Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings

Abstract

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.

Figure 1.

Longitudinal (A) grayscale ultrasound image of a 1-month-old newborn baby (36 week premature infant who was born via C-section). The baby was diagnosed with an adrenal cyst in utero. The images show a heterogeneous mass that measures up to 2.7 cm (arrow in a). The mass shows significant decrease in size in multiple follow-ups with near complete resolution after 1 year (arrow in b).

Figure 2.

Axial CT image without i.v. contrast (a) and multiple post-contrast axial CT images (b, c) showing a heterogeneous left adrenal mass with high attenuation areas within in the pre contrast image (arrow), with adjacent left retroperitoneal enhancement. The lesion shows no significant enhancement in post-contrast images (b, c). The mass was surgically resected and was pathologically proven to represent adrenal adenoma with hemorrhage.

Figure 3.

A mass is present within the left adrenal gland (a) with peripheral curvilinear wall calcifications. This demonstrates fluid attenuation, with wall calcification; features of typical pseudocyst. CT and MR images in a different patient: Axial contrast enhanced CT (b) demonstrates a large heterogeneous predominately hypoattenuating mass with a focus of peripheral calcification (curved arrow). Axial T₁ weighted (c) and coronal T₂ weighted (d) MR images demonstrate high signal intensity on T₁WI and heterogeneous mixed signal intensity on T₂WIs, consistent with internal hemorrhage. Based on the large size and heterogeneous appearance of this mass, this was prospectively diagnosed as adrenocortical carcinoma. This mass was surgically resected and was pathologically proven to represent hemorrhagic pseudocyst.

Figure 4.

Multiple CT (a) and MR (b, c) images in a 39-year-old female with incidentally discovered left adrenal lesion. The lesion has wall calcifications (arrow in a), without post-contrast enhancement, this calcification appears hypointense on T₂ weighted image (arrow in c). Imaging features are consistent with an adrenal cyst with calcifications, possible related to old hemorrhage.

Figure 5.

53-year-old man with intermittent abdominal pain radiating to the back. Axial T₁ FS image (a) shows large bilateral adrenal hemorrhagic masses. PET/CT images (b) demonstrate necrotic bilateral adrenal masses with FDG avid peripheral foci (straight arrow). Additionally, there is a large RP FDG avid mass (curved arrow). Other images show large bilateral adrenal hemorrhagic masses without significant enhancement. Surgical pathology consistent with bilateral adrenal hemorrhagic metastases, likely from a retroperitoneal high-grade leiomyosarcoma. FDG, fludeoxyglucose; PET, positron emmision tomography; RP, retroperitoneal.

Figure 6.

57-year-old male with non-traumatic bilateral adrenal hemorrhagic lesions. The patient has anti-phospholipid syndrome with anticoagulation. Axial CT image without contrast shows near symmetric enlargement of the bilateral adrenal glands with high attenuation lesions without significant enhancement (a). The lesions have homogenous low T2 signal (c), and heterogenous intermediate bright T1 signal with high signal of the periphery (d).

Figure 7.

67-year-old male patient with 2 weeks of pneumonia. There are bilateral adrenal masses (Straight arrows in a). Enhanced Axial CT performed after 2 weeks (b) demonstrated resolution of the previously noted adrenal masses (curved arrows) indicative sepsis-related bilateral adrenal hemorrhages (Waterhouse-Friedrickson syndrome).

Figure 8.

Multiple MR images before and after contrast. There is a 6.5 cm heterogeneously T2 hyperintense (a, straight arrow) right adrenal mass with multiple foci of T1 hyperintensity (b) compatible with intralesional hemorrhage. Peripheral enhancement of the right adrenal mass in post contrast images. Filling defect within the IVC (c, arrow head) adjacent to the right adrenal mass consistent with thrombus, possibly tumor thrombus. Patient underwent right adrenalectomy with en bloc IVC wall resection and reconstruction. The adrenal mass proved to be pheochromocytoma and the IVC filling defect turned out to be an organized bland thrombus. IVC, inferior vena cava.

Figure 9.

Axial CT image post-i.v. contrast administration showing a heterogeneous left adrenal mass with attenuation value of 35 HU. The mass showed progressively enhancing peripheral nodularity (white arrow). Surgical pathology showed a hematoma with secondary papillary endothelial hyperplasia. HU, Hounsfield unit.

Figure 10.

59-year-old patient presenting with acute left flank pain. Axial unenhanced and post-contrast CT images (a, b) demonstrate a large heterogeneous predominately hypoattenuating mass involving the left adrenal gland. This mass demonstrates hyperdense foci of presumably hemorrhage and/or calcification (a, arrows). There is a layering fluid in the left retroperitoneum (b, arrow). This appearance was interpreted by the radiologist to represent an adrenal hemorrhage. 6 months follow-up CT (c) demonstrates interval enlargement of the mass which mandated surgical resection. On surgery, this was found to represent adrenal angiosarcoma with intratumoral hemorrhage.

Figure 11.

61-year-old male with history of lung cancer presenting with abdominal pain and dropped hemoglobin level. Color Doppler ultrasound image (a) shows a large heterogeneous metastatic mass in the right adrenal fossa without significant Doppler flow. Axial (b) and coronal (c) post-contrast CT images show a 10.5 cm heterogeneous right adrenal mass (curved arrow) causing inferolateral displacement of the right kidney. Additionally, there is right retroperitoneal hemorrhage extending medially inferior to the right kidney.

Figure 12.

Large right retroperitoneal, predominantly fat-containing mass (a, straight arrow) in the right suprarenal fossa measuring up to 13 cm. The mass demonstrates high attenuation foci of active internal hemorrhage within (curved arrow). There is associated moderate retroperitoneal and perinephric hematoma. Selective catheterization of the vessels in the mass (c) showing a small aneurysm in the superior aspect of the mass (white circle). This vessel was super selectively catheterized and coil embolization was performed with no flow in the post embolization images (d, arrow). Images to another 51-year-old male with right bleeding adrenal myelolipoma (e). Axial CT image without contrast demonstrates a large heterogeneous lesion with fat (straight arrow) and high attenuation contents (curved arrow) content denoting intralesional hemorrhage. No significant post-contrast enhancement noted (f).