Adrenal glands hemorrhages: embolization in acute setting

Abstract

Background: Acute adrenal hemorrhages are a rare event compared to other abdominal visceral injuries because of the anatomic localization of the adrenal glands; main causes are trauma and ruptured neoplasms. This manuscript reports on a single center experience of transarterial embolizations of adrenal hemorrhages in emergency setting.

Methods: In this retrospective analysis from 2010 to date, 17 patients (12 men and 5 women, mean age: 59.8 years) presenting with adrenal bleedings were treated by endovascular embolization. The etiology was traumatic in 7 cases, ruptured neoplasm in 8 cases and spontaneous in 2 patients assuming oral anticoagulant therapy. After thin slice contrast enhanced CT, a superselective embolization was conducted with different embolizing agents according to the type of vessel lesion and operator preference.

Results: Technical success rate, considered as interruption of adrenal bleeding detectable at angiography, was 94.1%. Clinical success rate, considered as hemodynamic stability restoration within 24 hours from the procedure, was 82.3%. Vessels involved were the superior adrenal artery in 5 patients, the middle adrenal artery in 8 patients, the inferior adrenal artery in one patient and more than one adrenal artery in 3 patients. No procedure-related major complications occurred and no patients had infarctions, necrosis, abscess formation, or required long-term steroid supplementation.

Conclusions: Acute adrenal hemorrhages can be safely and effectively managed by catheter directed embolizations; the source of bleeding has to be carefully investigated at CT and angiography because adrenal glands present with a wide and complex vascular arterial network.

Keywords: Adrenal gland; acute; embolization; hemorrhage.

Figure 1

Patient 1, a 66 years old male with neoplastic bleeding from lung metastasis of the left adrenal gland. Axial CT in basal (A), arterial (B), venous (C) and delayed (D) phases detecting a large hematoma (asterisk) with multiple foci of contrast agent extravasation (black arrows) increasing during the scan, sign of active bleeding.

Figure 2

Patient 1, same patient of Figure 1. Axial maximum intensity projection post-processing CT reconstruction (A): the superior adrenal artery is appreciable (black arrow). Procedural fluoroscopy (B) showing a 5 Fr Cobra catheter (dotted black arrow) at the origin of the left phrenic artery and a 2.7 Fr microcatheter (continuous black arrow) at the origin of superior adrenal artery: similar to CT (Figure 1), multiple foci of contrast agent extravasation are evident and so 300–500 micron microparticles were adopted as embolizing agent. Post embolization digital subtraction angiography (C) after contrast injection from the 5 Fr Cobra catheter (dotted black arrow), revealing no more extravasation in the embolized area. CT scan of control in arterial phase 24 hours after the embolization procedure (D) detecting left adrenal hematoma (black asterisk) without signs of active bleeding.

Figure 3

Patient 7, a 52 years old male with traumatic bleeding of the right adrenal gland after a motorbike accident. Axial CT in arterial phase (A) detecting a hematoma with contextual multiple spots of contrast agent extravasation (black asterisk) in correspondence of the right adrenal gland. Procedural digital subtraction angiography (B,C) showing a 5 Fr Cobra catheter (dotted black arrow) at the origin of the right renal artery from where originates the middle adrenal artery; a 2.7 Fr microcatheter (continuous black arrow) reaches the distal segment of the right middle adrenal artery and the contrast agent injection confirms the multiple spot extravasation findings (black circle), as CT; Gelfoam was adopted as embolizing agent. Post embolization digital subtraction angiography (D) after contrast injection from the 5 Fr Cobra catheter (dotted black arrow), revealing no more extravasation in the embolized area.