Adrenal Haemorrhage
By Andrew McGovern
Image: Underwood (2006)
The use of different imaging methods in:
Introduction
PART 1. Adrenal haemorrhage:• An overview• Pathophysiology
PART 2. Imaging in adrenal haemorrhage:
• Different imaging possibilities• Positive and negative aspects of each
type• Image examples
What is adrenal haemorrhage?• Uncommon, usually presents as bilateral
haemorrhage. (Light, 2006)
• Can occur at any age. (Light, 2006)
• Extensive necrosis of all three cortical layers and medulla. (Tritos, 2007)
• Can cause volume lossand shock in infantsand acute adrenalinsufficiency unlessrecognised andtreated properly.(Light, 2006)
Adrenal haemorrhage at autopsy Image: Underwood
(2004)
PathophysiologyCauses of adrenal haemorrhage:• Coagulopathies: causing thrombosis in
renal and adrenal veins.
• Waterhouse-Friderichsen syndrome: in children and young adults (occurring in 20% of meningitis cases).
• Trauma: found in 28% of severe trauma cases autopsy. (Sevitt, 1955)
• Asphyxia: in neonates – at birth the adrenal gland is very large and vascular.
• Also associated with adrenal tumours. (Light, 2006)
Imaging: Computed tomographyCT scanning is the preferred method for
identifying adrenal haemorrhage in all patients over 6 months old.
CT is rapid, widely available and accurate in diagnosis.
• Useful for the identification of an underlying neoplasm, tumour or large thrombosis.
• Allows examination of the adrenal glands in trauma patients with other imaging indications.
Adrenal haemorrhage is detected as a round or oval mass obliterating the normal chevron shape of the adrenal gland. (Light, 2006)
Imaging: Computed tomographyCT of normal adrenals several
months before the onset of haemorrhage.
CT two weeks after the onset of an acute haemorrhage.
Images excerpted from: Rao et al. (1989)
Imaging: Computed tomography
CT of acute bilateral haemorrhage. Image: Hentel (2008)
Imaging: Magnetic ResonanceIn general MRI identifies adrenal
abnormalities at a rate which is comparable to CT.
• Not as widely available as CT.• May be preferable in younger people due to CT
radiation risk:– 1 fatal cancer per 2000 scans. (FDA, 2007)
– 20% increased lifetime cancer mortality risk. (FDA, 2007)
– 5 fatal cancers per 6000 scans in under 15s.– May account for up to 2% of cancers in the US.
(Brenner, 2007)
• Evidence for these studies is 25,000 survivors of Hiroshima bombing. Not directly comparable?
(BRER, 2006)
Imaging: Magnetic Resonance
T1 weighted MRI displaying right adrenal infarction without haemorrhage, in a 42-year-old man with anti phospholipid syndrome. Image: Riddell and Khalili (2004)
Imaging: UltrasoundUS is the standard in neonates for
imaging adrenal masses.
• It is sensitive for enlargements of the adrenal glands.
• Can differentiate between causes of adrenal mass.
• Echogenicity is variable with the age of the haemotoma – can estimate age.
• Widely available.
• No ionising radiation.
• But US is operator dependant. (Light, 2006)
Imaging: Ultrasound
An adrenal haemorrhage as seen on ultrasound.Image: Hentel
(2008)
Imaging: Ultrasound
An adrenal haemorrhage as seen with Doppler ultrasound. This enables the avascular nature of the mass to be identified. Image: Hentel (2008)
Imaging: UltrasoundAdrenal
haemorrhage in a foetus at 34 weeks gestation caused by a neuroblastoma.
Image: Trop and Levine (2001)
Imaging: Other modalitiesPlain radiographs: Acute adrenal
haemorrhage is rarely detectable. It may cause mass effect in the upper abdomen. (Light, 2006)
Image: Kawashima et al. (1999)
Imaging: Other modalitiesNuclear medicine studies: Of very
little use as the main contrast agents used are not taken up by haematoma or normal adrenal tissue. (Light, 2006)
Image: Kawashima et al. (1999)
Summary
• Adrenal haemorrhage is an uncommon but serious condition which causes adrenal insufficiency.
• CT is the diagnostic method of choice.
• MRI should be considered as an alternative in children.
• Ultrasound should be used in neonates.
ReferencesBRENNER, D. J. (2007) Computed Tomography — An Increasing Source of Radiation Exposure. the New England
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