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Everything you need to know about Computed Tomography (CT) & CT Scanning

Adrenal: Adrenal Hematoma Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Adrenal ❯ Adrenal Hematoma

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  • 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
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