Genitourinary Imaging Pictorial Essay Jordan et al. drenal Hemorrhage Genitourinary Imaging Pictorial Essay Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved Eric Jordan 1 Liina Poder Jesse Courtier Victor Sai dam Jung Fergus V. Coakley Jordan E, Poder L, Courtier J, Sai V, Jung, Coakley FV Keywords: CT, MRI, nontraumatic adrenal hemorrhage DOI:10.2214/JR.11.7973 Received September 19, 2011; accepted after revision November 30, 2011. Supported by National Institute of iomedical Imaging and ioengineering T32 training grant 1 T32 E001631 (V. Sai). 1 ll authors: Department of Radiology, University of California San Francisco, ox 0628, M-372, 505 Parnassus ve, San Francisco, C 94143-0628. ddress correspondence to F. V. Coakley (fergus.coakley@radiology.ucsf.edu). WE This is a Web exclusive article. JR 2012; 199:W91 W98 0361 803X/12/1991 W91 merican Roentgen Ray Society Imaging of Nontraumatic drenal Hemorrhage OJECTIVE. The purpose of this pictorial essay is to review the imaging findings of acute, chronic, and tumor-related nontraumatic adrenal hemorrhage. CONCLUSION. Rapid development or evolution of a nonenhancing adrenal mass or masses with an adreniform shape or high T1 signal intensity on MR images of a patient under stress or with a bleeding diathesis, including anticoagulant use, suggests acute adrenal hemorrhage. Chronic hemorrhage appears as a thin-walled pseudocyst or atrophy. Imaging findings that may indicate underlying tumor include intralesional calcification, enhancement, and hypermetabolic activity on PET images. N ontraumatic adrenal hemorrhage is a rare but potentially fatal diagnosis. The adrenal glands are thought to be particularly prone to hemorrhage because of their abundant blood supply from three arteries. These arteries drain to only a single vein, which is subject to vasoconstriction from catecholamines excreted by the adrenal medulla. This arrangement has been called a vascular dam [1]. The clinical features are nonspecific and include abdominal pain, flank pain, nausea, vomiting, hypotension or hypertension, lowgrade fever, agitation, and decreasing hematocrit [2]. Historically, because of the nonspecific clinical presentation, the diagnosis of adrenal hemorrhage was usually first suggested at autopsy. With modern imaging, particularly CT and MRI, the diagnosis of adrenal hemorrhage is frequently made before death in both acute and chronic stages [3, 4]. Prompt diagnosis may matter clinically because 16 50% of patients with bilateral adrenal hemorrhage eventually have life-threatening adrenal insufficiency [5, 6]. 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. The purpose of this pictorial essay is to review the imaging findings in acute, chronic, and tumor-related nontraumatic adrenal hemorrhage. Causes of Nontraumatic drenal Hemorrhage 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 (Figs. 1 3). These causes are not mutually exclusive and can coexist (Fig. 1). Recognition of adrenal hemorrhage is particularly important because of the common use of anticoagulation (Fig. 4) and the introduction of agents such as dabigatran (Fig. 5). Noniatrogenic bleeding diathesis such as disseminated intravascular coagulopathy and antiphospholipid syndrome (Figs. 1 and 6) can also lead to adrenal hemorrhage. Procedures that can be complicated by adrenal hemorrhage include venous sampling (Fig. 7) and biopsy. cute intratumoral adrenal hemorrhage is most commonly seen in pheochromocytoma (Figs. 8 and 9), but hemorrhage has also been described in myelolipomas, metastatic lesions, adrenocortical carcinomas, adenomas (Fig. 10), and hemangiomas [7]. Interestingly, calcification suggestive of previous hemorrhage was seen in 26% of myelolipomas (22 of 86) in one study [8], but these tumors seem to rarely present with clinically overt hemorrhage. Imaging of cute Nontraumatic drenal Hemorrhage cute hemorrhage is characterized at imaging by the evolution of a nonenhancing low- or JR:199, July 2012 W91
Jordan et al. Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved mixed-attenuation mass in one or both adrenal glands. Focal preservation of normal adrenal enhancement may be seen and often has a peripheral distribution (Figs. 1, 2, 4, and 6). In its mildest form, the peripheral distribution may account for the occasional observation of a train-track appearance of the adrenal gland with preserved peripheral enhancement and central low attenuation [9] (Figs. 2 and 4). Other features that may be seen in acute adrenal hemorrhage include periadrenal infiltration (Figs. 2 5, 7, and 10), active extravasation with retroperitoneal bleeding (Fig. 10), and maintenance of an adreniform shape (Figs. 2, 4, and 5). 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. MRI may show high T1 signal intensity or rapidly evolving signal intensity (Fig. 3). leeding 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. 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 (Figs. 10 and 11). Old granulomatous disease such as tuberculosis and histoplasmosis can have imaging manifestations similar to those of adrenal hemorrhage [7]. Imaging of Chronic Nontraumatic drenal Hemorrhage 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 [10]. MRI shows a hematoma as hyperintense on both T1- and T2-weighted images from approximately 1 week to 2 months after trauma, after which the hematoma acquires a hypointense rim on both T1- and T2- weighted images as the result of hemosiderin deposition and fibrosis [7]. Later, chronic hemorrhage may appear as adrenal atrophy or a hemorrhagic adrenal pseudocyst. trophy appears on CT images as a shriveled, isoattenuating adreniform structure (Figs. 1, 4, and 7). hemorrhagic adrenal pseudocyst is a chronic organized collection of hemorrhage that presents as nonenhancing, thin-rimmed cystic structures. t CT, pseudocysts are nonenhancing and have central hypoattenuation close to that of simple fluid. oth adrenal atrophy and adrenal cysts result from many causes in addition to chronic hemorrhage. Most pseudocysts are unilocular and peripherally calcified [11] (Figs. 12 and 13). t MRI, the chronic presence of blood products can cause heterogeneous intracystic signal intensity (Fig. 14). Calcifications are less well appreciated but can cause peripheral loss of signal intensity [7]. Imaging of Tumor-Related drenal Hemorrhage 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 (Fig. 9) or impossible (Fig. 8), particularly in the acute phase. Imaging findings that suggest underlying tumor as the cause of adrenal hemorrhage include intralesional calcification, enhancement, and hypermetabolic activity at PET (Fig. 8). Conversely, the absence of a mass on recent CT or MR images, if available, would be an argument against tumor-related hematoma. MRI can contribute to the detection of intralesional enhancement (Fig. 9). The diagnosis of a hemorrhagic adrenal pseudocyst due to chronic nontumoral hemorrhage should be made cautiously because 7 44% of such suspected lesions prove to be neoplastic at surgery [12]. For example, a case of cystic rim-calcified adrenocortical carcinoma simulating a benign nontumoral hemorrhagic pseudocyst has been described [11]. lthough clinical experience suggests most unilocular rim-calcified lesions are benign and can be managed conservatively, this distinction may require careful follow-up or even resection. Conclusion 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. ilateral 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. References 1. Rao RH, Vagnucci H, mico J. ilateral massive adrenal hemorrhage: early recognition and treatment. nn Intern Med 1989; 110:227 235 2. Simon DR, Palese M. Clinical update on the management of adrenal hemorrhage. Curr Urol Rep 2009; 10:78 83 3. lbert SG, Wolverson MK, Johnson FE. ilateral adrenal hemorrhage in an adult: demonstration by computed tomography. JM 1982; 247:1737 1739 4. Vella, Nippoldt T, Morris JC. drenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc 2001; 76:161 168 5. Mehrazin R, Derweesh IH, Kincade MC, et al. drenal trauma: Elvis Presley Memorial Trauma Center experience. Urology 2007; 70:851 855 6. accot S, Tiffet O, onnot P, et al. ilateral post-traumatic adrenal hemorrhage: report of a case with acute adrenal insufficiency. nn Chir 2000; 125:273 275 7. Kawashima, Sandler CM, Ernst RD, et al. Imaging of nontraumatic hemorrhage of the adrenal gland. RadioGraphics 1999; 19:949 963 8. Kenney PJ, Wagner J, Rao P, Heffess CS. Myelolipoma: CT and pathologic features. Radiology 1998; 208:87 95 9. Huelsen-Katz M, Schouten J, Jardine DL, Soule SG, Liu H. Pictorial evolution of bilateral adrenal haemorrhage. Intern Med J 2010; 40:87 88 10. Rana I, Kenney PJ, Lockhart ME, et al. drenal gland hematomas in trauma patients. Radiology 2004; 230:669 675 11. Rozenblit, Morehouse HT, mis ES Jr. Cystic adrenal lesions: CT features. Radiology 1996; 201:541 548 12. Wedmid, Palese M. Diagnosis and treatment of the adrenal cyst. Curr Urol Rep 2010; 11:44 50 W92 JR:199, July 2012
drenal Hemorrhage Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved Fig. 1 30-year-old man with upper abdominal pain 1 week after appendectomy for acute appendicitis., xial contrast-enhanced CT image shows mass of soft-tissue attenuation in left adrenal gland and swollen and hypoenhancing right adrenal gland (arrow). Margins of adrenal glands are ill defined with periadrenal infiltration., xial contrast-enhanced CT image obtained 1 week before appendectomy shows normal right (arrow) and left adrenal glands, confirming changes in are due to hemorrhage. Further workup led to diagnosis of antiphospholipid antibody syndrome. Fig. 2 67-year-old woman with acute left sided abdominal pain. xial contrastenhanced CT image shows new mild bilateral adrenal enlargement (CT 3 months earlier showed normal adrenal glands) with peripherally preserved enhancement (train-track appearance), which is most pronounced in medial limb (arrow) of right adrenal gland. Mild infiltration is visible around left adrenal gland. These findings likely represent early imaging changes of adrenal hemorrhage. Fig. 3 32-year-old pregnant woman at 33 weeks gestation with left-sided abdominal pain for several days and acute severe right flank pain., Coronal T2-weighted MR image shows bilateral adrenal lesions with lower signal intensity in left adrenal gland (thin arrow) than right adrenal gland (thick arrow). Periadrenal infiltration and edema (arrowheads) track inferiorly toward upper poles of kidneys. Findings are suggestive of bilateral hemorrhage. (Fig. 3 continues on next page) JR:199, July 2012 W93
Jordan et al. Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved C Fig. 3 (continued) 32-year-old pregnant woman at 33 weeks gestation with left-sided abdominal pain for several days and acute severe right flank pain., Coronal T2-weighted MR image obtained 2 weeks after shows marked interval change in signal intensity and development of increased T2 signal intensity in both adrenal lesions (arrows). C, xial T1-weighted gradient-echo MR image obtained at same time as shows peripheral hyperintensity in both lesions (arrows). Evolution of MRI findings was considered diagnostic of bilateral adrenal hemorrhage. iochemical evaluation showed no features of pheochromocytoma. Patient later needed steroid replacement therapy for adrenal insufficiency. Fig. 4 31-year-old woman 2 weeks after splenectomy for splenic rupture associated with long-standing warfarin use for atrial fibrillation., xial contrast-enhanced CT image shows both adrenal glands (arrows) are enlarged and of low attenuation but retain adreniform shape and exhibit preserved peripheral enhancement. Findings are typical of adrenal hemorrhage. ilateral hemorrhage can cause life-threatening adrenal insufficiency; patient later needed steroid replacement therapy., xial contrast-enhanced CT image obtained 1 year after. oth adrenal glands are atrophic. Right adrenal gland (arrow) has shrunk to wispy strandlike structure. Fig. 5 80-year-old man with acute abdominal pain 1 month after beginning treatment with dabigatran for recurrent deep venous thrombosis. and, xial contrast-enhanced CT images show adreniform enlargement and hypoenhancement of both adrenal glands (arrows) associated with bilateral periadrenal infiltration. W94 JR:199, July 2012
drenal Hemorrhage Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved Fig. 6 30-year-old woman with continued nausea, vomiting, and abdominal pain after cholecystectomy., xial contrast-enhanced CT image shows bilateral heterogeneous adrenal lesions (arrows) representative of adrenal hemorrhage., xial contrast-enhanced T1-weighted MR image 5 days after shows bilateral adrenal lesions with peripherally preserved enhancement of residual adrenal gland and nonenhancing central hypointense area representative of hemorrhage (arrows). Further testing revealed antiphospholipid syndrome. Fig. 7 36-year-old man undergoing adrenal vein sampling., nteroposterior intraoperative fluoroscopic image shows extravasation of contrast material (arrow). Patient experienced severe right-sided pain, and procedure was aborted., xial unenhanced CT image obtained immediately after procedure shows right adrenal hematoma (arrow) with central high attenuation caused by extravasated contrast material. Mild periadrenal infiltration is present. CT scan 2 months before procedure (not shown) depicted normal adrenal glands. C, xial contrast-enhanced CT image 2 years after shows hematoma has resolved and right adrenal gland (arrow) is atrophic. C JR:199, July 2012 W95
Jordan et al. Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved Fig. 8 57-year-old man with right flank pain and decreasing hematocrit., xial contrast-enhanced CT image shows large, heterogeneous, high-attenuation right adrenal mass. Differential diagnosis includes adrenal hematoma, but central focus of calcification (arrow) prompts consideration of underlying tumor., xial PET image 1 month after shows focal hypermetabolism (arrow) at periphery of right adrenal lesion, concerning for tumor. Diagnosis of hemorrhagic pheochromocytoma was established at pathologic examination of surgical specimen. Fig. 9 46-year-old woman with abdominal and back pain., Sagittal reformatted contrast-enhanced CT image shows large, heterogeneous retroperitoneal mass posterior to inferior vena cava. Mass may represent adrenal hematoma, but right adrenal gland (arrow) separate from lesion is evident., Coronal T1-weighted MR image 1 month after shows smaller lesion with peripheral T1 hyperintensity (arrow), indicating resolving hematoma. Mass and right adrenal gland were resected, and pathologic examination revealed extraadrenal pheochromocytoma and normal adrenal gland. Fig. 10 59-year-old woman with severe left flank pain., xial contrast-enhanced CT image shows large heterogeneous left adrenal hematoma with active extravasation (arrow) and periadrenal infiltration (arrowhead)., xial unenhanced CT image 2 months after shows hematoma (arrow) is smaller and periadrenal stranding has largely resolved. ecause of severity of initial episode and because underlying tumor could not be excluded, left adrenal gland was resected, and 1-cm adenoma with central necrosis was found. W96 JR:199, July 2012
drenal Hemorrhage Fig. 11 71-year-old woman with abdominal pain. Coronal reformatted unenhanced CT image shows large homogeneous, high-attenuation left adrenal mass (arrow) that suggests adrenal hemorrhage. On further questioning, patient reported contrast material had been injected into abdominal cyst 30 years before. Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved Fig. 13 68-year-old woman with right flank pain for 1 month. Coronal unenhanced CT image shows rim-calcified cystic right adrenal mass (arrow). enign hemorrhagic adrenal pseudocyst was found at surgical resection. Fig. 12 67-year-old woman with diaphoresis. xial unenhanced CT image in shows rim-calcified cystic right adrenal mass (arrow). Surgical resection (performed because of clinical rather than radiologic concern) revealed benign hemorrhagic adrenal pseudocyst. JR:199, July 2012 W97
Jordan et al. Downloaded from www.ajronline.org by 37.44.192.13 on 12/29/17 from IP address 37.44.192.13. Copyright RRS. For personal use only; all rights reserved C Fig. 14 51-year-old woman undergoing evaluation for Nissen fundoplication., xial CT image shows large, homogeneous, thin-rimmed left adrenal lesion., Coronal T1-weighted MR image shows large adrenal lesion has high T1 signal intensity. C, xial fat-saturated T2-weighted MR image shows high signal intensity within mass, excluding fat-containing tumor. Surgical resection (performed because of clinical rather than radiologic concern) confirmed hemorrhagic adrenal pseudocyst. W98 JR:199, July 2012