Imaging Pearls ❯ Adrenal ❯ Adrenal Hematoma
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- “Prompt diagnosis may matter clinically because 16– 50% of patients with bilateral adrenal hemorrhage eventually have life-threatening adrenal insufficiency. Recognition of adrenal hemorrhage secondary to underlying tumor is also important so that potentially dangerous masses such as pheochromocytoma do not go untreated. Despite the importance of adrenal hemorrhage and the critical role of imaging, relatively little has been published on this topic in the radiologic literature.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “The causes of nontraumatic adrenal hemorrhage include stress; bleeding diatheses, including anticoagulant use; procedures; and intratumoral bleeding. Stress includes recent surgery, organ failure, sepsis, and pregnancy. These causes are not mutually exclusive and can coexist. Recognition of adrenal hemorrhage is particularly important because of the common use of anticoagulation and the introduction of agents such as dabigatran. Noniatrogenic bleeding diathesis such as disseminated intravascular coagulopathy and antiphospholipid syndrome can also lead to adrenal hemorrhage.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “Acute intratumoral adrenal hemorrhage is most commonly seen in pheochromocytoma, but hemorrhage has also been described in myelolipomas, metastatic lesions, adrenocortical carcinomas, adenomas, and hemangiomas. Interestingly, calcification suggestive of previous hemorrhage was seen in 26% of myelolipomas (22 of 86) in one study, but these tumors seem to rarely present with clinically overt hemorrhage.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “Other features that may be seen in acute adrenal hemorrhage include periadrenal infiltration, active extravasation with retroperitoneal bleeding, and maintenance of an adreniform shape. Unenhanced CT in isolation, performed either because adrenal hemorrhage is suspected clinically or because of a contraindication to IV contrast administration, may show adrenal enlargement of greater than simple fluid attenuation and periadrenal infiltration.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “Bleeding often continues until the adrenal gland expands beyond the adreniform shape and forms a round or oval hematoma in the gland. The size of hematomas varies, ranging from a few centimeters to well over 10 cm. A hematoma appears on CT images as a circular nonenhancing mass of greater than simple fluid attenuation (e.g., 50–90 HU). Occasionally, extravasation of contrast material during catheter angiography or venous sampling or prior injection of contrast material for cystography results in an appearance resembling acute adrenal hemorrhage, but correlation with the history should help with the distinction.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “Over time, the size and CT attenuation of adrenal hemorrhage decrease, eventually reaching simple fluid attenuation or even complete resolution. The time course of these changes in nontraumatic adrenal hemorrhage has not been well described, but shrinkage and decreased attenuation were seen in most of 35 traumatic adrenal hemorrhages evaluated with repeat CT after a mean interval of 19 days.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “Later, chronic hemorrhage may appear as adrenal atrophy or a hemorrhagic adrenal pseudocyst. Atrophy appears on CT images as a shriveled, isoattenuating adreniform structure. A hemorrhagic adrenal pseudocyst is a chronic organized collection of hemorrhage that presents as nonenhancing, thin-rimmed cystic structures. At CT, pseudocysts are nonenhancing and have central hypoattenuation close to that of simple fluid”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “The frequency with which adrenal hemorrhage is associated with an underlying adrenal tumor has not been well described, although our experience suggests this type of hemorrhage is a relatively rare occurrence. The distinction of tumoral from nontumoral hemorrhage is straightforward when a neoplastic mass can be appreciated within or adjacent to a hematoma, but finding the mass can be difficult or impossible, particularly in the acute phase.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - “The rapid development or evolution of a nonenhancing adrenal mass or masses that retain an adreniform shape or have high T1 signal intensity at MRI of a patient under stress or with a bleeding diathesis should suggest acute adrenal hemorrhage. Bilateral hemorrhage can cause life-threatening adrenal insufficiency. Chronic hemorrhage may appear at imaging as a thin-walled adrenal pseudocyst or adrenal atrophy. Imaging findings that suggest underlying tumor as a cause of adrenal hemorrhage are intralesional calcification, enhancement, and hypermetabolic activity on PET images.”
Imaging of Nontraumatic Adrenal Hemorrhage
Eric Jordan et al.
AJR 2012; 199:W91–W98 - The majority of cases of adrenal trauma do not display specific signs and symptoms; however, the presence of adrenal trauma may indicate the presence of severe trauma and should prompt an evaluation for associated injuries. Due to the possible life-threatening events associated with adrenal injuries, several authors have advised aggressive management and early intervention to avoid complications such as delayed adrenal insufficiency. In contrast, an increasing number of studies have reported that conservative management can be used for patients with adrenal trauma.
Adrenal Gland Trauma: An Observational Descriptive Analysis from a Level 1-Trauma Center.
Al-Thani H, et al.
J Emerg Trauma Shock. 2021 Apr-Jun;14(2):92-97. - “Adrenal hematomas with a mass-like configuration offer a potential diagnostic dilemma for radiologists and surgeons. Although it is rare that an adrenal hemorrhage is surgically resected, awareness of the potential appearances of these lesions is important to spare patients from unnecessarily aggressive surgery.”
Computed Tomography Appearance of Surgically Resected Adrenal Hematomas.
Rowe SP, Mathur A, Bishop JA, Epstein JI, Prescott JD, Salvatori R, Siegelman SS, Fishman EK.
J Comput Assist Tomogr. 2016 Nov/Dec;40(6):892-895. - “Incidental adrenal lesions are found in 2% to 10% of the population. The presence and pattern of calcifications, in conjunction with other clinical and imaging features, such as soft tissue attenuation, enhancement, and laterality, can aid in narrowing a differential diagnosis, thereby preventing unnecessary biopsies and avoiding delays in management. Calcified adrenal lesions can be categorized under the clinical and laboratory headings of normal adrenal function, hyperfunctioning adrenal tissue, and adrenal insufficiency.”
Calcified Adrenal Lesions: Pattern Recognition Approach on Computed Tomography With Pathologic Correlation.
Consul, Nikita MD et al.
Journal of Computer Assisted Tomography 44(2):p 178-187, 3/4 2020
- “There are no established guidelines for follow-up to assess for an underlying mass after resolution of hemorrhage; however, follow-up imaging is often warranted, and 6–12 weeks after resolution of the hemorrhage is reasonable.”
Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards
Ryan Chung et al.
RadioGraphics 2023; 43(7):e220191 July 2023 - Adrenal Masses with Hemorrhage
- Pheochromocytoma (most common)
- Metastasis
- Adrenocortical carcinoma
- Myelolipoma
- Adenoma - “It may be impossible to distinguish a large atypical adenoma from an ACC or other malignant mass with imaging because of overlapping imaging features. If there are no benign diagnostic features, evaluation of the clinical context, including hormonal assessment, is essential for assessing the need for surgical resection of a 4-cm or larger adrenal mass. Patients with a large adrenal mass should be managed by a multidisciplinary team that includes surgeons, endocrinologists, and radiologists.”
Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards
Ryan Chung et al.
RadioGraphics 2023; 43(7):e220191 July 2023 - “Adrenal cyst is a differential diagnosis for a low-attenuation (0–20-HU) adrenal lesion. There are four types of adrenal cysts: endothelial-vascular, pseudocyst, epithelial, and parasitic. Endothelial cysts and pseudocysts make up more than 80% of all adrenal cysts. All adrenal cysts demonstrate simple fluid attenuation with varying degrees of loculation, septa, and calcification. Endothelial and epithelial cysts are usually thin walled and multilocular and can contain septal calcifications, whereas pseudocysts have a slightly thicker wall, are unilocular, and can contain peripheral calcifications. A pseudocyst arises from prior hemorrhage. Parasitic (echinococcal) cysts have the thickest walls, are unilocular or multilocular, and can contain peripheral calcifications and daughter cysts.”
Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards
Ryan Chung et al.
RadioGraphics 2023; 43(7):e220191 July 2023 - “Between 22% and 97% of pheochromocytomas demonstrate cystic and/or necrotic change. Cystic and/or necrotic change is defined as a focal central area of low attenuation subjectively similar to fluid attenuation within a solid mass or nodule on CT images and hyperintense signal on T2- weighted MR images, without corresponding enhancement. It is an imaging appearance, but it does not imply a pathologic diagnosis of necrosis. On images, the distinguishing feature of pheochromocytoma with a cystic and/or necrotic appearance is a thick enhancing wall that retains contrast enhancement on delayed postcontrast images; septa may or may not be present . In the case of an incidental solid adrenal mass with cystic and/or necrotic change, pheochromocytoma should be strongly considered. Laboratory evaluation is recommended to confirm the diagnosis.”
Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards
Ryan Chung et al.
RadioGraphics 2023; 43(7):e220191 July 2023 - “Hemorrhage is a rare complication; however, pheochromocytoma is the most common primary tumor to hemorrhage. Although the underlying mechanism of pheochromocytoma with hemorrhage is unknown, some theories suggest increased intracapsular pressure from trauma, a rapidly enlarging tumor that outgrows its blood supply, and vasodilatation and interstitial hemorrhage caused by the use of antihypertensive medications. Patients may present with symptoms of a hypertensive crisis secondary to excessive catecholamine release from a ruptured pheochromocytoma.”
Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards
Ryan Chung et al.
RadioGraphics 2023; 43(7):e220191 July 2023
- The adrenal gland is the most common endo-crine site of extrapulmonary TB, with a preva ence of up to 6% in cases of active pulmonary TB seen at autopsy. Adrenal involvement is almost always bilateral, and this can lead to Addi-son disease. The adrenal glands are the fifth most common site of extrapulmonary TB, following the liver, spleen, kidneys, and bones. If greater than 90% or more of the glands is destroyed, then a life-threatening addisonian crisis ensues. When Thomas Addison described his first series of patients in 1855, all of the cases were attributable to TB; however, in a more recent large study, one-third of the cases of Addison disease were due to TB, compared with 70% of the cases in past series.”
Imaging Manifestations of Genitourinary Tuberculosis
Muhammad Naeem et al.
RadioGraphics 2021;41:1123–1143 - “On radiographs, adrenal TB has no specific imaging feature. Adrenal calcifications can be seen with both treated and untreated TB. Nearly half of cases of untreated TB can manifest as adrenal calcifications. The CT appearance depends on the chronicity, as well as the treat-ment status of the patient. Masslike enlargement is seen in 50%–65% of cases, and adreniform hyperplasia is seen in 35%–50% of cases. One-third of cases involve heterogeneous enhancement of the adrenal glands. The classic pattern of peripheral rimlike enhancement usually is seen in half of affected patients and is more commonly seen with TB than with centrally necrotic adrenal tumors.”
Imaging Manifestations of Genitourinary Tuberculosis
Muhammad Naeem et al.
RadioGraphics 2021;41:1123–1143
- Adrenal Hemorrhage: Etiology
- Trauma
- Anticoagulant therapy
- Stress related
- Underlying tumor (benign and malignant) - “The imaging appearance of acute non-traumatic hemorrhage is similar to that of traumatic hemorrhage, typically a round to oval lesion appearing hyperdense on non-contrast enhanced CT images, hypointense on T1W and markedly hypointense on T2W images is observed. As with traumatic hemorrhages, hemorrhage gradually decreases in size and attenuation on CT and has a variable appearance on MRI depending on the stage of blood products, as described previously.Adrenal hemorrhage is often preceded by congestion which can be seen on CT as diffuse thickening of the gland with peri-adrenal fat stranding.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302 - “Hemorrhage into an existing adrenal tumor can often mask the underlying lesion, especially in the acute stage and when there is no prior imaging available at time of first presentation. Intratumoral hemorrhage can either be spontaneous or secondary to trauma. Although rare, intratumoral adrenal hemorrhage is the fourth most common cause of spontaneous retroperitoneal hemorrhage after renal cell carcinoma, renal angiomyolipoma and renal artery aneurysm.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302 - “The most common adrenal tumors associated with hemorrhage include pseudocyst, myelolipoma, adrenal hemangioma, pheochromocytoma, adrenocortical carcinomas, hemorrhagic adrenal metastases (most commonly from bronchogenic carcinoma and malignant melanoma) and rarely adrenal adenoma .Benign tumors more commonly hemorrhage compared to malignant tumors and pheochromocytoma is the most common benign tumor which may bleed.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302 - “Adrenal infarction is a rare cause of adrenal insufficiency and can be hemorrhagic or non-hemorrhagic, the latter being less common. Most reports have been described in patients with primary antiphospholipid-antibody syndrome (PAPS) and less commonly in pregnancy, heparin induced thrombocytopenia, myelodysplastic syndrome and Crohn’s disease. Up to 36% of patients with PAPS present with adrenal insufficiency as the first manifestation of the disease.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302 - “On CT, the infarcted adrenals are seen as enlarged hypodense glands with absent or poor contrast enhancement. Moschetta et al. described the capsular rim sign in 83% of patients with adrenal infarction, seen as diffusely enlarged hypodense gland with a thin rim of peripheral enhancement, likely due to residual perfusion of the adrenal capsular veins. On MRI, the infarcted adrenal glands have an edematous appearance with retroperitoneal edema, best seen as hyperintensity on fat saturated T2W images. A few recent case reports have described restricted diffusion in the infarcted adrenal glands.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302 - “On CT, the infarcted adrenals are seen as enlarged hypodense glands with absent or poor contrast enhancement. Moschetta et al. described the capsular rim sign in 83% of patients with adrenal infarction, seen as diffusely enlarged hypodense gland with a thin rim of peripheral enhancement, likely due to residual perfusion of the adrenal capsular veins. On MRI, the infarcted adrenal glands have an edematous appearance with retroperitoneal edema, best seen as hyperintensity on fat saturated T2W images. A few recent case reports have described restricted diffusion in the infarcted adrenal glands.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology (2021) 46:290–302
- “Non-traumatic bleeding in the adrenal glands is a rare clinical event and diagnosis may be difficult due to non-specific nature of the symptoms. Early diagnosis and intervention are critical as fatality rate has been reported to be as high as 16% to 50% due to life-threatening adrenal insufficiency. Historically, ante mortem diagnosis was rare due to non-specific nature of the process, however with the ever expanding use of cross-sectional imaging the diagnosis may be frequently made before death in current practice. Vomiting, hypotension, flank pain, low-grade fever, agitation, and abdominal pain have been reported as common presenting symptoms.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - "The size of the hematoma is also highly variable and may range from a few centimeters to over 10 cm. The adrenal hematomas characteristically appear as hyperattenuating in the acute phase and measure between 50 and 90 HU. Infiltration in the periadrenal fat tissue is another suggestive finding, which can be appreciated with CT. Active contrast extravasation may be seen but it is very rare, based on our experience. Cystic degeneration may be detected in subacute and chronic phases as the hematoma evolves.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - "Anticoagulation, especially heparin, is the most common underlying reason for non-traumatic SAH. Heparin may act in two ways: (1) It may increase the bleeding risk when used in the setting of acute illness, (2) Heparin induced thrombocytopenia (HIT), where heparin plate- let factor 4 antibodies are stimulated, may also contribute. As HIT may induce thrombocytopenia and paradoxic thromboembolism, the coagulative occlusion of the central adrenal vein may be the underlying pathophysiology for bleeding. Despite the fact that most reported cases are heparin related, other anticoagulant agents may also cause non-traumatic SAH.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - "Antiphospholipid syndrome (APS) is an autoimmune dis- ease which is characterized by recurrent arterial and venous thrombosis. It is most commonly seen in women of child- bearing age and associated with specific autoantibodies called antiphospholipid antibodies. As these patients may be prone to adrenal vein throm- bosis, adrenal hematomas can be observed in the course of the disease. Bilateral bleeding and subsequent hemorrhagic infarction may cause acute adrenal insufficiency. Major surgical interventions, trauma and infection may also trigger this potentially fatal event. Adrenal insufficiency may even be the first presenting symptom of APS.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - "Imaging diagnosis may be difficult considering the rarity of the disease. ACCs are predominantly unilateral and solid in nature. Hemorrhage with associating necrosis is generally located in the center of the tumor. The detection of enhancing soft tissue islands within the hematoma and predominantly peripheral enhancement on CT or MR images may be suggestive for ACC. However, enhancement may also be detected in spontaneously bleeding adenomas or pheochromocytomas.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - "These metastases are mostly clinically silent but spontaneous bleeding is very rare. Lung, breast, hepatocellular carcinoma are the common primary sources with bronchogenic tumors being the most common cause of hemorrhagic adrenal metastases. In case of spontaneous rupture clinical symptoms may be severe including flank pain and hypotension.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Ali Devrim Karaosmanoglu et al.
Abdominal Radiology (2021) 46:1091–1102 - Adrenal Masses That Bleed
- Primary adrenal cortical carcinoma
- Metastases to the adrenal
- Myelolipoma
- Adrenal adenomas
- Pheochromocytomas - “Our study identified several CT characteristics of adrenal tumors, which are consistently reported by radiologists and determined which of these characteristics correlated with pathologic diagnosis. The most predictive characteristic was precontrast attenuation. Lesions that were classified as < 10 HU in attenuation by the readers were all benign, and the lowest precontrast attenuation for an adrenocortical carcinoma was measured at 18.6 HU. Low precontrast attenuation has been demonstrated to be specific for benign adenomas due to the fact that adrenal adenomas often display abundant intracytoplasmic lipid.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography
Aaron J. Thomas et al.
Abdom Radiol (2018) 43:3101–3108 - "The presence of fat on CT was correlated to a benign pathologic diagnosis in our study with a specificity of 93%, and there was moderate interobserver agreement regarding its presence or ab- sence. However, macroscopic fat, likely representing myelipomatous metaplasia, is not common within adenomas, and has been reported in other entities as well, such as adrenocortical carcinoma and pheochromocytoma. Readers substantially agreed on the evaluation of shape, and a round shape was also significantly correlated with benign pathology. Finally, lesions rated as likely benign by the radiologists were significantly more likely to be adenomas than those rated malignant, but agreement between radiologists on this dimension was only fair, indicating a high degree of subjectivity in this determination.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography
Aaron J. Thomas et al.
Abdom Radiol (2018) 43:3101–3108 - "The importance of the above morphologic charac- teristics is underscored by the fact that the contrast washout pattern, which has been demonstrated to be accurate for distinguishing between small benign and malignant adrenal lesions, was not significantly dif- ferent between the two groups, although our study may be underpowered to detect small differences between the groups. The adrenocortical carcinomas were also generally larger than adenomas, but there was significant overlap between the two groups, and this was not found to be a specific finding.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography
Aaron J. Thomas et al.
Abdom Radiol (2018) 43:3101–3108 - "In conclusion, our study identified morphologic CT characteristics that correlate with the pathologic diagnosis for large adenomas and adrenocortical carcinomas, adenoma. For some CT characteristics, including precontrast attenuation, shape, and the presence of fat, which can be determined by different radiologists with moderate or greater consistency. Two of these, attenuation and the presence of fat were both highly specific for benign pathology, although the sensitivity for each was low, and many lesions therefore remain indeterminate by CT. Attenuation was both more specific and had higher interobserver agreement, indicating it may be the best indicator of the underlying pathology.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography
Aaron J. Thomas et al.
Abdom Radiol (2018) 43:3101–3108
- “Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Karaosmanoglu AD et al.
Abdominal Radiology 2020 (in press) - "Acute adrenal bleeding is seen as a mass with heterogenous internal texture in one or both adrenal glands and contrast enhancement is unusual in these pseudomasses. The hemorrhage distorts the shape of the adrenal gland and adreniform shape is typically not preserved. The size of the hematoma is also highly variable and may range from a few centimeters to over 10 cm [3]. The adrenal hematomas characteristically appear as hyperattenuating in the acute phase and measure between 50 and 90 HU. Infiltration in the periadrenal fat tissue is another suggestive finding, which can be appreciated with CT.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Karaosmanoglu AD et al.
Abdominal Radiology 2020 (in press) - "Anticoagulation, especially heparin, is the most common underlying reason for non-traumatic SAH. Heparin may act in two ways: (1) It may increase the bleeding risk when used in the setting of acute illness, Heparin induced thrombocytopenia (HIT), where heparin platelet factor 4 antibodies are stimulated, may also contribute. As HIT may induce thrombocytopenia and paradoxic thromboembolism, the coagulative occlusion of the central adrenal vein may be the underlying pathophysiology for bleeding. Despite the fact that most reported cases are heparin related, other anticoagulant agents may also cause non-traumatic SAH.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Karaosmanoglu AD et al.
Abdominal Radiology 2020 (in press) - “Spontaneous adrenal bleeding is a relatively rare clinical event, especially beyond the neonatal age. Imaging studies should be liberally used to search for an underlying mass for early treatment. However, it should be considered that any underlying mass may be obscured in certain cases by the large hematoma and, in these patients, close clinical follow- up with imaging studies is mandatory.”
Can we differentiate neoplastic and non‐neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation
Karaosmanoglu AD et al.
Abdominal Radiology 2020 (in press) - Adrenal Hemorrhage: Etiology
- Trauma
- Anticoagulation
- Antiphospholipid syndrome
- Metabolic stress
- Tumors
--- Adrenocortical carcinoma
--- Pheochromocytoma
--- Metastases
- Acute Adrenal Emergencies
- Trauma
- Non traumatic hemorrhage
- Infarction
- Infection - “The most common imaging manifestation of adrenal trauma is hemorrhage which is seen as a round-ovoid non- enhancing hyperdense mass replacing the entire adrenal gland with a mean reported size of 2.8- 3.3 cm and mean attenuation value of soft tissue/hemorrhage density (reported to be in the range of + 43 to + 52 Hounsfield Units [HU]). Hematomas appear heterogeneous on post-contrast images with no enhancement. Peri-adrenal soft tissue stranding is also commonly seen, reported in up to 78–89% cases.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology https://doi.org/10.1007/s00261-020-02580-w - “Patients with trauma can present with shock, most commonly due to hemorrhage, causing reduced blood volume (hypovolemic shock). Increased sympathetic activity can give rise to a constellation of findings on CT, termed as the CT hypoperfusion complex, first described by Taylor et al. These findings are more commonly observed in children but can also be seen in adults.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology https://doi.org/10.1007/s00261-020-02580-w - "The findings on CT include dilated fluid-filled loops of bowel with intense mucosal enhancement, hyperenhancing mesenteric vasculature, decreased caliber of the aorta, slit-like IVC, intense enhancement of the kidneys. Intense enhancement of bilateral adrenal glands with maintained contour and without focal mass is also a documented finding in patients with the CT hypoperfusion complex.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology https://doi.org/10.1007/s00261-020-02580-w
- Waterhouse-Friderichsen syndrome was originally described by the English physician Waterhouse in 1911. Friderichsen, a Danish pediatrician, completed a literature review and described a further case in 1918. The syndrome is characterized by massive adrenal hemorrhage in the context of septicemia (classically, meningococcus septicemia). However, other causative organisms and even noninfectious causes are now recognized . Neisseria meningitidis remains the most common culprit of bilateral adrenal hemorrhages, but other common infectious agents include group A Streptococcus, Streptococcus pneumoniae, Rickettsia rickettsi, and Staphylococcus aureus.
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - Waterhouse-Friderichsen syndrome was originally described by the English physician Waterhouse in 1911. Friderichsen, a Danish pediatrician, completed a literature review and described a further case in 1918. The syndrome is characterized by massive adrenal hemorrhage in the context of septicemia (classically, meningococcus septicemia).”
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - “Other causes of massive bilat- eral adrenal hemorrhage include anticoagulants, antiphospholipid syndrome, physiologic stress (eg, burns), tumor metastasis, and postoperative hemorrhage.”
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - “In the context of sepsis, the process leading to adrenal hemorrhage is thought to result from the release of bacterial endotoxins (lipopolysaccharide in gram-negative bacteria and peptidoglycan in gram-positive bacteria). The circulating endotoxins lead to activation of coagulation, fibrinolysis, and proinflammatory pathways . The circulating up-regulated proinflammatory cytokines result in adrenal parenchymal damage and hemorrhage.”
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - “Because these symptoms are signs of shock and are nonspecific, making the clinical diagnosis of adrenal hemorrhage can be challenging. It is also important to recognize that although adrenal hemorrhage can lead to adrenal in- sufficiency, symptoms such as hyponatraemia, hyperkalaemia, and hypotension occur only when more than 90% of the gland has been affected .”
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - Management of adrenal hemorrhage depends on the stage of the bleed. In the acute setting, treatment is supportive resuscitation to achieve hemostasis. If the patient develops adrenal insufficiency, additional administration of high-dose glucocorticoids is necessary. Failure to promptly recognize and treat adrenal insufficiency after adrenal hemorrhage can be fatal. This patient received resuscitation and antibiotics; unfortunately, given his extensive metastatic disease, he eventually received palliative care and died 4 weeks later.
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506 - In summary, Waterhouse-Friderichsen syndrome is a rare diagnosis that should be considered in the context of acute bilateral adrenal enlargement and sepsis. The key features are enlargement of the adrenal glands, with loss of their normal Y shape. The attenuation of the gland depends on the age of the hematoma or hemorrhage. In the acute stage, this finding typically has high attenuation.
Bilateral Adrenal Hemorrhage in the Context of Sepsis
Fatima D. Alves Pereira et al.
Radiology 2019; 292:503–506
- “Posttraumatic adrenal hemorrhage is usually unilateral, although bilateral involvement can occur . While uncommon overall, nontraumatic adrenal hemorrhage is typically bilateral and can be caused by a wide range of conditions, with the most common being stress, hemorrhagic diathesis or coagulopathy, or an underlying adrenal mass . One series of 2000 consecutive autopsies performed over an 8-year period yielded an overall prevalence of 1.8% for bilateral adrenal hemorrhage in a nontrauma setting.”
From the Radiologic Pathology Archives: Adrenal Tumors and Tumor-like Conditions in the Adult: Radiologic-Pathologic Correlation Grant E. Lattin, Jr et al. RadioGraphics 2014 34:3, 805-829 - “Common stress events include severe burns, sepsis, surgery, or hypotension. Anticoagulant therapy can cause spontaneous adrenal hemorrhage. Causes of adrenal vein thrombosis, including hypercoagulable states, can cause hemorrhagic infarction of the gland. ACAs, myelolipomas, pheochromocytomas, metastases, and ACC are some of the adrenal masses known to cause spontaneous adrenal hemorrhage, therefore careful inspection is required at imaging to exclude such lesions when adrenal hemorrhage is identified.”
From the Radiologic Pathology Archives: Adrenal Tumors and Tumor-like Conditions in the Adult: Radiologic-Pathologic Correlation Grant E. Lattin, Jr et al. RadioGraphics 2014 34:3, 805-829 - “In the setting of nontraumatic hemorrhage, the primary differential diagnostic considerations are an underlying mass that has spontaneously bled, including, as noted earlier, ACA, pheochromocytoma, myelolipoma, and a hypervascular metastasis. Identifying a small mass that has caused the bleeding can be challenging, especially at initial presentation. Clinical history, such as symptoms of adrenergic overactivity in the setting of pheochromocytoma, can help narrow the differential diagnosis. Identifying macroscopic fat can strongly suggest an underlying myelolipoma. Serial imaging can be helpful to assess for the evolution of a hematoma, as described earlier.”
From the Radiologic Pathology Archives: Adrenal Tumors and Tumor-like Conditions in the Adult: Radiologic-Pathologic Correlation Grant E. Lattin, Jr et al. RadioGraphics 2014 34:3, 805-829
- “ The most common imaging features include a 2-3 cm oval hematoma, irregular hemorrhage obliterating the adrenal gland, periadrenal hemorrhage or fat stranding, and uniform adrenal swelling with increased attenuation.”
Imaging of traumatic adrenal injury
To’o KJ, Duddalwar VA
Emerg Radiol (2012) 19:499-503 - “ Traumatic adrenal injury occurs in 5% of cases of blunt abdominal trauma and most commonly affects the right adrenal gland only. While rare, adrenal injury is an indicator of severe trauma and should prompt a search for associated injuries. The most common imaging feature of adrenal injury is a 2-3cm oval hematoma.”
Imaging of traumatic adrenal injury
To’o KJ, Duddalwar VA
Emerg Radiol (2012) 19:499-503 - Adrenal Trauma: CT Findings
- Adrenal hematoma (oval or round)
- Irregular hemorrhage obliterating the gland
- Uniform adrenal gland swelling with increased attenuation
- Periadrenal hemorrhage or stranding
- Retroperitoneal hemorrhage
- Adrenal pseudocyst (chronic)
- Imaging of traumatic adrenal injury
To’o KJ, Duddalwar VA
Emerg Radiol (2012) 19:499-503
- Adrenal Masses
- Adenoma
- Myelolipoma
- Metastases
- Pheochromocytoma
- Adrenal Cortical Carcinoma
- Lymphoma - Adenoma with Hemorrhage
- Rarely an adenoma can hemorrhage
- Usually anticoagulated patient
- Heterogeneous
- Regions of high attenuation
- “ Adrenal hemorrhage is rarely suspected clinically, exhibits no specific clinical symptoms or laboratory findings, and yet is immediately life threatening when bilateral. Recognition of adrenal hematomas is complicated by the variable appearance of these lesions.”
CT of the Adrenal Gland: the many faces of adrenal hemorrhage
Sacerdote MG, Johnson PJ, Fishman EK
Emerg Radiol 2011 Oct 30 (epud ahead of print) - Adrenal Hemorrhage
- Relatively uncommon, but potentially life threatening
- Neonates > children > adults: Most common cause of adrenal mass in infancy
- Usually occurs within first week of life
- Incidence 1.7- 3% per 1000 births
- Neonatal gland is relatively hypervascular and weighs more than the adult gland
- Unilateral or bilateral - Traumatic Hemorrhage
- Blunt abdominal trauma
- Unilateral in 80% of cases - Right 85%, Left 15%
- Bilateral in 20% of cases - Nontraumatic Hemorrhage
- Stress
- Bleeding diathesis, coagulopathy
- Adrenal tumors
- Idiopathic - Adrenal Hemorrhage
-Bilateral adrenal hemorrhage in 15% of patients who die of shock
- Adrenal insufficiency occurs when 90% of adrenal tissue is destroyed
- Stress or adrenal tumor --- increased ACTH --- increased arterial blood flow and limited venous drainage ---- adrenal hemorrhage - Adrenal Hemorrhage: CT Findings: Acute
- Round or oval mass of high attenuation (50-90 HU)
- Asymmetric enlargement
- +/- associated adrenal or renal vein thrombosis
- Homogeneous and no enhancement with contrast