Traumatic and Non Traumatic Adrenal Emergencies

Transcription

1 Traumatic and Non Traumatic Adrenal Emergencies Michael N. Patlas, MD, FRCPC (1), Christine O. Menias, MD (2), Douglas S. Katz, MD, FACR (3), Ania Z. Kielar, MD, FRCPC (4), Alla M. Rozenblit, MD (5), Jorge A. Soto, MD (6) 1. McMaster University, Hamilton, ON, Canada 2. Mayo Clinic, Scottsdale, AZ, USA 3. Winthrop University Hospital, Mineola, NY, USA 4. University of Ottawa, ON, Canada 5. Montefiore Medical Center, New York, NY, USA 6. Boston University, Boston, MA, USA

2 Disclosure Statement The authors have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source 2

3 Introduction Multiple traumatic and nontraumatic adrenal emergencies are encountered during imaging of critically ill patients Traumatic adrenal hematomas are markers of severe polytrauma and can be easily overlooked due to multiple concomitant injuries Acute nontraumatic abnormalities are usually detected during evaluation of nonspecific abdominal pain or presentations related to acute adrenal insufficiency or paroxysmal hypertension A high index of suspicion is required for the establishment of timely diagnosis in cases of adrenal hemorrhage or infection 3

4 Learning Objectives 1. To illustrate critical imaging findings in traumatic and nontraumatic adrenal emergencies 2. To discuss advantages of different cross-sectional modalities for diagnosis of acute adrenal abnormalities 3. To review management options with emphasis on interventional radiology 4

5 Blunt Polytrauma American Association for the Surgery of Trauma (AAST) grade 4 hepatic laceration, AAST grade 5 injury of the left kidney and mesenteric hematoma with active extravasation. Left adrenal hematoma (black arrow) had been overlooked during original interpretation 5

6 Blunt Polytrauma AAST grade 3 splenic injury and AAST grade 5 left renal injury Bilateral traumatic adrenal hematomas (arrows) are uncommon injuries 6

7 Traumatic Adrenal Injury Occurs in 2% of patients with blunt abdominal trauma Right adrenal injury in 75% of cases, left adrenal injury in 15% and both adrenals are involved in 10% Bilateral hematomas can manifest as adrenal insufficiency Requires major force Associated injuries in majority of cases 7

8 Non specific Right Flank Pain in Patient on Anticoagulation due to Atrial Fibrillation Presentation Presentation Six days later Right adrenal hematoma on US and CT (yellow arrow). Follow up CT was performed 6 days later due to left flank pain and hypotension and showed bilateral adrenal hematomas (black arrows) 8

9 Non specific Abdominal Pain Large heterogeneous right adrenal mass on unenhanced CT MR (next slide) was requested to rule out malignancy 9

10 Organizing Hematoma T1WI IP T1WI OOP T2WI n Post contrast 10 Lack of enhancement on subtraction images confirms benign etiology

11 Acute Right Abdominal Pain 70-year-old woman with lung cancer. Bilateral adrenal metastases complicated by hemorrhage (arrows) 11

12 However, there are also benign causes for adrenal hemorrhage in patients with cancer One month prior Presentation Presentation Diagnosis: IVC thrombosis (blue arrow) extending to right adrenal vein with secondary adrenal hemorrhage (yellow arrow) in patient with breast cancer 12

13 Non Traumatic Adrenal Hemorrhage Primary causes of adrenal hemorrhage include surgical stress sepsis hypotension primary tumor: benign (adenoma, myelolipoma) or malignant (adrenal carcinoma, pheochromocytoma) metastases (especially melanoma) anticoagulant treatment coagulopathy 13

14 Non Traumatic Adrenal Hemorrhage Unilateral hemorrhage is most commonly seen in the right adrenal Bilateral hemorrhage is almost always caused by anticoagulation or underlying bleeding disorder, particularly antiphospholipid antibody syndrome 14

15 Waterhouse Friderichsen Syndrome 81 y.o. female admitted to ED with fever, tachycardia and labile blood pressure History of recent postoperative hypotension CT: bilateral adrenal hemorrhage Abnormal ACTH stimulation test Quick improvement on steroid replacement 15

16 Adrenal Abscess 47 y.o. male patient with sepsis and multiorgan failure CT demonstrated multiple hepatic and right adrenal abscesses (arrows) Image-guided drainage was performed 16

17 Candidiasis Bilateral complex adrenal collections in a patient with fever of unknown origin, weight loss and back pain Diagnosis was made by image-guided biopsy 17

18 Histoplasmosis Presentation Three months later Admitted to the ED after fainting. Unexplained low BP and suspicion for Addison s disease. Bilateral adrenal masses on CT. Diagnosis was made by biopsy 18 Reimaged due to severe abdominal pain and adrenal failure. CT shows bilateral adrenal necrosis

19 Adrenal Tuberculosis Presentation Two months later Patient with bilateral tuberculous (TB) adrenalitis. Note edema and inflammation of bilateral adrenal glands involving retroperitoneal fat. Image-guided biopsy confirmed TB. Patient was reimaged two month later due to hypotension and adrenal insufficiency. He developed bilateral adrenal hemorrhage (black arrows) 19

20 Adrenal Infections Adrenal abscess is a very rare entity Most cases of adrenal abscesses occurred in immunocompromised patients (AIDS, chronic steroid treatment, diabetes) A high index of suspicion is required when a fluidcontaining adrenal lesion is detected in a septic patient Image-guided drainage procedures have replaced surgery for diagnosis and treatment of adrenal abscess 20

21 Acute Abdominal Pain T1WI T2WI T1 FS with gadolinium Cystic adrenal mass without mural nodule or thick septae. Patient underwent resection of the lesion. Pathology showed necrosis of the large adrenal hematoma 21

22 Paroxysmal Hypertension Large left pheochromocytoma with central degeneration. Note small foci of anterior calcification 22

23 Pheochromocytoma ED patients with paroxysmal hypertension and adrenal lesion on crosssectional imaging should undergo assessment to exclude pheochromocytoma Non-contrast enhanced CT: round small masses are homogenous while larger masses are heterogeneous Most have attenuation values >10 HU on non-contrast CT, but atypical pheochromocytomas (those with cystic degeneration and necrosis) may be confused with adenomas because of attenuation values <10 HU Hemorrhagic pheochromocytomas can have very high attenuation values (i.e. 100 HU) 23

24 Conclusions Traumatic and non traumatic adrenal emergencies are uncommon Clinical scenario dictates imaging approach Bilateral adrenal emergencies can cause acute adrenal failure MDCT is the modality of choice for the evaluation of emergency room patients with traumatic and non traumatic adrenal emergencies MRI should be considered in patients with atraumatic hemorrhage to exclude underlying adrenal neoplasm 24

25 References Blake MA, Cronin CG, Boland GW. Adrenal imaging. AJR 2010;194: Boland GWL, Black MA, Hahn PF, et al. Incidental adrenal lesions: principles, techniques and algorithms for imaging characterization. Radiology 2008;249: Johnson PT, Horton KM, Fishman EK. Adrenal mass imaging with multidetector CT: pathologic conditions, pearls and pitfalls. Radiographics 2009;29: Lam KY, Lo CY. Metastatic tumors of the adrenal glands: a 30 year experience in a teaching hospital. Clin Endocrinol 2002;56: Patlas M, Hadas-Halpern I. Postpartum fever: adrenal abscess. Eur Radiol 2003;13(4): Sinelnikov AO, Abujudeh HH, Chan D, et al. CT manifestations of adrenal trauma: experience with 73 cases. Emerg Radiol 2007;13(6): Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology. 2012;265(3):