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Radiology > GENITOURINARY
Adrenal Hemorrhage
Article Last Updated: Oct 26, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Dawn Light, MD, MPH, Clinical Assistant Professor of Radiology and Pediatrics, Department of Radiology, Consulting Staff, Dayton Children's Medical Center
Dawn Light is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American College of Radiology, and Phi Beta Kappa
Editors: Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Arnold C Friedman, MD, FACR, Associate Chairman, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
Waterhouse-Friderichsen syndrome, adrenal insufficiency, Beckwith-Wiedemann syndrome, Beckwith-Wiedmann syndrome
Background
Adrenal hemorrhage is an uncommon but potentially catastrophic event observed in patients of all ages and usually occurs as a complication of physiologic stress, trauma, or a coagulopathic state. In acute adrenal hemorrhage, ultrasound (US), computed tomography (CT) scanning, and magnetic resonance imaging (MRI) all demonstrate nonspecific enlargement and hemorrhage into one or both adrenal glands.
When an incidental adrenal mass is noted on US, CT, MRI, or a nuclear medicine study for another indication, serial imaging may confirm adrenal hemorrhage by demonstrating complete resolution of the mass with or without residual calcification. Biopsy has been required to make this diagnosis in unusual cases. Complications of adrenal hemorrhage include volume loss and shock in infants, adrenal pseudocysts, and adrenal calcifications. Adrenal insufficiency can be fatal, but fatal cases have been rarely reported.
Pathophysiology
Because adrenal hemorrhage occurs in the setting of blunt abdominal trauma, sepsis, or neonatal asphyxia or as a complication of systemic coagulopathy, this condition likely has a multifactorial pathophysiologic cause rather than a single explanation. Patients with nontraumatic adrenal hemorrhage often are reported to be critically ill, primarily coagulopathic, or coagulopathic as a result of medication or sepsis. In neonates, the adrenal glands are large, well-vascularized organs; neonates also are prone to hypotension and/or asphyxia. Any condition leading to hypoxia may lead to shunting of blood flow to vital organs. Furthermore, hypoxia causes damage to the endothelial cells, making them more prone to hemorrhage. The complexity of the adrenal vasculature may make it disproportionately susceptible to massive intraglandular hemorrhage. In times of physiologic stress or shock, endogenous adrenocorticotropic hormone (ACTH) release increases blood inflow rates to critical organs by severalfold. Because many patients with adrenal hemorrhage also have coexisting renal vein thrombosis, one theory (Kawashima et al, 1999) is that the eccentric musculature of the adrenal vein encourages turbulence and local stasis, which, in turn, contribute to adrenal vein thrombosis. Other authors (Fox, 1976) have suggested that high levels of catecholamine in the adrenal vein predispose to thrombosis as well. At least 4 mechanisms of traumatic injury have been suggested:
- The adrenal gland may be directly crushed between the spine and liver.
- Blunt abdominal trauma may lead to acutely increased adrenal venous pressure that is transmitted from the acutely compressed inferior vena cava (IVC).
- IVC thrombosis may result in adrenal hemorrhage.
- Significant deceleration forces may result in shearing of the small adrenal vessels.
Researchers report (see the bibliography from Hinrichs et al, 2001) that adrenal hemorrhage is unilateral in 80% of patients and occurs on the right in 85%. This injury pattern supports the theory of transmitted pressure from the IVC, given that the right adrenal vein is shorter than the left.
Frequency
United States
According to autopsy reports (Felc, 1995), neonatal adrenal hemorrhage is identified in 1.7 per 1000 births. Subsequently, several examiners (Felc) reported that adrenal hemorrhage is detected by US at a rate of 1.9 cases per 1000 live births. One autopsy series (Sevitt, 1955) found adrenal hemorrhage in 28% of cases with severe trauma. Another autopsy review (Fox) found renal vein thrombosis in nearly 50% of cases with adrenal hemorrhage. A third autopsy series (Fox) demonstrated adrenal vein thrombosis in 33 of 78 cases of adrenal hemorrhage and necrosis. Right adrenal hemorrhage has been reported in 2% of patients following orthotopic liver transplantation and in 4% of infants treated with extracorporeal membrane oxygenation (ECMO). Most cases of anticoagulant-associated adrenal hemorrhage occur in the initial month of therapy.
International
International literature is in agreement with literature from the United States on presentation and methods of detection of adrenal hemorrhage.
Mortality/Morbidity
Unilateral adrenal hemorrhage is rarely of clinical significance. Deaths from adrenal hemorrhage are frequently attributed to massive blood loss in the neonate and adrenal insufficiency in the adult. Adrenal insufficiency has not been reported until at least 90% of adrenal tissue is destroyed; thus, the precipitating hemorrhage is nearly always bilateral. In the trauma situation, adrenal hemorrhage may be a marker for serious injury to multiple organ systems. The prognosis of a patient with adrenal hemorrhage is more strongly related to the primary etiology than to the extent of adrenal hemorrhage.
Race
No difference has been reported in the frequency or severity of adrenal hemorrhage unique to a specific race or ethnic population.
Sex
No sex predilection has been established for adrenal hemorrhage.
Age
Adrenal hemorrhage is more common in neonates than in children or adults. At birth, the adrenal gland weighs up to twice as much as the adult adrenal gland. During the first weeks of life, rapid regression occurs primarily as a result of thinning of the fetal cortex. Pathologic studies suggest that in neonates, adrenal hemorrhage is almost always preceded by ischemic necrosis and a palpable mass may be present. However, as the baby matures, any palpable abdominal mass is much more likely to be renal in origin.
Anatomy
The adrenals are paired (but not identical) chevron-shaped glands found in the suprarenal retroperitoneal area. The right adrenal gland is posterior to the IVC, is situated slightly more cephalad than the left adrenal gland, and is pyramidal, with its apex upward. The left adrenal gland is more chevron shaped and extends further down the medial margin of the left kidney.
Both adrenal glands are rotated with the hilum anterior and are encased in the perirenal fascia. These glands are relatively large in neonates, weighing 2-4 g at birth. At least 3, and as many as 50-60, arteries (from the inferior phrenic, aortic, and renal arteries) supply blood to a subcapsular plexus, which drains into the medulla and juxtamedullary sinusoids. The sinusoids and venules all drain into a single central vein, which leads to potential outflow obstruction. This has been termed the vascular dam.
Clinical Details
Adrenal hemorrhage is rarely life threatening in adults, but it may cause hypotension in neonates from blood loss. When these young patients have a large hemorrhage, they may present with a palpable flank mass, anemia, prolonged jaundice, or hypovolemic shock. A scrotal hematoma is an unusual clinical manifestation. In adults, adrenal hemorrhage is usually identified incidentally during the workup of abdominal pain or trauma. The prompt identification of adrenal hemorrhage is important, because it can be an index symptom for unsuspected coagulopathy and an early indicator of severe stress in critically ill patients with sepsis, burns, blunt abdominal trauma, or hypoxia/shock states. Adrenal hemorrhage that is bilateral and severe enough to cause adrenal insufficiency is a significant risk and seen more often in adults than children.
The finding of unilateral adrenal hemorrhage in the absence of blunt trauma or instrumentation necessitates follow-up to resolution to exclude spontaneous hemorrhage in an occult neoplasm.
Preferred Examination
CT scanning is the method of choice for identifying adrenal hemorrhage in all patients but neonates. CT scanning is rapid, accurate, and widely available, and it permits rapid concurrent evaluation of multiple abdominal organ systems, which also may be affected by the primary process that caused the adrenal hemorrhage. In neonates, US is the preferred modality because it is portable, particularly sensitive for the condition, and avoids the use of ionizing radiation.
Limitations of Techniques
US, noncontrast CT scan studies, and MRI usually demonstrate the acute hematoma, but they may initially miss an underlying neoplasm. Contrast administration may demonstrate enhancement of a primary neoplasm at the time of presentation, but it must be compared with a noncontrast image to differentiate hemorrhage from neoplasm. Serial imaging of an adrenal hematoma confirms complete resolution if a primary mass is not present.
Adrenal Adenoma
Adrenal Carcinoma
Adrenal Metastases
Adrenal Myelolipoma
Neuroblastoma
Tuberculosis, Genitourinary Tract
Other Problems to be Considered
Adrenal hemorrhage may complicate several of the above conditions. Follow-up imaging is desirable to confirm the diagnosis and exclude a precipitating neoplasm. Also consider Beckwith-Wiedemann syndrome with adrenocortical macrocysts.
Findings
Plain radiographic film images often are obtained to evaluate abdominal pain in the acute phase. Acute adrenal hemorrhage is rarely detectable on plain radiographs, but it may cause mass effect in the retroperitoneal area of the upper abdomen. Large hematomas may anteromedially displace air-filled bowel loops and displace the kidneys caudally. When intravenous (IV) contrast has been administered, the inferior displacement of the kidney and lucent focus in the region of the adrenal mass may suggest the diagnosis.
When adrenal hemorrhage is associated with a coexisting renal hematoma or renal vein thrombosis, the kidney may be enlarged. During the resolution phase, the adrenal hematoma may calcify, and these retroperitoneal calcifications often are peripheral and appear eggshell shaped. In neonates, calcifications have been identified as soon as 1-2 weeks after the initial trauma.
Degree of Confidence
No information is available. Plain radiographic films are neither sensitive nor specific for acute adrenal hemorrhage in any identifiable subgroup of patients.
False Positives/Negatives
A large variety of retroperitoneal masses may mimic the plain radiographic film appearance of acute hemorrhage. In neonates, one should especially consider a variety of causes of renal enlargement, including hydronephrosis, multicystic renal disease, and malignancies. In general, the adrenal calcifications of resolving hemorrhages are rimlike and those observed with neuroblastoma are stippled, but several case reports (Westra, 1994) demonstrate that imaging cannot reliably differentiate these 2 conditions.
Neuroblastoma is the most frequent adrenal malignancy encountered in the neonatal period; thus, it should be considered in the differential diagnosis of a retroperitoneal adrenal mass. Increased serum levels of vanillylmandelic acid (VMA) are virtually diagnostic of neuroblastoma but are not a sensitive screen. Adrenal enlargement with extensive punctate calcification on plain radiographic films of the neonate may result from familial xanthomatosis (Wolman disease), an unrelentingly progressive lysosomal storage disease associated with severe failure to thrive that eventually leads to death in the first months of life.
Intra-abdominal calcifications from antepartum meconium ileus also are commonly observed and can be documented to be extra-adrenal by US. In older patients, splenic and renal masses more commonly calcify or cause retroperitoneal mass effect. Metastatic disease to the adrenal glands occurs quite commonly, but it is rarely detectable as masslike on plain radiographic films and seldom calcifies.
Findings
CT scanning is considered the criterion standard for imaging the adrenal glands in patients older than 6 months. It is quite sensitive for identifying a mass on the adrenal glands, but it cannot reliably differentiate adrenal hemorrhage from a hemorrhagic tumor. For patients who are considered most likely to have adrenal hemorrhage, which most often will show cystic changes within the first 3 weeks, the author recommends serial examinations at 3-4 weeks by CT scanning to document complete resolution of the hemorrhage. An adrenal neoplasm is unlikely to resolve and will frequently enlarge.
Consider adrenal hemorrhage whenever the adrenal gland is enlarged or the chevron shape is distorted by a round or oval mass. Inflammatory stranding of the periadrenal fat is noted, usually detectable on CT scan with and without contrast administration, and can be observed both in patients with traumatic etiologies and in patients with nontraumatic etiologies. In trauma patients, the adrenal glands should be examined carefully in the presence of related upper abdominal trauma, including pneumothorax, rib fracture, and parenchymal contusion of the lung, liver, spleen, or pancreas.
Without contrast administration, acute adrenal hemorrhage causes a hyperdense (50-75 Hounsfield units [HU]) masslike distortion of the normal adrenal gland's shape on CT scans, with thickening of the adjacent diaphragmatic crura and streakiness of periadrenal fat. Further evaluation is indicated if the adrenal mass enhances, especially if the enhancement is heterogeneous.
Degree of Confidence
No information is available on the sensitivity or specificity of CT scanning for adrenal hemorrhage either before or after contrast enhancement.
False Positives/Negatives
A large adrenal mass that enhances after contrast administration is most likely neoplastic in origin. Large adrenal masses (>5 cm) must have careful follow-up and be sampled if enhancement is observed or resolution is not prompt. When adrenal carcinoma presents, it is often noted to be at least 5 cm. Central areas of necrosis and calcification can be present with adrenal cancer. Half of adrenal cancers are hormonally active (usually with Cushing disease) and can be detected serologically.
Bronchogenic carcinoma is the most common cause of hemorrhagic and enhancing adrenal metastasis. Adrenal hyperplasia causes bilateral glandular enlargement, but it enhances smoothly after contrast administration. On CT scan images, adrenal abscess is suggested if a thick-walled cystic mass with rim enhancement is observed. If fat is demonstrated within the mass, the diagnosis is more likely myelolipoma.
Findings
MRI is also considered a criterion standard for imaging the adrenal glands in patients older than 6 months and is quite sensitive for identifying a mass. Although MRI cannot reliably differentiate adrenal hemorrhage from a hemorrhagic tumor, it is very specific in its ability to stage hemorrhage from any cause.
MRI is most useful to confirm the presence and chronicity of hemorrhage associated with an adrenal gland mass. Because of intracellular deoxyhemoglobin, in the acute stages ( <7 days), adrenal hemorrhage has an iso-slightly low signal on T1-weighted images and markedly low signal on T2-weighted images. During the subacute phase (1-8 weeks), the clot begins to evolve. On T1-weighted images, an initial rim hyperintense signal is observed, which gradually shrinks and fills in the mass over a period of weeks.
Occasionally, with large hemorrhages, irregular clot lysis and fluid-fluid levels can be observed. T2-weighted sequences during this phase are hyperintense from the presence of serum and clot lysis products.
In the chronic phase, both hemosiderin and calcification result in low signal on T1- and T2-weighted images. Calcification is often eggshell or rimlike, and the characteristic dark ring is identifiable. MRI also may be especially useful when adrenal hemorrhage is possibly related to renal vein thrombosis. Clots in the renal vein are shown as high signal on both T1- and T2-weighted sequences, and extension of the thrombus into the IVC also can be demonstrated by MRI.
Degree of Confidence
No sensitivity and specificity for MRI with regard to adrenal hemorrhage are reported in the literature.
False Positives/Negatives
Adrenal neoplasms, including myelolipomas, are prone to hemorrhage. The presence of hemosiderin products does not exclude an associated mass. On MRI, adrenal abscesses often display central necrosis and rim enhancement after contrast administration; however, the normal high signal characteristics of heme may be lost. Although adrenal hemangiomas are rare, they also may appear as a hyperintense, heterogeneous mass on T1- and T2-weighted images. When considering this entity, bolus contrast imaging with rapid sequencing on CT scanning or MRI may confirm the expected nodular contrast enhancement pattern.
Findings
US is the criterion standard in neonates and is extremely sensitive for masslike enlargement of the adrenal glands. US is very specific in differentiating the 2 major causes of adrenal masses; serial US will show interval resolution of adrenal hemorrhage but persistence or enlargement of adrenal neoplasm.
Adrenal hemorrhage is most often detected by US in newborns after a traumatic delivery or a neonatal course complicated by hypoxia or hypotension. In early adrenal hemorrhage, the adrenal glands are large, hyperechoic, and masslike. As the hemorrhage resolves, the glands reduce, and the hematoma becomes more centrally hypoechoic. Eventually, if the hemorrhage is minor, it resolves completely and the adrenal glands are no longer demonstrated on US.
In both infants and adults, adrenal hemorrhage is usually right-sided. This diagnosis should be considered in critically ill or trauma patients whenever the adrenal gland is clearly identified by US in those older than 6 weeks.
Degree of Confidence
No sensitivity and specificity for US with regard to adrenal hemorrhage is reported in the literature. Use of power Doppler may suggest the presence of an underlying vascular mass.
False Positives/Negatives
When adrenal hemorrhage results from renal vein thrombosis, US images of the kidney often are abnormal. The affected kidney may be enlarged with loss of the corticomedullary differentiation, and generalized increased renal echogenicity may be depicted. Thrombus in the renal vein is often demonstrated as an elevated resistance to vascular outflow. More commonly, concurrent left adrenal and left renal vein thrombosis is observed, likely the result of common venous drainage on the left. Benign hemorrhage has been reported in adrenal cortical cysts in patients with Beckwith-Wiedemann syndrome. Although US is not a sensitive test, the finding of a fluid-debris level in a complex cystic adrenal mass may suggest adrenal abscess; thus, this modality is useful to guide fine-needle aspiration. Evidence of air in the cyst suggests a pyogenic etiology.
Findings
Nuclear scintigraphy is of little use in making the diagnosis of adrenal hemorrhage. Scintigraphic imaging of the adrenal is performed using iodine-131 (131I) metaiodobenzylguanidine (MIBG). Adrenal hematomas do not sequester this agent. In fact, the 3 most common renal scintigraphic agents are not taken up by either hemorrhagic or normal adrenal tissue; thus, when a nonfunctioning adrenal mass is present, one may observe a photopenic area that distorts the kidney from its expected location. Nephromegaly demonstrated on a scintigraphic study, especially when it is associated with suprarenal photopenia, may suggest the diagnosis of concurrent adrenal hemorrhage and renal vein thrombosis.
False Positives/Negatives
No normal variants for nuclear scintigraphy with regard to adrenal hemorrhage are reported in the literature.
Findings
Although angiography may demonstrate the vascular supply of an adrenal mass and confirm the lack of vascularity of adrenal hemorrhages or pseudocysts, it offers no additional information that cannot be obtained by contrast-enhanced CT scan studies or MRI. Angiography is not recommended either in the diagnosis or treatment of adrenal hemorrhage.
An underlying adrenal hemorrhage may develop into an abscess source because of hematogenous seeding during a period of sepsis. CT scan– or US-directed aspiration is useful to obtain culture material in patients with sepsis who are unresponsive to antibiotics. Percutaneous biopsy should be avoided if pheochromocytoma is part of the differential diagnosis and should be preceded by serologic studies to exclude a functioning tumor. Consider confirmatory scintigraphic imaging or biopsy in a young child if neuroblastoma is in the differential diagnosis of a suprarenal mass; calcifications have been reported in both entities. Note that the identification of calcifications in an adrenal mass should not unduly influence the decision to sample for tissue, because neuroblastomas commonly calcify.
Medical/Legal Pitfalls
- Note that hemorrhage also may occur in underlying malignancy and should have close follow-up to complete resolution.
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Incidental identification of soft-tissue calcifications may lead to ultrasonic evaluation to differentiate benign lesions from calcification in a neoplasm. |
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A normal adrenal gland is often identified by ultrasound in the neonate. |
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Adrenal hematomas may liquefy with time and can be difficult to differentiate from an exophytic renal cyst. In this case, the ultrasound findings were symmetrical bilaterally. |
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Adrenal calcification is easily demonstrated on ultrasound. In this case, the calcification is chunky and there is no associated mass of the kidney or adrenal gland. |
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Typical enhanced computed tomography scan appearance of acute adrenal hemorrhage. |
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Enhanced computed tomography scan images of adrenal adenoma confirm liver iso enhancement. |
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Unenhanced computed tomography scan of adrenal adenoma. Hounsfield units are 0-20, in contrast with higher attenuation of fresh blood. |
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Ultrasound demonstrates a solid heterogeneous mass in the region of the Morrison pouch that displaces the kidney inferiorly. |
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With time, adrenal enlargement may resolve, becoming undetectable by computed tomography scan. This confirms the suspicion that the adrenal mass was caused by a hemorrhage. |
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When the hemorrhage is less than 7 days old, it is isointense to slightly hypointense on T1-weighted images and markedly hypointense on T2-weighted images. |
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Adrenal carcinoma presents with a large heterogeneous mass on ultrasound. It is usually considered as part of the diagnostic workup in a child with early pubertal presentation. |
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Adrenal carcinomas can be so large that it is difficult to determine where they originate even with computed tomography scan studies. These can bleed but are not commonly confused with an isolated adrenal hematoma. |
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Adrenal Hemorrhage excerpt Article Last Updated: Oct 26, 2006
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