Imaging of nontraumatic hemorrhage of the adrenal gland

Incidence, Presentation, and Natural History of Adrenal Hemorrhage: An Institutional Analysis

INTRODUCTION

Adrenal hemorrhage (AH) can occur due to multiple etiologies with variable radiographic appearance, often indistinguishable from underlying adrenal neoplasms. There is a lack of AH literature and evidence-based guidelines. Our study aimed to understand the prevalence and etiology of AH, follow-up, and incidence of underlying neoplasm.

METHODS

An institutional database was queried from January 2006 to October 2021 for patients with AH on imaging, excluding patients with known malignancies, adrenal masses, or prior adrenal surgery. Demographics, medical history, hematoma size, laterality, biochemical evaluation, intervention, and additional imaging were reviewed.

RESULTS

Of 490,301 imaging reports queried, 530 (0.11%) with AH met inclusion criteria. Most imaging (n = 485, 91.5%) was performed during trauma evaluation. Two patients underwent dedicated intervention at presentation. Interval imaging was performed in 114 (21.5%) patients at a median of 2.6 (interquartile range 0.99-13.4) mo, with resolution (n = 84, 73.7%) or decreased size of AH (n = 21, 18.4%) in most patients. Only 10 patients (1.9%) saw an outpatient provider in our system to address AH or evaluate for underlying mass, and 9 (1.7%) underwent biochemical screening. Thirteen patients (11% of 118 patients with any follow-up) had evidence of an adrenal mass, confirmed on serial imaging (n = 10) or adrenalectomy (n = 3). Scans performed for nontrauma indications were significantly more likely to have an underlying mass (n = 6/26 [23.1%]) than those performed for trauma evaluation (n = 7/92 [7.6%], P = 0.04).

CONCLUSIONS

AH is a rare finding associated with an increased rate of underlying adrenal mass, particularly when unrelated to trauma. Most AH resolves spontaneously without intervention. Follow-up imaging at 6 mo can help distinguish mass-associated AH from simple hemorrhage.

Peripheral nodular enhancement in adrenal and renal hematomas: A report of 3 cases

There are a wide range of benign and malignant pathologies that the radiologist may encounter in the adrenal glands and kidneys, often incidentally when imaging is performed for other indications. Many imaging modalities including CT, MR, and US are often used in an attempt to characterize these lesions. A definitive radiological diagnosis, however, is not always possible. This is at times due to atypical presentations of typical lesions which may be mistaken for more aggressive or concerning pathologic conditions. Adrenal lesions that do not demonstrate characteristic benign imaging features might require surgical excision. Similarly, cystic renal lesions that demonstrate nodular enhancement are concerning for Bosniak IV lesions and require surgical management. We report 3 cases in 3 different patients of incidentally discovered hematomas with peripheral enhancement, 2 involving the adrenal gland and 1 involving the kidney. All 3 of these histologically proven hematomas demonstrated similar radiological manifestations of peripheral nodular progressive enhancement, mimicking neoplastic conditions, and necessitating surgical removal.

Adrenal Hemorrhaging in a Patient with Severe Obstructive Sleep Apnea Syndrome with Elevated Plasma ACTH Levels

Adrenal hemorrhaging (AH) is a rare condition characterized by bleeding into the suprarenal glands. A 62-year-old man with untreated obstructive sleep apnea syndrome (OSAS) was admitted to our hospital complaining of abdominal stiffness. He was diagnosed with left-sided AH and underwent adrenalectomy. Pre- and post-surgery, elevated plasma adrenocorticotropic hormone (ACTH) levels were observed. However, Cushing's syndrome and adrenal insufficiency were negative, and nasal continuous positive airway pressure (CPAP) normalized the plasma ACTH levels. Elevated ACTH levels are reportedly present in patients with OSAS. ACTH may be associated with the development of AH through the change in blood supply and other mechanisms.

Adrenal congestion in perinatal hypoxia: Sonographic assessment and relationship with hypoxic ischemic encephalopathy

BACKGROUND

During hypoxia, blood flow to the brain, myocardium, and adrenal glands is preserved or even increased to maintain homeostasis. Adrenal congestion occurs when venous return remains insufficient. Several different ultrasound measurements of adrenal glands in neonates have been reported in the literature. However, there is no data related on adrenal gland size in neonates with perinatal hypoxia.

AIMS

To evaluate the adrenal congestion using by ultrasound (US) measurements in perinatal hypoxia, and to reveal the relationship of adrenal congestion with hypoxic-ischemic encephalopathy (HIE) grades and magnetic resonance imaging (MRI) findings.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

Infants with perinatal hypoxia who met therapeutic hypothermia criteria and were being cooled were included in the present study. The control group was established from healthy neonates admitted to our center during the recruitment.

OUTCOME MEASURES

The gland area was measured by tracing, and both the corpus and crura widths were measured.

RESULTS

We reported adrenal gland area data of 110 newborns with HIE and compared them with 56 normal neonates. The adrenal size was significantly higher in the HIE group than in the control group (p<0,01). The frequency of adrenal congestion was 72.7% based on the selected cut-off values. The adrenal gland measurements were increased in the patients with perinatal hypoxia than those of the controls.

CONCLUSIONS

In the systemic evaluation of newborns with perinatal hypoxia, additional care should be taken regarding adrenal congestion. The measurement of adrenal size with 2D US will help us to diagnose or confirm adrenal congestion and possible hemorrhagic changes. The morphological data and cut-off values given in our study will be useful for neonatologists and pediatric radiologists to evaluate the patient while managing perinatal hypoxia.

Approach to the Patient With Adrenal Hemorrhage

Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.

Non-traumatic spontaneous abdominal haemorrhage

Spontaneous abdominal hemorrhage is defined as intra-abdominal hemorrhage from a non-traumatic cause. It is a challenging clinical situation and in most cases the diagnosis is made on the basis of imaging findings. CT is the technique of choice for the detection, localization and extension of bleeding. Objective is to review the main imaging findings expected in spontaneous abdominal hemorrhage as well as its main etiologies.

CT of hemorrhagic adrenal adenomas: radiologic-pathologic correlation

PURPOSE

To describe the appearance of chronically hemorrhagic adenomas on adrenal protocol CT and correlate imaging with pathologic findings.

METHODS

Retrospective case series of adult patients with resected adrenal adenomas showing internal hemorrhage at histology. Seven of nine patients underwent pre-operative adrenal protocol CT and 2/7 underwent unenhanced CT with portal venous phase CT. Two abdominal radiologists in consensus assessed the CT images for the presence of calcifications, macroscopic fat, cystic/necrotic appearance, and the presence, pattern, and percent nodule volume of areas < 10 HU on unenhanced CT. Absolute washout was calculated using a large ROI, and ROIs on the highest and lowest attenuating regions on the portal venous phase.

RESULTS

Mean adenoma length was 4.9 cm. All adenomas had areas measuring < 10 HU on unenhanced CT, ranging from < 20 to > 80% nodule volume. Calcifications were present in 4/9 adenomas and gross fat in 4/9 on CT. Of the seven cases with adrenal protocol CT, the absolute washout was < 60% in 5/7 using the large ROI, 5/7 using the low attenuation ROI, and 7/7 using the high attenuation ROI. At histology, all nine cases had microscopic evidence of hemorrhage, lipid rich adenoma cells, and fibrosclerosis. Myelolipomatous changes were identified in 4/9 cases, with the remaining five cases showing lipomatous metaplasia without a myeloid component.

CONCLUSION

Chronically hemorrhagic adrenal adenomas demonstrated variable areas < 10 HU on unenhanced CT corresponding to lipid rich adenoma cells. Absolute washout was most often < 60%, hypothesized to be due to fibrosclerosis within the adenomas.

Morrison's Pouch: Anatomy and Radiological Appearance of Pathological Processes

Morrison's pouch is the intraperitoneal space in the supramesocolic compartment located between the right liver lobe and right kidney. Pathological conditions that can involve this peritoneal space include fluid collections, infectious or inflammatory processes, and neoplasms. Frequent involvement by disease entities can be attributed to its dependent location, communication with the inframesocolic compartment, close proximity to the adjacent organs and peritoneal fluid dynamics. Knowledge of the appearance of pathological entities on various imaging modalities helps the radiologist in making the correct diagnosis.

Multimodality imaging of adrenal gland pathologies: A comprehensive pictorial review

The assessment of acute abdominal and pelvic emergencies typically involves a multimodal approach consisting of plain radiographs, ultrasound, computed tomography (CT), and rarely magnetic resonance imaging (MRI). Although MRI is not traditionally employed in acute care settings, there are several instances in which MRI provides superior functional and prognostic information. In this manuscript, we highlight multimodal findings of adrenal gland emergencies: Hemorrhage, infarction, and infection. The purpose of our study is to highlight significant findings in various modalities, including CT, MRI, ultrasound, and PET/CT. Due to the scarcity of published data and limited clinical use, primary ultrasound findings are limited in our multimodal review. In conclusion, we find that synergistic use of CT, MRI, and functional imaging provides an effective tool for evaluation and management of adrenal pathology.

Presumptive nontraumatic adrenal hemorrhage preceding hypoadrenocorticism in a dog

Nontraumatic adrenal hemorrhage (NTAH) has been associated with stress-induced catecholamines release in underlying conditions such as sepsis and recent surgery in humans. It can lead to primary hypoadrenocorticism (HOAC) when both adrenal glands are involved, with nonspecific clinical signs and laboratory findings that can lead to a missed diagnosis. Bilateral thickening of the adrenal glands with periadrenal fat stranding was identified in a 10-year-old male Maltese dog after abdominal surgery. The dog showed clinical signs and biochemical changes consistent with HOAC, but treatment for presumed critical illness-related corticosteroid insufficiency was initiated. Clinical signs relapsed with a 3-week dose reduction of hydrocortisone, and a reduction in adrenal size was observed on follow-up ultrasound examination. Hormonal testing confirmed HOAC in the dog. To the best of our knowledge, HOAC caused by spontaneous NTAH has not been reported in the veterinary literature. This report describes a dog that developed HOAC with presumed adrenal atrophy after suspected spontaneous bilateral NTAH.

Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department

BACKGROUND

Adrenal insufficiency can result in significant patient morbidity and mortality, but due to the range of symptoms and variable clinical course and etiologies, it can be a challenging condition to diagnose and manage.

OBJECTIVE

This narrative review will discuss the evaluation of an adult patient at risk for a new diagnosis of adrenal insufficiency and the management of a patient with known or suspected adrenal insufficiency.

DISCUSSION

A new presentation of adrenal insufficiency can range from nonspecific, minor symptoms including fatigue, to a life-threatening adrenal crisis with hemodynamic instability. Due to the variety of signs and symptoms, the diagnosis is often missed. Those with known adrenal insufficiency are at risk for adrenal crisis, which may occur due to a variety of triggers. Initial evaluation includes assessment for the underlying etiology or concomitant condition, laboratory analysis, and imaging, when clinically indicated. Although not necessary for evaluation in the emergency department setting, the diagnosis is confirmed by specific testing such as the cosyntropin stimulation test. The mainstay of treatment in adrenal crisis is hydrocortisone, intravenous fluid, glucose repletion, and treatment of the underlying acute trigger.

CONCLUSIONS

Emergency clinicians must be prepared to recognize, evaluate, and manage those with known or suspected adrenal insufficiency or adrenal crisis.

Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review

Background

Adrenal hemorrhage (AH) is a rare condition that can result in a life-threatening medical emergency. This medical condition could be caused by several underlying factors, one of which is the use of anticoagulants. As far as we are aware, direct oral anticoagulant (DOAC) agents are a rare but possible cause of AH.

Case presentation

Herein, we described two cases of AH due to DOACs. The first case was a 35-year-old Iranian woman with a past medical history of Hashimoto thyroiditis who was being treated with apixaban due to the previous thrombosis. Her first symptoms of AH (November 2021) were strangely similar to symptoms of autoimmune Addison disease (AAD) which led to a confirmed diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). An abdominal MRI revealed an oval shape well-encapsulated cystic mass with a diameter of 20 × 14 mm with a thick and low signal intensity rim in the left adrenal gland, highly suggestive of sub-acute left-sided AH. Our second case was an 89-year-old Iranian woman who had been admitted to the hospital (August 2021) with low blood pressure and disorientation. At the beginning of her admission, the evaluation showed hyponatremia, and further evaluations confirmed adrenal insufficiency (AI). The patient reported rivaroxaban usage for deep vein thrombosis prophylaxis after femur fixation surgery. Her abdominal CT scans showed bilateral adrenal masses highly suggestive of AH. Her follow-up examination showed persistent AI after three months.

Conclusion

Given the history of our cases, physicians should be aware of AH in patients receiving DOACs, particularly in elderly patients who are at high risk of bleeding. It is also worth noting that AH can occur in any patient with any medical history and history of DOAC use, which is why patients must be closely monitored.

Spontaneous adrenal haemorrhage in pregnancy and review of the literature

Spontaneous adrenal haemorrhage (SAH) is a rare condition. The incidence of adrenal haemorrhage in pregnancy is currently not known; however, an association with pregnancy has been reported.An acute presentation with severe back or flank pain should raise suspicion of this condition. Diagnosis is based on imaging. An ultrasound scan is a basic and readily available investigation in pregnancy to rule out renal and suprarenal pathology while CT or MRI scan can help to confirm the diagnosis. A multidisciplinary team (MDT) approach, involving the obstetric, anaesthetic, medical and endocrine team, is essential in management of this condition.We present a case of an SAH; managed conservatively, in an otherwise healthy and low-risk pregnant woman and describe the literature review on this rare condition, including pathophysiology and management.

Neonatal bilateral adrenal hemorrhage and adrenal insufficiency accompanied by Subgaleal hematoma: a case report with brief review of literature

Background

Neonatal adrenal hemorrhage (NAH) is an almost infrequent phenomenon (0.2–0.55%). Mechanical compression and alterations of venous pressure during delivery are considered the most probable explanations. Approximately 10% of the cases might have bilateral involvement. Clinical symptoms include abdominal mass, poor feeding, vomiting, prolonged jaundice, and anemia. Subgaleal hemorrhage (SGH) is one of the most clinically remarkable and potentially hazardous postnatal cranial injuries.

Case presentation

An early-term Iranian male neonate who was born through spontaneous vaginal delivery and experienced shoulder dystocia was diagnosed with bilateral NAH leading to adrenal insufficiency requiring glucocorticoid and mineralocorticoid supplementation. The SGH and jaundice were other postnatal complications. Serial monthly abdominal and brain ultrasound revealed complete regression of lesions after 70 days. However, after 16 months, the neonate has been still treated with hydrocortisone and fludrocortisone for the adrenal insufficiency diagnosis. He has a lower limit weight for age; however, developmental milestones have been appropriate for age.

Discussion and conclusion

Adrenal hemorrhage and SGH should be examined and looked for, particularly with proven evidence of difficult delivery and asphyxia in at-risk newborns. Clinical and ultrasound follow-up is mandatory for the assessment of hemorrhage resolution and conservative management. The early detection and treatment of adrenal insufficiency by laboratory examination is strongly recommended in bilateral cases. Furthermore, the early recognition of postnatal SGH to prevent clinical and neurological outcomes seems essential.

Subclinical phaeochromocytoma: a diagnostic and management challenge

There is a paradigm shift in the detection of phaeochromocytomas with more being identified as adrenal 'incidentalomas'. While majority of these individuals are asymptomatic, they are nevertheless at risk of subtle cardiovascular dysfunction and phaeochromocytoma crises. Therefore, early resection of phaeochromocytomas, even if subclinical, is recommended. However, the perioperative management can be challenging as the normotension can limit the initiation and titration of alpha-blockade. We present a man in his 60s with a subclinical phaeochromocytoma, discuss the evaluation of an incidentally discovered adrenal nodule, as well as the practical considerations in the perioperative management.

Adrenal bleeding due to pheochromocytoma - A call for algorithm

BACKGROUND

Adrenal hemorrhage is a rare, usually life-threating complication. The most common neoplasm resulting in spontaneous adrenal bleeding is pheochromocytoma and it accounts for nearly 50% of cases. Currently, the recommendations for the diagnosis and management of patients with adrenal bleeding due to pheochromocytoma are unavailable.

MATERIALS AND METHODS

We performed a database search for all pheochromocytoma patients, diagnosed and treated from 2005 to 2021 in tertiary endocrinology center. 206 patients were identified, 183 with complete data were included in the analysis. We investigated clinicopathological characteristics, treatment and outcomes of hemorrhagic pheochromocytoma cases and characterize our approach to perioperative diagnosis and medical management. Finally our experiences and data from previously published articles concerning adrenal hemorrhage were analyzed to propose a diagnostic and therapeutic algorithm for hemorrhagic pheochromocytomas.

RESULTS

In the whole group, seven patients (4 men and 3 women) with adrenal bleeding were found, (3.8%). Median patient's age was 49 years (range: 36-78 years). The most common manifestation of adrenal bleeding was acute abdominal pain (5/7). Two patients developed shock. Hormonal assessment was performed in five patients, based on 24-hour urinary fractionated metanephrines with urinary 3-methoxytyramine. Normetanephrine was elevated in all patients, metanephrine and 3-methoxytyramine - in four cases (4/5). Most patients (6/7) had symptoms suggesting pheochromocytoma before hemorrhage - most commonly paroxysmal hypertension (4/7). One patient died, before the diagnosis of adrenal bleeding was made. Diagnostic imaging performed in six out of seven patients revealed adrenal tumor, with median largest diameter equal to 7.4 cm (range: 5-11 cm). Five patients had elective surgery, in one case an urgent surgery was performed. In all cases the diagnosis of pheochromocytoma was confirmed in postoperative histopathology or in autopsy. The perioperative survival rate was 85.7%.

CONCLUSIONS

Diagnosis of pheochromocytoma should be always considered in patients with adrenal bleeding, especially with accompanying abdominal pain, hemodynamic shock and previous history of pheochromocytoma-associated symptoms. Lack of proper diagnosis of pheochromocytoma before surgery is associated with an additional perioperative risk. To improve the decision making in this life-threatening clinical situation, based on our results and literature data, we proposed a diagnostic and treatment algorithm.

CT findings after left renal vein division during abdominal aortic surgery

BACKGROUND

The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop.

PURPOSE

To describe computed tomography (CT) findings after LRVD during aortic surgery.

MATERIAL AND METHODS

Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned.

RESULTS

The median time period of the first postoperative follow-up CT was 36 days (range 7-1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (-0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (-0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports.

CONCLUSION

Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.

Pediatric Abdominal Masses: Imaging Guidelines and Recommendations

Pediatric abdominal masses are commonly encountered in the pediatric population, with a broad differential diagnosis that encompasses benign and malignant entities. The primary role of abdominal imaging in the setting of a suspected pediatric abdominal mass is to establish its presence, as nonneoplastic entities can mimic an abdominal mass, and to identify characteristic imaging features that narrow the differential diagnosis. In the setting of a neoplasm, various imaging modalities play an important role to characterize the mass, stage extent of disease, and assist in presurgical planning. The purpose of this article is to discuss a practical imaging algorithm for suspected pediatric abdominal masses and to describe typical radiological findings of the commonly encountered abdominal masses in neonates and children with emphasis on imaging guidelines and recommendations.

Idiopathic Retroperitoneal Hematoma with Spontaneous Resolution

A 54-year-old man was transferred from another hospital due to a hematoma in the third portion of the duodenum on abdomen CT. He had been admitted for 2 weeks due to vomiting at another hospital. He had abdominal discomfort and nausea without abdominal pain when he visited the Gwangyang Sarang Hospital. Other than a distended abdomen and mild general abdominal tenderness, the results of physical examination were unremarkable. Abdominal CT revealed an approximately 9 cm thick walled hematoma at the anteroinferior site of the duodenal third portion. Upper endoscopy revealed stenosis of the third portion of the duodenum without mucosal lesions. The endoscope was not advanced through the narrowed duodenal lumen. A retroperitoneal hematoma was diagnosed, and his state was classified as subacute rather than acute based on the duration. The surgeon did not recommend surgical treatment. Urgent treatment was unnecessary; he was managed conservatively. The size of the hematoma decreased from 9.0 cm to 5.8 cm on the following CT. He could begin to eat food on the 26th admission day, and he was discharged on the 31st admission day. The hematoma disappeared entirely on the following CT. This paper describes a rare case of idiopathic retroperitoneal hematoma with a spontaneous resolution.

Ultrasound and alternative multimodality imaging of intra-abdominal and pelvic cystic masses in the newborn

Introduction: Ultrasound is used commonly to detect and diagnose intra-abdominal and pelvic cystic masses in the newborn as it is easily available, relatively low cost, and non-invasive. Discussion: The diagnosis can be made or narrowed down by determining the location, size, sonographic features, organ involvement, and internal vascularity. The differential diagnoses include hydronephrosis, multicystic dysplastic kidney, adrenal haemorrhage, cystic teratomas, ovarian cysts, enteric cysts, meconium cysts, and liver haemangiomas. With the appropriate radiological knowledge, the ultrasound practitioner can help obtain an accurate diagnosis. Conclusion: This pictorial essay will familiarise the reader with the different common causes of intra-abdominal and pelvic masses detected on ultrasound through a wide range of conditions. The role of ultrasound in the evaluation of these conditions will be discussed and alternative imaging correlates will be offered.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

A Rare Case of Hemorrhagic Giant Adrenal Myelolipoma: Radiographic and Pathologic Correlation

Myelolipomas are rare benign tumors made up of adipose and hematopoietic tissue that commonly occur in the adrenal glands unilaterally. Spontaneous hemorrhage occurs in < 5% of these tumors, and often present as large masses. A 50-year-old male presented with right flank pain that had been growing increasingly worse over a two-week period. Contrast-enhanced Computed Tomography (CT) revealed a large suprarenal 15-cm mass exerting mass effect on the kidney and liver along with possible hemorrhage. T1 fat saturated and T2 non-fat saturated magnetic resonance imaging (MRI) confirmed the diagnosis of a myelolipoma with hemorrhage. The patient was treated with surgical resection of the mass and the follow-up pathology report confirmed a giant hemorrhagic adrenal myelolipoma. Spontaneous hemorrhage of a large myelolipoma measuring 15 cm is a rare entity and the correct imaging needs to be done in order to carry out the appropriate treatment.

Retroperitoneal hematoma by different causes: Presentation of two emergency cases at computed tomography

Retroperitoneal hematoma is a rare clinical entity with variable aetiology, which is increasing in incidence mainly due to complications related to interventional procedures. The causes of RE are different. We present 2 suggestive cases of RE, one for renal cause and another of adrenal origin. Both came to our attention as a matter of urgency. Retroperitoneal hematoma, therefore, originated from different causes, with consequent different treatments. Both cases were diagnosed, as a matter of urgency, thanks to the use of contrast Computed Tomography, which allowed a rapid diagnosis, careful specialist evaluation, a monitoring of their clinical conditions, and a consequent adequate outcome for the patients.

Technical and Interpretive Pitfalls in Adrenal Imaging

The adrenal gland may exhibit a wide variety of pathologic conditions. A number of imaging techniques can be used to characterize these, although it is not always possible to attain a definitive diagnosis radiologically. Incorrect diagnoses may be made if radiologists are not attentive to technical parameters and interpretive factors associated with adrenal gland imaging. Hence, an appreciation of the intricacies of adrenal imaging strategies and characterization is required; this can be aided by understanding the pitfalls of adrenal imaging. Technical pitfalls at CT may relate to the imaging parameters, including region of interest characteristics, tube voltage selection, and the timing of contrast material-enhanced imaging. With MRI, imaging acquisition technique and evaluation of the reference tissues used in chemical shift MRI are important considerations that can directly influence image interpretation. Interpretive errors may occur when evaluating adrenal washout at CT without considering other radiologic features, including the size of adrenal nodules, the presence of fat or calcification, the attenuation of nodules, and atypical imaging features. The characterization of an incidental adrenal lesion as benign or malignant does not end the role of the radiologist; consideration as to whether an adrenal lesion is associated with endocrine dysfunction is required. While imaging may not be optimal for establishing endocrine activity, there are imaging features from which radiologists may infer function. In cases of known endocrine activity, imaging can guide clinical management, including further investigations such as venous sampling. ^©RSNA, 2020.

Proposition of a Simplified Protocol and New Parameter Introduction in NMRI Mice Anhedonia Induction

Introduction: A broad spectrum of research involving stress and stress protocols has long proven that a point of anhedonia, social defeat and learned helplessness can be achieved and observed – with anhedonia being a clinical symptom of Anxiety, Depression and Bipolar Affective Disorder.

Aim: The aim of this study is the development of a simplified protocol for anhedonia induction in NMRI male mice in order to shorten the period of mice suffering and decrease complexity of the procedure for other researchers and introduction of new parameter in order to achieve better standardization of results.

Materials and Methods: 21 male NMRI mice were introduced to 2 different stress protocols (one found in literature and one simplified) where cognitive- behavioral status was tested using the Sucrose Preference Test, Open Field Test, Grooming Pattern and histological examination of adrenal glands, and to propose a new protocol for fellow researchers.

Results: Results observed include the successful induction of anhedonia proven by Sucrose Preference Tests, Barbering effect and microhemorrhage of the adrenal glands. Simplified protocol showed superiority compared to the one found in literature.

Conclusion: Simplified protocol showed higher efficiency and reduced amount of work during testing phase. Introduction of NMI as a new parameter during behavioral evaluation resulted in better standardization of measured SPT values that incorporates common knowledge of mammal physiology. A big developmental step was the introduction of the Normalised Mass Index to even out mass fluctuations and differences in basal metabolism, which we recommend to other researchers and institutions.

Vanishing Adrenal Mass in Pregnancy

Objectives

The evaluation of an adrenal mass is challenging. We present the case of a 33-year-old pregnant woman who was found to have an adrenal incidentaloma. Four months after the initial imaging, the mass vanished.

Methods

We described the case of a pregnant woman with hypertension and an incidentally found right adrenal mass.

Results

A magnetic resonance imaging scan showed a right adrenal mass measuring 7.9 × 3.9 × 3.0 cm with a multilobulated appearance. Initial biochemical testing was concerning for a pheochromocytoma with positive metanephrines during hospitalization while being treated for an infection. Repeat outpatient adrenal hormone results, including metanephrines, were negative. Four months after her initial magnetic resonance imaging scan, the right adrenal mass was no longer present.

Conclusion

A 33-year-old pregnant woman was found to have a right adrenal mass that later vanished as a result of the resolution of a unilateral adrenal hemorrhage. Predisposing factors to adrenal hemorrhage in the presented case include pregnancy, infection, and hypertension.

A collision between vascular adrenal cyst and adrenocortical adenoma

We report a patient with sigmoid colon cancer who revealed a unique collision of hemorrhagic vascular adrenal cyst and adrenocortical adenoma with myelolipomatous changes. Two months before referral to our hospital, anticoagulant therapy was started for acute myocardial infarction. The components of the adrenocortical adenoma demonstrated a typical signal drop in opposed-phase magnetic resonance (MR) images although macroscopic fat was also depicted both on CT and MR images. The components of the vascular adrenal cyst demonstrated peripheral nodular enhancement with progressive enhancement on dynamic contrast-enhanced CT and a hemorrhagic change in the central region, which showed hyper intensity on T1-weighted images (T1WI) and hypo intensity on T2-weighted images (T2WI). Microscopically, the cyst was filled with foci of hemorrhage, fibrin, fibrosis, and hemosiderin. Furthermore, a white thrombus was found that corresponded to the central low signal intensity depicted on T2WI. Dilated vascular channels that were immunohistochemically positive for CD31 and CD34 were identified within the cyst. They were consistent with the pathological findings of hemorrhagic vascular adrenal cyst. Radiologists should be aware that the diagnosis of adrenal vascular cyst could be challenging since image findings may resemble hemangiomas, pheochromocytomas, and malignancy.

Bilateral adrenal hemorrhage in a man with severe COVID-19 pneumonia

This case report demonstrates bilateral adrenal hemorrhage in a fifty-year old man with severe COVID-19 pneumonia. We discuss how adrenal hemorrhage can be one of the possible complications of COVID-19. The case also shows how adrenal hemorrhage can be diagnosed incidentally in a scan performed for a different reason given the difficulty of clinical diagnosis and the non-specific clinical presentation.

Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation

Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.

Coincidence of Large Adrenal Cyst and Prominent Hyporeninemic Hyperaldosteronism

A 67-year-old Japanese woman who had end-stage renal disease was referred to our hospital for kidney transplantation. Abdominal CT revealed a large adrenal mass with inhomogeneity. She had a history of hospitalization for stroke and heart failure and exhibited prominent hyporeninemic hyperaldosteronism. Histological examination of the resected tumor with anti-CYP11B2 antibody indicated that she had a vascular endothelial cyst with primary aldosteronism (PA) due to multiple adrenocortical micronodules. This report implicates the pathological interaction between adrenal vascular cysts and PA-mediated vascular damage of the adrenal vein.

Fatal Waterhouse-Friderichsen syndrome in an adult due to serogroup Y Neisseria meningitidis

Waterhouse-Friderichsen syndrome (WFS), defined as severe adrenal insufficiency due to bilateral adrenal gland haemorrhagic necrosis, occurred in a 59-year-old woman. An underlying serogroup Y Neisseria meningitidis (NM) infection was diagnosed, with a rapid progression to purpura fulminans, disseminated intravascular coagulation and WFS. Intensive treatment including fluid resuscitation, broad-spectrum antibiotic therapy, ventilatory support, platelet and factor replacement were administered. The meningococcaemia in the presence of WFS had a fulminant progression, leading to a fatal outcome within 24 hours of symptom onset. This case details the diagnosis and management challenges of the WFS, a rare complication of NM septicaemia, and describes the identification of a NM serogroup that is rare in Portugal in middle-aged patients.

Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review

The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.

CT and MR imaging of acute adrenal disorders

The adrenal glands may be overlooked when evaluating acutely ill patients. Acute adrenal disorders may result from complications of an underlying systemic disease, which may be unsuspected clinically. Various acute adrenal emergencies including trauma, spontaneous hemorrhage, infarction and infection can be diagnosed using CT and MRI; however, in uncertain cases follow-up to resolution of imaging findings or histological sampling may be required for diagnosis.

Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report

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Bilateral adrenal hemorrhage is a rare complication associated with major insult, associated with sepsis and coagulopathy.

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Postoperative bilateral adrenal hemorrhage could be lifethreatening and its essential to have high level of suspicion.

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The diagnosis for bilateral adrenal hemorrhage is based on biochemical testing and cross-sectional imaging.

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Treatment is with steroid replacement which could be temporary or permanent.

Introduction

Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency. This is a rare complication in the post-operative setting, and we present a case in which it developed after a colectomy for perforated diverticulitis.

Presentation of case

The patient is a 65-year-old female who presented with abdominal pain, nausea, emesis, and hematochezia, and CT scan showing sigmoid diverticulitis with peri-sigmoid abscess. After a failure of non-operative treatment, she underwent Hartmann’s resection, and her post-operative course was complicated by refractory tachycardia, hypotension, hyponatremia, and nausea/vomiting. Bleeding, hypovolemia, and sepsis were ruled out. A CT scan showed enlarged poorly defined adrenals bilaterally, suggestive of bilateral adrenal hemorrhage. Serum cortisol level was low and diagnostic of acute adrenal insufficiency. With intravenous steroid therapy (hydrocortisone), her vital signs, laboratory abnormalities, and diet intolerance all resolved. She was discharged on oral prednisone and continued long term.

Discussion

Bilateral adrenal hemorrhage is rare post-operatively and can lead to adrenal insufficiency. 15% of patients who die in shock have bilateral adrenal hemorrhage on autopsy, indicating the necessity of timely diagnosis and treatment of this condition. Corticosteroid therapy is the mainstay of treatment.

Conclusion

This case study illustrates that post-operative delay of progression or worsening of condition, with no alternative explanation, can be due to acute adrenal insufficiency resulting from bilateral adrenal hemorrhage, and timely diagnosis and treatment of this condition is paramount for a favorable outcome.

Rare Bilateral Adrenal Haemorrhage with Addisonian Crisis: When Risk Factors Come in Droves

Addisonian crisis is the life-threatening acute manifestation of adrenal insufficiency due to absolute or relative glucocorticoid deficiency. Adrenal haemorrhage is a rare condition of unknown incidence with the risk of adrenal insufficiency and death, not uncommonly first being diagnosed on the pathologists table. We report the case of a 68-year-old female patient with respiratory tract infection suffering acute life-threatening adrenal insufficiency caused by bilateral adrenal haemorrhages following orthopedic surgery while taking anticoagulation therapy. The patient rapidly deteriorated with hypotension, showing how important it is to consider a possible Addisonian crisis when this scenario occurs, especially with precipitating factors such as anticoagulant therapy, sepsis, or surgery.

Advances in paediatrics in 2019: current practices and challenges in allergy, endocrinology, gastroenterology, public health, neonatology, nutrition, nephrology, neurology, respiratory diseases and rheumatic diseases

We highlight the main developments that have been published during the first semester of the last year in the Italian Journal of Pediatrics. We have carefully chosen information from numerous exciting progresses issued in the Journal in the field of allergy, endocrinology, gastroenterology, neonatology, nutrition, nephrology, neurology, public health, respiratory diseases and rheumatic diseases. The impact on the care of patients has been placed in the broader context of studies that appeared in other journals. We think that many observations can be used directly to upgrade management of patients.

Precocious ischemia preceding bilateral adrenal hemorrhage: A case report

We present a case of a middle-age male who presented in emergency room with nonspecific abdominal pain. A contrast-enhanced computer tomography (ceCT) scan showed a reduced perfusion of both adrenal glands. The clinical examinations and the laboratory tests were negative for an adrenal pathological process. To reassess the adrenal ischemia, a second ceCT scan was performed 5 days later showing an acute bilateral adrenal hemorrhage. These findings demonstrated that the previous adrenal hypoperfusion represented the prodromal manifestation of a hemorrhagic intraglandular process. This case suggests that adrenal hypoperfusion detected on tomographic imaging dictates a prompt clinical management finalized to strictly monitor the potential evolution towards a more aggressive pathological condition and confirms the pivotal role of imaging in the diagnosis of such uncommon disorder.

A pictorial review of non-traumatic adrenergic crisis

Non-traumatic adrenal crisis is a rare but critical diagnosis to make in emergency settings due to grave consequences. Various pathologies can present as acute crisis, such as spectrum of endocrine imbalance, ranging from catecholamine excess in pheochromocytomas to acute adrenal insufficiency related to glandular dysfunction. Critical manifestations may be due to structural causes related to adrenal hemorrhage, especially when they are bilateral. Oncological complications such as vascular invasion, tumoral bleed, rupture, and hormonal dysfunction can occur. Due to non-specific clinical presentation, these conditions may come as a surprise on imaging performed for other reasons. Recognition of these imaging findings is critical for appropriate patient management. Although there are few articles discussing non-traumatic emergencies in literature, this review is inclusive of all possible etiologies, thus provides a holistic approach and insight into each situation. Specific imaging approach is needed to tailor the diagnosis. This article will also discuss about the advanced imaging techniques that will complement diagnosis.

Haemorrhage in pre-existing adrenal masses. A case series

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Diagnosis of haemorrhage in adrenal masses is more common, due to use of CT.

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We present 13 cases either spontaneous or after blunt abdominal trauma.

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Emergency operation is rarely warranted, due to possibility of pheochromocytoma.

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Haemorrhage should raise the high likelihood of undiagnosed metastatic disease.

Introduction

Adrenal haemorrhage in the context of a pre-existing adrenal mass is a rare, underestimated and potentially fatal surgical emergency. It is a rare cause of acute abdominal pain.

Presentation of cases

Data from 13 patients with adrenal haemorrhage in a pre-existing adrenal mass were prospectively collected during a 9 year period from a single institution. All patients underwent CT imaging which formed the basis of diagnosis and a complete endocrinological evaluation. Seven out of 13 patients underwent an elective surgical procedure and 2 patients underwent emergency laparotomy. Five out of 13 patients were diagnosed with metastatic disease. One patient was diagnosed with pheochromocytoma.

Discussion

The likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious. Complete patient evaluation includes testing for hormonally active adrenal tumors and malignancy. Emergency surgery is reserved for cases where conservative management fails.

Conclusion

Haemorrhage of an adrenal mass constitutes a diagnostic and therapeutic challenge. Most patients respond well to initial resuscitation efforts. When feasible, patients should undergo a complete hormonal and oncologic evaluation before surgical intervention is considered.

Adrenal cortical adenoma: current update, imaging features, atypical findings, and mimics

Adrenal adenoma is the most common adrenal lesion. Due to its wide prevalence, adrenal adenomas may demonstrate various imaging features. Thus, it is important to identify typical and atypical imaging features of adrenal adenomas and to be able to differentiate atypical adrenal adenomas from potentially malignant lesions. In this article, we will discuss the diagnostic approach, typical and atypical imaging features of adrenal adenomas, as well as other lesions that mimic adrenal adenomas.

Adrenocortical hyperplasia: a review of clinical presentation and imaging

Adrenal hyperplasia is non-malignant enlargement of the adrenal glands, which is often bilateral. It can be incidental or related to indolent disease process and may be related to benign or malignant etiologies causing biochemical alterations in the hypothalamic-pituitary-adrenal axis which controls steroidogenesis and in particular cortisol production. Clinical significance of the adrenal hyperplasia is variable ranging from asymptomatic finding to serious manifestations of Cushing syndrome. This is often associated with anatomical changes in the adrenal glands, which typically manifests as diffuse and sometimes nodular enlargement of the adrenal glands radiologically. Approaching adrenal hyperplasia requires careful clinical and biochemical evaluation in correlation with imaging review to differentiate ACTH-dependent and ACTH-independent etiologies. CT is the primary modality of choice for adult adrenal imaging owing to reproducibility, temporal and spatial resolution and broader access, while MRI often serves a complimentary role. Ultrasound and MRI are most commonly used in pediatric cases to evaluate congenital adrenal hyperplasia. This article will discuss the clinical presentation and imaging features of different types and mimics of adrenal cortical hyperplasia.

Case 268: Bilateral Adrenal Hemorrhage in the Context of Sepsis

History A 65-year-old man presented to the emergency department with a 1-week history of constipation, which was associated with increasing abdominal distention and not passing flatus. Four weeks prior to the current admission he had been diagnosed with metastatic primary adenocarcinoma of the appendix. One week ago, he had been hospitalized with small-bowel obstruction, for which he required laparotomy and loop ileostomy. His medical history included basal cell carcinoma, rheumatoid arthritis, and Barrett esophagus. Physical examination revealed a distended abdomen with tenderness at palpation within the right upper quadrant and lower abdomen and reduced bowel sounds at auscultation. Initial plain-film radiography of the abdomen at admission revealed dilated gas-filled small-bowel loops, suggestive of obstruction. His small-bowel obstruction was managed conservatively on this occasion. Nine days after admission, the patient became unwell and reported a productive cough. He became tachycardic, tachypneic, and hypotensive. Relevant blood tests at this stage revealed a C-reactive protein level of 206 mg/L (normal range, 0-10 mg/L), a white blood cell count of 24.5 × 10⁹/L (normal range, [4.0-11.0] × 10⁹/L), a red blood cell count of 3.39 × 10¹²/L (normal range, [4.5-5.5] × 10¹²/L), a hemoglobin level of 93 g/L (normal range, 130-170 g/L), and a hematocrit level of 0.27 (normal range, 0.4-0.5). CT of the abdomen and pelvis with intravenous contrast material (100 mL Omnipaque 350; GE Healthcare, Oslo, Norway) was performed.

Pheochromocytoma

Pheochromocytomas are rare tumors originating in the adrenal medulla. They may be sporadic or in the context of a hereditary syndrome. A considerable number of pheochromocytomas carry germline or somatic gene mutations, which are inherited in the autosomal dominant way. All patients should undergo genetic testing. Symptoms are due to catecholamines over production or to a mass effect. Diagnosis is confirmed by raised plasma or urine metanephrines or normetanephrines. Radiology assists in the tumor location and any local invasion or metastasis. All the patients should have preoperative preparation with α-blockers and/or other medications to control hypertension, arrhythmia, and volume expansion. Surgery is the definitive treatment. Follow up should be life-long.

Anticoagulation-induced unilateral adrenal haemorrhage and pseudoaneurysm

Spontaneous unilateral adrenal haemorrhage (AH) is extremely rare. Its presentation is usually non-specific and requires a high degree of suspicion as it is associated with high morbidity and mortality if diagnosis is delayed. Hereby, we present a case of 67-year-old man with significant cardiac history presented with right-sided chest pain and non-specific abdominal pain. He was previously treated for non-ST elevation myocardial infarction 5 days ago prior to the current presentation. CT scan of abdomen and pelvis demonstrated a right-sided active AH. The patient subsequently underwent digital subtraction angiography. Angio-embolisation was attempted for the pseudoaneurysm but failed due to spasm of the vessel. He was managed conservatively and discharged after clinical improvement. Clinic review 6 months later showed significant size reduction of the pseudoaneurysm.

Unilateral adrenal hematoma with associated giant mass: a report of two cases

Background: Adrenal hematoma is a rare yet potentially life-threatening event that occurs both in traumatic conditions and in a variety of nontraumatic conditions. In the present study, we report the two cases with idiopathic unilateral adrenal hematoma. Case presentation: Case 1 involved a 72-year-old man who was complaining of upper abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a giant mixed density tumor in the right retroperitoneal space. To remove the tumor, we carried out an adrenalectomy on the right adrenal gland, resecting a specimen measuring 15 × 13.5 cm. The histopathological findings of the specimen revealed a hematoma with normal adrenal tissue. Case 2 involved a 53-year-old woman who complained of an uncomfortable feeling in her left upper abdomen. A retroperitoneal tumor had formed a multicystic lesion and resected because the left renal vein had become compressed. The resected specimen was 10.5 × 10 cm in size and revealed an adrenal hematoma. In the absence of any obvious etiology, the diagnoses in both cases were idiopathic adrenal hematoma. Conclusion: An accurate diagnosis of idiopathic adrenal hematoma is quite difficult to make prior to surgery. Some imaging modalities are useful in generating a differential diagnosis.