aldosterone Secretion (Conn’s Syndrome): About half of adrenal masses produce aldosterone hormone causing primary hyperaldosteronism.
Age Group:
The typical age group in which adrenal incidentalomas are more commonly found is between 40 and 60. However, the prevalence increases significantly with advancing age, particularly in individuals over 60 years.
General assessment
Endocrine examination
Abdominal examination
Subclinical Cushing’s Syndrome
Pheochromocytoma
Aldosteronoma
Hyperlipidemia
Hypertension
Age Group: The average age when the incidence of adrenal incidentalomas is higher is between 40 and 60 years. But there is a progressive increase in the prevalence with increasing age especially persons above 60.
Acute Presentation: This incidentaloma can be discovered during a routine imaging investigation for trauma or acute abdomen pain, for example. Occasionally it may be an incidentaloma that can be hormonally functioning to cause an acute event such as adrenal haemorrhage, acute cushing’s disease or pheochromocytoma crisis. For such reasons, immediate treatment is necessary, and more so, if there are indications of hormonal overproduction, pheochromocytoma and cortisol producing tumor.
Chronic Presentation: Most of the time, adrenal incidentalomas are discovered during cross-sectional imaging performed for nonadrenal diseases, and none of the imaging studies initially point to adrenal pathology. These cases typically require stepwise evaluation rather than emergent management of hormonal activity and have the potential for malignancy.
Non-functioning Adrenal Adenoma (Benign)
Adrenocortical Carcinoma (ACC)
Pheochromocytoma
Adrenal Metastasis
Adrenal Myelolipoma
Cushing’s Syndrome (Cortisol-producing Adenoma)
Aldosterone-producing Adenoma (Conn’s Syndrome)
Treatment Paradigm:
Initial Evaluation Imaging Characteristics: The appearance is indicated on imaging (CT, MRI) and should assess a difference between a benign and malignant mass.
Fatty masses with homogeneity should be regarded as benign adenomas, however, irregular or enlarging masses are suspect of malignancy.
Size:
Mass measuring less than 4 cm are generally benign.
Mass measuring more than 4-6 cm is generally believed to be malignant.
Hormonal Evaluation: It is also important to do some tests to see if the tumor is hormone secreting.
Key tests include:
Cortisol: Screening for Cushing’s syndrome.
Aldosterone: For screening of primary hyperaldosteronism in hypertensive patients and as an adjunct to biochemical testing in primary aldosteronism diagnosis.
Catecholamines: Exclude pheochromocytoma with metanephrine measurements.
Sex Hormones: Some of the rare tumors may produce androgens or estrogens.
Management Based on Hormonal Activity
Non-Functioning Tumors:
Small, non-functioning masses (<4 cm) with benign imaging characteristics are often managed by having periodic imaging and clinical follow-ups to monitor for growth.
Repeat imaging at 6-12 months and then annually for 2-5 years is advised if growth is not noted.
Functional Tumors:
Cushing’s Syndrome: Adrenalectomy is usually recommended if the mass is producing cortisol.
Pheochromocytoma: Surgical resection should be performed only after adequate medical preparation with alpha-blockade.
Aldosterone-producing tumors (Conn’s Syndrome): The treatment of choice is adrenalectomy, especially in patients with unilateral disease.
Endocrinology, Metabolism
Stress Management: If the adrenal incidentaloma is functional, for example causing excess cortisol production such as in subclinical Cushing’s syndrome, then the patient should reduce stressful activities. Some stress relieving strategies that can be recommended include, the mindfulness, relaxation and improving sleep.
Diet and Exercise: Daily food choices and exercise regimen should be kept healthy especially when the adrenal incidentalomas related to metabolic syndrome, such as hypertension, obesity, or glucose intolerance.
Monitoring and Medical Environment: Incidentaloma requires monitoring by checkups with imaging and laboratory tests to evaluate the size, function, or development of complications.
Exposure to Endocrine Disruptors: Reducing the contact with hormone disruptor agents like some pesticides, plastics, and chemicals can also reduce other risks attributed to hormone imbalance.
Endocrinology, Metabolism
Endocrinology
Laparoscopic Adrenalectomy
The procedure is most used for functioning or benign adrenal tumors and larger tumors 4-6 cm with benign features.
Less postoperative pain, recovery time, and scarring,
The procedure involves making three or four small incisions, usually on either side of the abdomen, in which a camera and instruments are used by the surgeon to remove the adrenal gland.
Open Adrenalectomy:
Usually recommended for large tumors greater than 6 cm, suspected malignancy, and in cases where laparoscopic access is not possible.
It invasively requires a larger incision. Due to this, it enables better visualization and access to the adrenal gland. Sometimes this is performed with the help of a flank, an anterior or posterior approach.
Endocrinology, Metabolism
Initial Evaluation:
Patient History and Physical Examination: Evaluate signs associated with hypercortisolism, hyper aldosteronism or pheochromocytoma. Imaging Studies: Normally, CT or MRI defines the size, density, and the enhancement of the adrenal mass.
Hormonal Evaluation
Biochemical Screening:
Cortisol: Screen for Cushing’s syndrome by undergoing a 24-hour free urine cortisol test or a late-night salivary cortisol test.
Aldosterone and Renin: Screening for; the first condition that you should look out for is primary hyperaldosteronism particularly in patients who have been diagnosed with hypertension.
Risk Assessment Size and Imaging Characteristics: Only adrenal masses > 4 cm or those with imaging characteristics highly suggestive, presumably malignant, should be considered malignant.
Malignancy Criteria: Assess through size, shape and high density on the imaging.
Management Decisions
Hormone-Secreting Adenomas: If functional, management depends on the hormone involved (e.g., medical therapy for Cushing or adrenalectomy for aldosterone-producing neoplasm).
Non-Functioning Adenomas: If the mass is non-aggressive (generally small and not hormone producing) management may entail periodic follow up by imaging and hormonal assays.
Surgical Intervention
Indications for Surgery: Usually advised for patients with large tumors greater than 4 cm in size, any tumors that have typical features of malignancy or tumours that secrete hormones.
Type of Surgery: Laparoscopic adrenalectomy is done where there is a resectable tumor in the adrenals.
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