Imaging of nontraumatic hemorrhage of the adrenal gland

Adrenal lesions: spectrum of imaging findings with emphasis on multi-detector computed tomography and magnetic resonance imaging

The adrenal gland is a common site of a large spectrum of abnormalities like primary tumors, hemorrhage, metastases, and enlargement of the gland from external hormonal stimulation. Most of these lesions represent nonfunctioning adrenal adenomas and thus warrant a conservative management. Multi-detector computed tomography (CT) and magnetic resonance (MR) imaging are still considered highly specific and complementary techniques for the detection and characterization of adrenal abnormalities. Radiologist can establish a definitive diagnosis for most adrenal masses (i.e., carcinoma, hemorrhage) based on imaging alone. Imaging therefore can differentiate malignant lesions from those benign and avoid unnecessary aggressive management of benign lesions. The article gives an overview of the adrenal lesions and their imaging characteristics seen on CT and MR imaging.

Adrenal collision tumors and their mimics: multimodality imaging findings

Adrenal collision tumors (ACTs) refer to coexistence of two adjacent, but histologically distinct neoplasms involving the adrenal gland without histologic admixture at interface. ACTs include adenoma with myelolipoma, adenoma with metastases, hemangioma with adenoma, and adrenocortical carcinoma with myelolipoma. In addition, hemorrhage into a pre-existing adrenal mass can mimic an ACT, and it is important to differentiate these two pathologies. Accurate characterization of ACTs is difficult, but critical, for correct staging of patients with malignancies and to guide percutaneous biopsy. Magnetic resonance imaging (MRI) and multidetector computed tomography imaging techniques may depict different tumor components separately; however, biopsy may be required in selected patients for confirmation. [¹⁸F]Fluorodeoxyglucose-positron emission tomography (PET) shows increased uptake in the malignant component of ACTs, and guides percutaneous biopsy. Even in patients requiring percutaneous biopsy for a definite diagnosis, imaging findings can help in guiding the appropriate component to be biopsied. Knowledge of imaging findings of different ACTs and their mimics on MRI, computed tomography, and PET help in optimal patient management.

Adrenal hemorrhagic pseudocyst as the differential diagnosis of pheochromocytoma--a review of the clinical features in cases with radiographically diagnosed pheochromocytoma

BACKGROUND

Clinical diagnosis of pheochromocytoma is difficult for some adrenal tumors.

AIM

Herein, we review clinical and pathological findings of 31 cases with radiographically diagnosed pheochromocytoma, including three cases of hemorrhagic pseudocysts (HPC).

MATERIALS/SUBJECTS AND METHODS

Between January 1992 and December 2010, 31 patients with adrenal tumors were pre-operatively diagnosed as having pheochromocytoma by radiographic imaging, and underwent adrenalectomy. Histological examination revealed HPC in 3 patients (9.7%), and pheochromocytoma in the remaining 28 patients. We reviewed and compared the clinical features, including the biochemical and radiographic features, of HPC and pheochromocytoma cases.

RESULTS

Biochemical testing showed no definitive excessive catecholamine secretion in any of the three patients with HPC and four (14.3%) of those with histologically proven pheochromocytoma. (131)Imetaiodobenzylguanidine scintigraphy was negative in the three with HPC, but positive in all of the four with pheochromocytoma who did not have suggestive biochemical results. All HPC patients had concomitant disease or symptoms suggestive of pheochromocytoma, and two had received an anti-coaglant or anti-platelet agent. Laparoscopic surgery was completed in two cases of HPC uneventfully.

CONCLUSIONS

Adrenal HPC may have radiographic characteristics similar to those of pheochromocytoma. Adrenal HPC should be considered as a differential diagnosis of pheochromocytoma.

Adrenomegaly and septic adrenal hemorrhage (Waterhouse-Friderichsen syndrome) in the setting of congenital adrenal hyperplasia

Congenital adrenal hyperplasia refers to a spectrum of autosomal recessive inherited disorders of steroidogenesis most commonly identified on newborn screenings. We describe a young woman who presented with abdominal pain and on subsequent imaging was found to have features of congenital adrenal hyperplasia. Imaging findings, treatment, and potential complications are discussed.

Idiopathic bilateral adrenal haemorrhage related to acute adrenal insufficiency

A 54-year-old woman presented with sudden epigastralgia and left back pain. She had no significant history. Laboratory data showed mild inflammation and no liver or renal dysfunction. Abdominal CT showed left adrenal enlargement and haemorrhage. Hydrocortisone therapy was started to prevent adrenal insufficiency before laboratory findings for ACTH (adrenocorticotropic hormone) and cortisol levels. On the second hospital day, abdominal CT showed additional right adrenal enlargement and haemorrhage. The serum cortisol level suggested adrenal insufficiency. No specific findings were detected by bilateral adrenal angiography. 6 to 12 months later, abdominal CT showed decreased bilateral adrenal haemorrhage. This case illustrates the importance of prompt diagnosis and treatment of acute adrenal insufficiency, and shows sequential changes in the size of bilateral adrenal haemorrhage. Rapid corticosteroid replacement is important if acute adrenal insufficiency is suspected. In a case with unilateral adrenal haemorrhage, the possibility of additional adrenal haemorrhage on the opposite side should also be considered.

Idiopathic unilateral adrenal haemorrhage and adrenal mass: a case report and review of the literature

We report an unusual case of idiopathic unilateral adrenal haemorrhage (AH) in a 55-year-old patient. This rare case had two characteristics that made it worth of report. First, idiopathic adrenal haemorrhage is very uncommon, and second it was presented as a huge, 23 cm diameter and 2,123 gr weight, "silent" adrenal mass. It is important to distinguish a benign lesion like this from a neoplasm, although we were not able to identify it preoperatively and the diagnosis was only made after the excised specimen was examined by a group of experienced histopathologists. Only a few similar published cases, to our knowledge, are described in the worldwide literature and even fewer of this size.

Spontaneous rupture of a rare adrenal artery aneurysm mimicking a ruptured abdominal aortic aneurysm

Spontaneous adrenal artery aneurysm rupture is an exceedingly rare but life-threatening condition that requires emergent treatment. We report on an 80-year-old male who underwent an emergent exploratory laparotomy and repair of a ruptured adrenal artery aneurysm and highlight the role of both vascular surgery and interventional radiology in the management of this scenario.

Spontaneous adrenal hemorrhage with associated masses: etiology and management in 6 cases and a review of 133 reported cases

BACKGROUND

Spontaneous adrenal hemorrhage associated with a mass is uncommon and treatment strategies are not standardized. Current treatment modalities range from supportive management and blood transfusion to embolization or immediate operative extirpation. Our objectives were to describe six cases from a single institution and to perform a literature review of the etiology of the condition and recommended management of patients with hemorrhagic adrenal masses.

METHODS

Records from six patients diagnosed with adrenal hemorrhage and an associated mass at a single institution were reviewed. Clinical records and outcomes were analyzed. A comprehensive review of 133 reported cases in the literature was performed.

RESULTS

Six patients presented with spontaneous adrenal hemorrhage that appeared to be associated with a mass, with tumor sizes ranging from 3.7 to 15 cm. Three patients underwent adrenalectomy for pheochromocytoma or adrenocortical cancer. Three patients did not undergo adrenalectomy: one had a metastasis from lung cancer, one underwent embolization, and one had resolution of the mass on interval imaging. A comprehensive review of the literature identified 133 cases, with pheochromocytoma the most commonly reported lesion (48%).

CONCLUSIONS

Spontaneous adrenal hemorrhage is rare. When it does occur, a high level of suspicion for malignant disease or pheochromocytoma should be maintained. The possibility of a hematoma masquerading as a neoplasm should also be considered. In cases of ongoing hemorrhage, embolization may be a lifesaving temporizing measure. Acute surgical intervention should be considered in selected patients, and surgery may not be required in all patients. A cautious approach with a comprehensive biochemical and imaging work-up is advised prior to operation.

Imaging of nontraumatic adrenal hemorrhage

OBJECTIVE

The purpose of this pictorial essay is to review the imaging findings of acute, chronic, and tumor-related nontraumatic adrenal hemorrhage.

CONCLUSION

Rapid development or evolution of a nonenhancing adrenal mass or masses with an adreniform shape or high T1 signal intensity on MR images of a patient under stress or with a bleeding diathesis, including anticoagulant use, suggests acute adrenal hemorrhage. Chronic hemorrhage appears as a thin-walled pseudocyst or atrophy. Imaging findings that may indicate underlying tumor include intralesional calcification, enhancement, and hypermetabolic activity on PET images.

Idiopathic adrenal hematoma masquerading as neoplasm

We report herein a case of idiopathic adrenal hematoma. A 59-year-old Japanese man was referred to our hospital for evaluation of a 7.0 cm mass in the right upper abdominal cavity. The tumor was suspected to originate from either the posterior segment of the liver or the right adrenal gland. His chief complaint was weight loss of 8 kg over the previous 6 months. He had no past medical history and took no medications, including no anticoagulants. Laboratory data were almost normal except for a slight elevation of PIVKA-II. The origin of the tumor was found to be the adrenal gland, as angiography revealed the blood supply to the mass to derive from the right superior and inferior adrenal arteries. A fine needle biopsy of the lesion was unable to confirm the diagnosis. Open right adrenalectomy was performed. The histopathological findings of the surgical specimen revealed a hematoma with normal adrenal tissue. In the absence of any obvious etiology, the diagnosis was idiopathic adrenal hematoma.

Atypical imaging features of adrenal gland lesions in children - report of three cases and review of literature

BACKGROUND

The differential diagnosis of adrenal pathology depends on the child's age and imaging findings.

CASE REPORT

Three children without clinical symptoms of neoplasm, with an adrenal lesion discovered on diagnostic ultrasound imaging. Laboratory tests for neoplasm were negative. The final diagnosis was based on histopathological examinations after surgical resection.

CONCLUSIONS

1. The value of diagnostic imaging and laboratory tests in differential diagnosis of adrenal gland lesions is limited. 2. Malignant tumors of adrenal glands should be taken into account in children. 3. Surgical resection should be considered in diagnostic algorithm of adrenal gland masses. 4. The final diagnosis is always based on histopathological examination.

Dual-energy CT for characterization of the incidental adrenal mass: preliminary observations

OBJECTIVE

The purpose of our study was to evaluate the accuracy of virtual unenhanced images reconstructed from contrast-enhanced dual-energy CT for the differentiation of incidental adrenal masses in comparison with standard unenhanced CT.

MATERIALS AND METHODS

One hundred-forty patients (mean age, 74±9 years) underwent unenhanced and contrast-enhanced CT of the abdomen, the latter acquired with dual-energy for reconstruction of virtual unenhanced images. Two blinded and independent readers (R1 and R2) measured attenuation of each incidental adrenal mass on standard unenhanced and virtual unenhanced images using an optimized dual-energy three-material decomposition algorithm.

RESULTS

Fifty-one incidental adrenal masses were found in 42 of 135 patients (31%); 39 incidental adrenal masses were ≥1 cm. On the basis of unenhanced CT, 29 of 51 incidental adrenal masses and 22 of 39 incidental adrenal masses≥1 cm were classified as benign (HU<10). Virtual unenhanced image quality was rated as good or with mild impairment (2.45±0.83 for R1, 2.45±0.99 for R2). Image noise was 12.7±3.6 HU in unenhanced images and 8.8±2.0 HU in virtual unenhanced images (p<0.001). There was no significant difference in incidental adrenal mass attenuation between unenhanced and virtual unenhanced images for all incidental adrenal masses (5.9±21.0 HU vs 7.0±20.6 HU, p=0.48) and for those≥1 cm (6.6±18.5 HU vs 7.9±18.3 HU, p=0.87). Sensitivity, specificity, and accuracy of virtual unenhanced images for the characterization of incidental adrenal masses as probably benign were 76%, 82%, and 78% for R1 and 79%, 95%, and 86% for R2, respectively. For incidental adrenal masses≥1 cm, sensitivity, specificity, and accuracy increased to 95%, 100%, and 97% for R1 and 91%, 100%, and 95% for R2.

CONCLUSION

Reconstruction of virtual unenhanced images from contrast-enhanced dual-energy CT of the abdomen allows the characterization of the incidental adrenal masses with a good accuracy compared with standard unenhanced CT, with the most favorable results in incidental adrenal masses measuring≥1 cm.

Diagnosis and subsequent US-guided percutaneous drainage of an adrenal abscess in a 5-week-old infant

Adrenal abscess is an uncommon finding in neonates and young infants. It may have a fatal outcome if inadequately treated. This case report describes the successful diagnosis and treatment of a left-sided adrenal abscess in a 5-week-old girl. Abdominal US and antigranulocyte antibody-scintigraphy showed an encapsulated suprarenal mass with debris suspicious for an adrenal abscess. Treatment is generally surgical. In this case, however, we performed US-guided percutaneous drainage combined with intravenous antibiotic treatment. The child recovered fully.

CT of the adrenal gland: the many faces of adrenal hemorrhage

Adrenal hemorrhage is rarely suspected clinically, exhibits no specific clinical symptoms or laboratory findings, and yet is immediately life-threatening when bilateral. Recognition of adrenal hematomas is complicated by the variable appearance of these lesions. We survey the ways in which adrenal hematomas can appear on CT and provide strategies for differentiating hematomas from other adrenal pathologies.

Hemodynamic collapse following bilateral knee arthroplasty: a mysterious case

Severe hemodynamic collapse after knee surgery from bilateral adrenal hemorrhages is rare. Even rarer is it occurring from adrenal hemorrhage as a complication of heparin induced thrombocytopenia. Due to lack of awareness of this rare complication and associated complex scenario in critically ill patients, diagnosis is often made post mortem. A diagnosis of bilateral adrenal hemorrhage should be considered in any patient presenting with non-specific symptoms of fever, abdominal pain, confusion and rapid hemodynamic collapse not responding to standard therapy. This is crucial especially in the setting of heparin induced thrombocytopenia as thrombosis and not hemorrhage is often the most feared complication of this syndrome.

Which Arteries Are Expendable? The Practice and Pitfalls of Embolization throughout the Body

This article outlines general concepts of, and strategies for, therapeutic embolization throughout the body, touching on all major arterial distributions. Clinical scenarios that allow or prevent safe embolization of vessels are presented. Specific agents are recommended where appropriate, as are alternate approaches when embolization is not an option. Pre-embolization precautions and adjunctive measures are described in high-risk areas.

Idiopathic Adrenal Hemorrhage in a Patient with Gestational Trophoblastic Neoplasia

BACKGROUND: Idiopathic unilateral adrenal hemorrhage is rare. Described is the first case reported in the setting of nonmetastatic gestational trophoblastic neoplasia. CASE: A primigravida presented with abdominal pain, fever, and a right upper quadrant mass during the workup for gestational trophoblastic neoplasia. She was diagnosed with idiopathic unilateral adrenal hemorrhage. She was treated with surgical resection and single-agent chemotherapy and had complete remission. CONCLUSIONS: Idiopathic unilateral adrenal hemorrhage is a rare condition and must be considered in the presentation of abdominal pain, fever, and an abdominal mass.

Imaging findings after radiofrequency ablation of adrenal tumors

OBJECTIVE

The purpose of this study was to describe the imaging findings after radiofrequency ablation of adrenal tumors.

MATERIALS AND METHODS

We retrospectively reviewed the imaging findings of all patients with adrenal tumors treated with radiofrequency ablation in our department from January 2001 through August 2009. The studies were reviewed in consensus by two attending abdominal imaging radiologists and an abdominal imaging fellow. Imaging findings before, immediately after, and at short- and long-term follow-up after ablation were recorded.

RESULTS

Fourteen patients (seven men, seven women; mean age, 56 ± 8.4 years) underwent radiofrequency ablation of adrenal tumors. One case of small pneumothorax and one case of small hemothorax were the only minor complications (complication rate, 14%). The expected side effects of radiofrequency ablation were found in 35% of patients: in two patients adjacent liver parenchyma was ablated, in two patients the diaphragmatic crus was injured, and in two patients local hematoma occurred (in one patient, both adjacent liver and diaphragmatic crus were ablated). Immediate soft-tissue findings after radiofrequency ablation included air bubbles in 12 patients (86%) and fat stranding around the adrenal gland in 13 patients (93%). A fat rim sign was found in 60% of patients at long-term follow-up. The attenuation of the tumor immediately after the procedure increased an average of 7 HU (median, 5 HU; range, -2 to 18 HU) and tended to decrease in long-term follow-up. At long-term follow-up, most (75%) of the tumors had decreased in size and attenuation.

CONCLUSION

Air bubbles and fat stranding are frequently seen immediately after radiofrequency ablation of adrenal tumors. A fat rim sign is a common finding at long-term follow-up. Attenuation of the ablated zone increases immediately after the procedure and decreases in long-term follow-up. The volume of the ablated zone has a variable size response, suggesting the need for baseline imaging.

Adrenal hematoma after nephrectomy

OBJECTIVE

The objective of our study was to retrospectively define the incidence of adrenal hematoma on CT or MRI after nephrectomy.

MATERIALS AND METHODS

Between January 2008 and June 2009, 465 patients underwent nephrectomy at our institution. Of these, patients without both preoperative and postoperative abdominal CT or MR studies within 6 months of surgery (n = 83) and those with documented adrenalectomy at the time of radical nephrectomy (n = 33) were excluded. Thus, 349 patients (292 male, 57 female; mean age, 60.2 years; range, 2-88 years) were included in the study. Preoperative and postoperative CT or MR studies were reviewed by two radiologists in consensus for the presence or absence of adrenal hematoma. Diagnosis of adrenal hematoma was made by imaging findings and follow-up. The incidence of adrenal hematoma was calculated with a 95% CI.

RESULTS

Of the 349 patients (partial nephrectomy, n = 232; radical nephrectomy, n = 117), 19 patients developed adrenal hematoma after nephrectomy (partial nephrectomy, n = 12; radical nephrectomy, n = 7) with an incidence of 5.4% (95% CI, 3.1-7.8%). All adrenal hematomas were located on the side of nephrectomy (right adrenal gland, n = 8; left adrenal gland, n = 11). In nine patients, the adrenal hematoma appeared as a round or oval lesion on postoperative imaging with a mean size of 2.6 cm (range, 1.5-4.0 cm). In 10 patients, the adrenal hematoma appeared as diffuse enlargement of the adrenal gland on postoperative imaging with a mean thickness of 1.3 cm (range, 0.6-1.8 cm).

CONCLUSION

An adrenal hematoma was identified in 5.4% of patients on CT or MRI after nephrectomy. A new round or oval adrenal mass after nephrectomy should be differentiated from a metastasis.

Disappearing adrenal masses

Adrenal incidentalomas are a common finding due to the increasing use and improved technology of imaging studies. The majority of these enlargements are non-functional and irreversible. Publications on reversible adrenal enlargement are sparse. Our patient, a 66-year-old man, was admitted to the hospital due to abdominal discomfort. He was treated for rectal carcinoma 3 years before, and was now free of disease. Computed tomography (CT) scan showed no abnormalities other than the incidental finding of bilateral adrenal enlargement. Metastasis was suspected. The CEA-level, however, was within normal range and there was no evidence of hormonal overproduction. After 1 month the patient was reviewed. Physical examination and laboratory testing were normal. Surprisingly, the CT-scan showed a decreased size of both adrenals and after 3 months even showed completely normalized adrenals. Reversible adrenal enlargements are rare. Commonly described causes of adrenal enlargement are haematomas, cystic lesions and infections of the adrenal glands. The patient in this case did not show any clinical, laboratory or radiological signs of any of these diagnoses. The current existing differential diagnosis for bilateral adrenal enlargement is not sufficient to explain the findings in our patient.

[Adrenal hemorrhage acutised by adrenocorticotropin hormone]

OBJECTIVE

Many spontaneous adrenal hematomas have been observed in patients being treated by Synacthène. The purpose of this study is to define how to take those patients in charge on a short-, mid- and long-term.

PATIENTS AND METHODS

From January 2000 to December 2008, five patients (four males and one female), mean age 47, were taken in charge in our service for spontaneous adrenal hematomas. All those patients had been treated with Synacthène for a mid-sciatic pain for 72 hours. We associated a clinical, endocrine and radiologic staging to treat those patients.

RESULTS

Four patients underwent a watchful waiting, only one patient needed surgery. No adrenal tumor was ever found during the mean two years follow-up (one to four). Two patients suffered of the condition of the antiphospholipid syndrome.

CONCLUSION

Spontaneous adrenal hematomas are a most uncommon pathology. The clinical attitude has thus to be defined clearly. The patient must be under close clinical evaluation. Biological and morphological parameters have to be often repeated. An adrenal tumor has to be excluded by the evaluation, as that tumor could be secreting or could not be secreting. Antiphospholipid syndrome must also be excluded.

An unusual case of profound hyponatraemia and bilateral adrenal calcifications

We report a case of a 65-year-old lady who presented with acute confusion and profound hyponatraemia (plasma sodium of 97 mmol/L). Five years earlier she had developed sepsis and was found to have hyponatraemia, thought to be due to syndrome of inappropriate antidiuretic hormone secretion. The patient was lost to follow-up. The patient was covered with steroids and investigations confirmed primary adrenal failure with flat response of cortisol to adrenocorticotropic hormone (ACTH) stimulation and very high level of ACTH. Adrenal auto-antibodies were negative and a computed tomography of the adrenals showed bilateral adrenal calcifications, suggestive of previous haemorrhage or infarction. Bilateral adrenal calcification due to haemorrhage/infarction usually does not present with severe hyponatraemia; however, adrenal insufficiency should be excluded in all cases of severe hyponatraemia. In suspected cases, patients should be treated with steroids, even when symptoms or signs are absent, while results of investigations are awaited.

Spontaneous abdominal hemorrhage: causes, CT findings, and clinical implications

OBJECTIVE

The purpose of this article is to present the most common causes of spontaneous abdominal hemorrhage and to review the CT findings that are important in establishing the correct diagnosis and in guiding appropriate therapy.

CONCLUSION

Knowledge of the common CT manifestations of various causes of spontaneous abdominal hemorrhage allows their accurate diagnosis and has a direct impact on clinical decision making.

Computed tomography appearance of spontaneous adrenal hemorrhage in a pheochromocytoma

Pheochromocytomas are adrenal tumors that are diagnosed with time-consuming 24-h urine collection studies. Adrenal hemorrhage is a rare but serious complication of pheochromocytomas that has been reported in only about 50 cases [Sutton MG, Sheps SG, Lie JT. Prevalence of clinically unsuspected pheochromocytomas. Review of a 50-year autopsy series. Mayo Clin Proc 1981;56:354-360]. We had a patient with a classic presentation of pheochromocytoma complicated with hypertensive crisis leading to spontaneous adrenal hemorrhage. We report the computed tomographic (CT) findings of ruptured pheochromocytoma that helped us in early detection and treatment of this life-threatening complication.

Computed tomography findings in diseases of the adrenal gland

The adrenal gland is a common site of disease, with an abnormality prevalence as high as 9% in autopsy series. With the increasing use of CT, adrenal lesions are frequently found in the daily practice of radiology and are diagnosed in up to 5% of CT examinations performed for varied reasons. Imaging features on CT can establish a specific diagnosis of many of these lesions, including myelolipoma, hematoma and cysts. Once a diagnostic dilemma, now adenomas can be accurately diagnosed using unenhanced CT, chemical shift magnetic resonance imaging and CT contrast washout analysis. Because the adrenal gland is also a frequent site of metastasis, recent literature has focused on imaging characterization of adrenal masses for differentiation of adenomas from metastases. In patients without known malignancy, most adrenal lesions are benign and a specific diagnosis can now be made on the basis of imaging features. It is important to understand the prevalence of adrenal abnormalities because the gland is a common site of disorders, and the increased use of cross-sectional imaging has increased the frequency of detection of adrenal lesions. The prevalence of disease is important in predicting the risk of malignancy when an adrenal mass is discovered in a patient without known cancer. Detection of adrenal gland diseases has increased substantially with the advent and widespread use of imaging techniques. Although several imaging modalities can be used, CT has a central role in both detection and differential diagnosis of an adrenal lesion. The aim of this article is to review the CT findings of adrenal gland diseases.

Positive contrast visualization for cellular magnetic resonance imaging using susceptibility-weighted echo-time encoding

OBJECTIVE

The objective of this study was to investigate a method to generate positive contrast, selective to superparamagnetic iron oxide (SPIO) labeled cells, using the susceptibility-weighted echo-time encoding technique (SWEET).

MATERIALS AND METHODS

SPIO-labeled human epidermal carcinoma (KB) cells were placed in a gel phantom. Positive contrast from the labeled cells was created by subtraction between conventional spin-echo images and echo-time shifted susceptibility-weighted images. SPIO-labeled cells were injected into the left dorsal flank and hind limb of nude mice, and unlabeled cells were placed on the right side as controls. Tumor growth was monitored using the proposed method, and a histological analysis was used to confirm the presence of the labeled cells.

RESULTS

Based on in vitro testing, we could detect 5000 labeled cells at minimum and the number of pixels with positive contrast increased proportionally to the number of labeled cells. Animal experiments also revealed the presence of tumor growth from SPIO-loaded cells.

CONCLUSIONS

We demonstrated that the proposed method, based on the simple principle of echo-time shift, could be readily implemented in a clinical scanner to visualize the magnetic susceptibility effects of SPIO-loaded cells through a positive-contrast mechanism.

Clinical update on the management of adrenal hemorrhage

Adrenal hemorrhage is a rare yet potentially life-threatening event that occurs both in traumatic conditions and in a variety of nontraumatic conditions. Clinical manifestations of adrenal hemorrhage can vary widely depending on the degree and rate of hemorrhage, as well as the amount of adrenal cortex compromised by hemorrhage. Although an isolated focal unilateral adrenal hemorrhage may present subclinically, massive bilateral adrenal hemorrhage may lead to rapid cardiovascular collapse and ultimately death if not diagnosed appropriately and treated quickly. Diagnosis of adrenal hemorrhage is often complicated by its nonspecific presentation and tendency to occur in the setting of acute illness and other complicating medical conditions. This article outlines the variety of clinical situations in which adrenal hemorrhage can occur, summarizes the appropriate diagnostic tests available, and reviews the appropriate management of adrenal hemorrhage.

Surgical management of adrenal cysts: single-institution experience

OBJECTIVES

To assess the safety and efficacy of different surgical procedures used for managing benign adrenal cysts.

PATIENTS AND METHODS

The files of 245 patients presenting with adrenal masses was reviewed retrospectively; all had a thorough history taken and a physical examination. The radiological evaluation included abdominal plain X-rays, grey-scale abdominal ultrasonography and computed tomography with contrast medium. According to their clinical situation, patients had surgical open, laparoscopic intervention or were managed conservatively. The short- and long-term outcome of the open and laparoscopic techniques were evaluated.

RESULTS

Twenty-six (11%) patients presented with adrenal cysts; the mean (sd, range) age at the time of presentation for adults was 41.4 (15, 17-82) years, while a 1-month female neonate and 1-year-old boy presented with an adrenal cyst. The mean (sd, range) size of the cysts was 10 (3.5, 5-18) cm. Surgical intervention was the treatment of choice in 21 patients; 11 (42%) had open adrenalectomy, while 10 (38%) had laparoscopic intervention. Both groups were comparable in the term of cyst size and operative time, while the laparoscopically managed group had a shorter hospital stay. Five patients were followed with no surgical intervention. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. Compared with open techniques it has the advantages of a shorter hospital stay, less blood loss and enhanced cosmesis. Unlike aspiration of cyst contents, the recurrence of adrenal cysts after surgical removal is unlikely.

Diagnostic dilemma of adrenal enlargement after acute pancreatitis

A case is presented illustrating the diagnostic dilemma of adrenal enlargement following acute pancreatitis.

Neonatal adrenal hemorrhage presenting as a multiloculated cystic mass

Neonatal adrenal hemorrhage presenting as an abdominal mass in the newborn is not uncommon. However, judging the nature of a suprarenal mass is sometimes difficult, especially when the structure is more complex with unusual clinical course. We report a male newborn with neonatal adrenal hemorrhage presenting as a multiloculated cystic mass. The margins between the mass and left kidney were indistinct. All laboratory data including complete blood cell count, serum electrolytes, liver function, renal function, blood sugar, alpha-fetoprotein, beta-human chorionic gonadotropin, urinalysis, and 24-hour urine vanillylmandelic acid were within normal limits. Serial sonographic follow-up revealed failure to decrease in size without change in echogenicity. Surgical exploration was performed to exclude the possibility of malignancy. This case highlights the diagnostic problems that arise when a space-occupying lesion is found near or at the adrenal gland in the neonate. We suggest that early surgical intervention for the suprarenal mass without sufficient evidence of malignancy would not be prudent.

Acute adrenal insufficiency associated with heparin-induced thrombocytopenia

Although the thrombotic risk of heparin-induced thrombocytopaenia (HIT) is well recognized and may affect any vascular bed, the involvement of adrenal veins has been less commonly described. We report the case of a 86-year-old woman who developed bilateral massive adrenal haematoma associated with HIT, resulting in acute adrenal insufficiency. After immediate discontinuation of heparin and starting therapy with danaparoid and hydrocortisone, the clinical evolution was favourable, although adrenal failure was irreversible. When abdominal pain, hypotension and fever occur during heparin therapy, associated with a drop in platelet count, acute adrenal insufficiency secondary to HIT should be considered, as early diagnosis is essential for the treatment of this life-threatening complication.

Adrenal insufficiency after laparoscopic hysterectomy in a patient with primary antiphospholipid syndrome

BACKGROUND

We report a case of bilateral adrenal hemorrhage and subsequent adrenal insufficiency after a laparoscopic hysterectomy in a patient with anticardiolipin antibody syndrome.

CASE

A 55-year-old woman with a history of anticardiolipin antibody syndrome presented with nausea and vomiting 1 week after laparoscopic hysterectomy and staging for endometrial adenocarcinoma. Based on a diagnosis of adrenal insufficiency, the patient was started on oral hydrocortisone 20 mg in the morning and 10 mg in the afternoon, and fludrocortisone 0.05 mg twice daily on day 5. Her symptoms resolved completely within 24 hours of beginning steroids.

CONCLUSION

The diagnosis of adrenal insufficiency should be entertained in any patient with a history of thrombophilias presenting with general abdominal complaints.

F, Mattedi RL, Lucon AM, Leite CDC, Cerri GG. Avaliação por ressonância magnética dos tumores de adrenal com correlação histológica

A ressonância magnética é ferramenta importante para a detecção e caracterização dos tumores adrenais. O conhecimento das diferentes apresentações dos tumores primários e secundários à ressonância magnética e sua correlação com dados da histologia são essenciais para o correto raciocínio diagnóstico. Este artigo revisa os aspectos que podem estreitar o diagnóstico diferencial dos tumores adrenais, dando ênfase à correlação histológica daqueles mais comuns.

Incidental Finding of a Large Cystic Mass in the Left Upper Quadrant

Solitary cystic masses are less common in the middle-aged than in the elderly patient group. A woman in her mid-30s presented with a history of mild hypertension that had been treated for the past 3 months. An abdominal sonogram was performed, which revealed a large cystic mass in the left upper quadrant between the spleen, pancreatic tail, and left kidney. The differentials included cortical cyst of left kidney, pancreatic pseudocyst, and splenic and adrenal cyst. A computed tomography scan was ordered to help determine the origin of this cyst, which narrowed the differential to adrenal cyst or pancreatic pseudocyst. Lab findings, such as serum amylase, serum lipase, and urinary catecholamines, were unremarkable. Fine-needle aspiration of the cyst under sonographic guidance did not reveal any malignancy or pancreatic enzymes; therefore, clinicians assumed it was adrenal in origin.

Spontaneous retroperitoneal hemorrhage from adrenal artery aneurysm

Spontaneous adrenal hemorrhage is a very rare but serious disorder of the adrenal gland that can require emergent treatment. We report on a 42-year-old man who underwent selective angiography for diagnosis and treatment of retroperitoneal hemorrhage from small adrenal artery aneurysm. This case gives further details about the value of transluminal artery embolization in the management of visceral aneurysm rupture.