Imaging of Nontraumatic

Adrenal Hemorrhage
Halimah Tusadiah
1210070100199
Preseptor :
dr. Dessy Wimelda,Sp.Rad
 Imaging of Nontraumatic Adrenal Hemorrhage

Nontraumatic 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.
 The clinical features are nonspecific and
include

Abdominal pain,
Flank pain,
Nausea,
Vomiting,
Hypotension or hypertension,
Fever lowgrade
Agitation,
And decreasing hematocrit
 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
 Prompt diagnosis may matter clinically
because 16 50% of patients with bilateral
adrenal hemorrhage eventually have life-
threatening adrenal insufficiency
 Causes of Nontraumatic Adrenal
Hemorrhage

The causes of nontraumatic adrenal hemorrhage

Include ;
stress;
bleeding diatheses,
including anticoagulant use;
Procedures and intratumoral bleeding.
 Imaging of Acute Nontraumatic
Adrenal Hemorrhage

Acute hemorrhage is characterized at imaging by

the evolution of a nonenhancing low- or mixed-
attenuation mass in one or both adrenal glands.
 Imaging of Chronic Nontraumatic
Adrenal Hemorrhage

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 Tumor-Related
Adrenal Hemorrhage

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),
30-year-old man with upper abdominal pain
1 week after appendectomy for acute
appendicitis. Gambar 1 (A)

Axial 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.
 GAMBAR 1 (B)

Axial contrast-enhanced CT image obtained 1 week before

appendectomy shows normal right (arrow) and left adrenal
glands, confirming changes in A are due to hemorrhage. Further
workup led to diagnosis of antiphospholipid antibody syndrome.
 GAMBAR 2

67-year-old woman with acute left sided abdominal pain. Axial 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.
 GAMBAR 3 (A)

32-year-old pregnant woman at 33 weeks gestation with left-sided

abdominal pain for several days and acute severe right flank pain.
A, 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.
 GAMBAR 3 (B)
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 A shows marked

interval change in signal intensity and development of increased T2 signal intensity
in both adrenal lesions (arrows).
 GAMBAR 3 (C)

Axial T1-weighted gradient-echo MR image obtained at same

time as B shows peripheral hyperintensity in both lesions (arrows).
Evolution of MRI findings was considered diagnostic of bilateral
adrenal hemorrhage. Biochemical evaluation showed no features of
pheochromocytoma. Patient later needed steroid replacement
therapy for adrenal insufficiency.
431-year-old woman 2 weeks after splenectomy
for splenic rupture associated with long-standing
warfarin use for atrial fibrillation. GAMBAR 4 (A)

Axial 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. Bilateral hemorrhage can cause life-
threatening adrenal insufficiency; patient later needed steroid
replacement therapy.
 GAMBAR 4 (B)

Axial contrast-enhanced CT image obtained 1 year

after A. Both adrenal glands are atrophic. Right adrenal
gland (arrow) has shrunk to wispy strandlike structure.
 GAMBAR 5 (A DAN B)

580-year-old man with acute abdominal pain 1 month after

beginning treatment with dabigatran for recurrent deep venous
thrombosis.
A and B, Axial contrast-enhanced CT images show adreniform
enlargement and hypoenhancement of both adrenal glands (arrows)
associated with bilateral periadrenal
infiltration.
 GAMBAR 6 (A)
630-year-old woman with continued nausea, vomiting, and
abdominal pain after cholecystectomy.

Axial contrast-enhanced CT image shows bilateral

heterogeneous adrenal lesions (arrows) representative of adrenal
hemorrhage.
 GAMBAR 6 (B)

Axial contrast-enhanced T1-weighted MR image 5 days after A

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.
736-year-old man undergoing adrenal vein
sampling.
GAMBAR 7 (A)

Anteroposterior intraoperative fluoroscopic image shows

extravasation of contrast material (arrow). Patient experienced
severe right-sided pain, and procedure was aborted.
 GAMBAR 7 (B)

Axial 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.
 GAMBAR 7 (C)

Axial contrast-enhanced CT image 2 years after B shows hematoma

has resolved and right adrenal gland (arrow) is atrophic.
857-year-old man with right flank pain and
decreasing hematocrit. GAMBAR 8 (A)

Axial 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.
 GAMBAR 8 (B)

Axial PET image 1 month after A 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.
946-year-old woman with abdominal and back
pain. GAMBAR 9 (A)

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.
 GAMBAR 9 (B)

Coronal T1-weighted MR image 1 month after A 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.
1059-year-old woman with severe left
flank pain. GAMBAR 10 (A)

Axial contrast-enhanced CT image shows large heterogeneous

left adrenal hematoma with active extravasation (arrow) and
periadrenal infiltration (arrowhead).
 GAMBAR 10 (B)

Axial unenhanced CT image 2 months after A shows hematoma

(arrow) is smaller and periadrenal stranding has largely resolved.
Because 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.
 GAMBAR 11

1171-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.
 GAMBAR 12

1267-year-old woman with diaphoresis. Axial unenhanced CT image in shows rim-

calcified cystic right adrenal mass (arrow). Surgical resection (performed because of
clinical rather than radiologicconcern) revealed benign hemorrhagic adrenal
pseudocyst.
 GAMBAR 13

1368-year-old woman with right flank pain for 1 month. Coronal

unenhanced CT image shows rim-calcified cystic right adrenal mass
(arrow). Benign hemorrhagic adrenal pseudocyst was found at surgical
resection.
1451-year-old woman undergoing evaluation for
Nissen fundoplication. GAMBAR 14 (A)

Axial CT image shows large, homogeneous, thin-rimmed left adrenal

lesion.
 GAMBAR 14 (B)

Coronal T1-weighted MR image shows large adrenal lesion has high T1

signal
intensity.
 GAMBAR 14 (C)

Axial 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.