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Imaging of Nontraumatic Hemorrhage of the Adrenal Gland¹

¹ From the Departments of Radiology (A.K., C.M.S., R.D.E., N.T., S.M.G.) and Urology (C.M.S., S.M.G.), University of Texas–Houston Medical School; the Department of Radiology, Lyndon B. Johnson General Hospital, 5656 Kelley St, Houston, TX 77026 (A.K., C.M.S., R.D.E.); the Department of Radiology, University of Michigan Medical Center, Ann Arbor (M.A.R., N.R.D.); and the Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (E.K.F.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1997 RSNA scientific assembly. Received December 8, 1998; revision requested February 2, 1999, and received March 8; accepted March 11. Address reprint requests to A.K.

View larger version (191K): [in a new window]   Figure 1.  Adrenal hematoma in a 44-year-old man receiving coumarin for pulmonary emboli from deep venous thrombosis. Nonenhanced helical CT scan shows a large, hyperattenuating left adrenal mass, a finding consistent with acute hemorrhage.

View larger version (167K): [in a new window]   Figure 2.  Adrenal hematoma in a 3-day-old boy. Transverse US scan shows a complex right suprarenal mass. The differential diagnosis of the US findings includes cystic neuroblastoma. MR images (not shown) demonstrated the signal intensity characteristics of a subacute hematoma.

View larger version (138K): [in a new window]   Figure 3a.  Adrenal hematoma in a 3-day-old girl with an abdominal mass. (a, b) Coronal T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/11) (a) and axial T2-weighted fast spin-echo MR image (3,000/108, echo train length of eight) (b) show a 3 x 4-cm suprarenal mass. The mass is isointense on the T1-weighted image (a) and hypointense on the T2-weighted image (b) with a hyperintense rim, findings consistent with acute to subacute hemorrhage. (c) Coronal T1-weighted spin-echo MR image (550/26) obtained 19 days later shows a decrease in the size of the mass, which is now hyperintense. The mass was also hyperintense on the T2-weighted image (not shown), findings consistent with the evolution of hemorrhage.

View larger version (140K): [in a new window]   Figure 3b.  Adrenal hematoma in a 3-day-old girl with an abdominal mass. (a, b) Coronal T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/11) (a) and axial T2-weighted fast spin-echo MR image (3,000/108, echo train length of eight) (b) show a 3 x 4-cm suprarenal mass. The mass is isointense on the T1-weighted image (a) and hypointense on the T2-weighted image (b) with a hyperintense rim, findings consistent with acute to subacute hemorrhage. (c) Coronal T1-weighted spin-echo MR image (550/26) obtained 19 days later shows a decrease in the size of the mass, which is now hyperintense. The mass was also hyperintense on the T2-weighted image (not shown), findings consistent with the evolution of hemorrhage.

View larger version (139K): [in a new window]   Figure 3c.  Adrenal hematoma in a 3-day-old girl with an abdominal mass. (a, b) Coronal T1-weighted spin-echo MR image (repetition time msec/echo time msec = 500/11) (a) and axial T2-weighted fast spin-echo MR image (3,000/108, echo train length of eight) (b) show a 3 x 4-cm suprarenal mass. The mass is isointense on the T1-weighted image (a) and hypointense on the T2-weighted image (b) with a hyperintense rim, findings consistent with acute to subacute hemorrhage. (c) Coronal T1-weighted spin-echo MR image (550/26) obtained 19 days later shows a decrease in the size of the mass, which is now hyperintense. The mass was also hyperintense on the T2-weighted image (not shown), findings consistent with the evolution of hemorrhage.

View larger version (132K): [in a new window]   Figure 4a.  Simultaneous adrenal hemorrhage and renal vein thrombosis in a 6-day-old girl with hyperbilirubinemia and hypertension whose mother had diabetes mellitus (class B). Bedside US scans (not shown) demonstrated a complex right suprarenal mass, a finding consistent with adrenal hemorrhage. (a) Tc-99m mercaptoacetyltriglycine scan (posterior view) shows a suprarenal area of decreased activity (arrow), a finding consistent with adrenal hemorrhage. There is only faint uptake in the right kidney. The left kidney (LK) is normal. (b) Coronal T2-weighted fast spin-echo MR image (2,200/112, echo train length of eight) shows a hyperintense mass of the right adrenal gland, a finding consistent with subacute hemorrhage. Note the high signal intensity of the right kidney, a finding consistent with acute and subacute hemorrhage. The right adrenal mass was hyperintense and the right kidney was isointense on a T1-weighted spin-echo MR image (500/14) (not shown).

View larger version (166K): [in a new window]   Figure 4b.  Simultaneous adrenal hemorrhage and renal vein thrombosis in a 6-day-old girl with hyperbilirubinemia and hypertension whose mother had diabetes mellitus (class B). Bedside US scans (not shown) demonstrated a complex right suprarenal mass, a finding consistent with adrenal hemorrhage. (a) Tc-99m mercaptoacetyltriglycine scan (posterior view) shows a suprarenal area of decreased activity (arrow), a finding consistent with adrenal hemorrhage. There is only faint uptake in the right kidney. The left kidney (LK) is normal. (b) Coronal T2-weighted fast spin-echo MR image (2,200/112, echo train length of eight) shows a hyperintense mass of the right adrenal gland, a finding consistent with subacute hemorrhage. Note the high signal intensity of the right kidney, a finding consistent with acute and subacute hemorrhage. The right adrenal mass was hyperintense and the right kidney was isointense on a T1-weighted spin-echo MR image (500/14) (not shown).

View larger version (119K): [in a new window]   Figure 5a.  Proved hemorrhagic pseudocyst in a 21-year-old woman who experienced blunt trauma 6 months earlier. (a) Excretory urogram shows inferior displacement of the right kidney. (b) Longitudinal US scan of the right kidney shows a complex, echogenic suprarenal mass. (c) Nonenhanced CT scan shows a right suprarenal mass containing a rounded area of increased attenuation (curved arrow). The intracystic clot mimics a mural nodule in a cystic tumor. A fluid-fluid level in the mass (straight arrow) is indicative of hemorrhage in the lesion.

View larger version (154K): [in a new window]   Figure 5b.  Proved hemorrhagic pseudocyst in a 21-year-old woman who experienced blunt trauma 6 months earlier. (a) Excretory urogram shows inferior displacement of the right kidney. (b) Longitudinal US scan of the right kidney shows a complex, echogenic suprarenal mass. (c) Nonenhanced CT scan shows a right suprarenal mass containing a rounded area of increased attenuation (curved arrow). The intracystic clot mimics a mural nodule in a cystic tumor. A fluid-fluid level in the mass (straight arrow) is indicative of hemorrhage in the lesion.

View larger version (111K): [in a new window]   Figure 5c.  Proved hemorrhagic pseudocyst in a 21-year-old woman who experienced blunt trauma 6 months earlier. (a) Excretory urogram shows inferior displacement of the right kidney. (b) Longitudinal US scan of the right kidney shows a complex, echogenic suprarenal mass. (c) Nonenhanced CT scan shows a right suprarenal mass containing a rounded area of increased attenuation (curved arrow). The intracystic clot mimics a mural nodule in a cystic tumor. A fluid-fluid level in the mass (straight arrow) is indicative of hemorrhage in the lesion.

View larger version (174K): [in a new window]   Figure 6.  Nontraumatic bleeding from a myelolipoma in a 65-year-old man. Enhanced CT scan shows a large mass (M) that contains areas of fat. Acute hemorrhage is present in and around the mass.

View larger version (157K): [in a new window]   Figure 7a.  Proved cavernous hemangioma in a 69-year-old man. (a) Enhanced helical CT scan obtained during the corticomedullary junction phase shows a left adrenal mass with peripheral nodular enhancement. (b) Delayed CT scan shows heterogeneous enhancement. (c) Axial T1-weighted spin-echo MR image (500/20) shows a right adrenal mass with a small, rounded area of high signal intensity (arrow), a finding consistent with subacute hemorrhage. (d) Axial T2-weighted spin-echo MR image (1,820/70) shows a heterogeneously hyperintense mass with a smaller focal area of low signal intensity (arrow). Note the large area of mixed low and high signal intensity within the mass laterally, a finding consistent with chronic hemorrhage. (Figs 7a-7d courtesy of Kotaro Yasumori, MD, and Toru Muranaka, MD, National Kyushu Medical Center Hospital, Fukuoka, Japan.)

View larger version (152K): [in a new window]   Figure 7b.  Proved cavernous hemangioma in a 69-year-old man. (a) Enhanced helical CT scan obtained during the corticomedullary junction phase shows a left adrenal mass with peripheral nodular enhancement. (b) Delayed CT scan shows heterogeneous enhancement. (c) Axial T1-weighted spin-echo MR image (500/20) shows a right adrenal mass with a small, rounded area of high signal intensity (arrow), a finding consistent with subacute hemorrhage. (d) Axial T2-weighted spin-echo MR image (1,820/70) shows a heterogeneously hyperintense mass with a smaller focal area of low signal intensity (arrow). Note the large area of mixed low and high signal intensity within the mass laterally, a finding consistent with chronic hemorrhage. (Figs 7a-7d courtesy of Kotaro Yasumori, MD, and Toru Muranaka, MD, National Kyushu Medical Center Hospital, Fukuoka, Japan.)

View larger version (142K): [in a new window]   Figure 7c.  Proved cavernous hemangioma in a 69-year-old man. (a) Enhanced helical CT scan obtained during the corticomedullary junction phase shows a left adrenal mass with peripheral nodular enhancement. (b) Delayed CT scan shows heterogeneous enhancement. (c) Axial T1-weighted spin-echo MR image (500/20) shows a right adrenal mass with a small, rounded area of high signal intensity (arrow), a finding consistent with subacute hemorrhage. (d) Axial T2-weighted spin-echo MR image (1,820/70) shows a heterogeneously hyperintense mass with a smaller focal area of low signal intensity (arrow). Note the large area of mixed low and high signal intensity within the mass laterally, a finding consistent with chronic hemorrhage. (Figs 7a-7d courtesy of Kotaro Yasumori, MD, and Toru Muranaka, MD, National Kyushu Medical Center Hospital, Fukuoka, Japan.)

View larger version (144K): [in a new window]   Figure 7d.  Proved cavernous hemangioma in a 69-year-old man. (a) Enhanced helical CT scan obtained during the corticomedullary junction phase shows a left adrenal mass with peripheral nodular enhancement. (b) Delayed CT scan shows heterogeneous enhancement. (c) Axial T1-weighted spin-echo MR image (500/20) shows a right adrenal mass with a small, rounded area of high signal intensity (arrow), a finding consistent with subacute hemorrhage. (d) Axial T2-weighted spin-echo MR image (1,820/70) shows a heterogeneously hyperintense mass with a smaller focal area of low signal intensity (arrow). Note the large area of mixed low and high signal intensity within the mass laterally, a finding consistent with chronic hemorrhage. (Figs 7a-7d courtesy of Kotaro Yasumori, MD, and Toru Muranaka, MD, National Kyushu Medical Center Hospital, Fukuoka, Japan.)

View larger version (165K): [in a new window]   Figure 8a.  Proved pheochromocytoma in a 37-year-old man with von Hippel-Lindau disease. (a) Enhanced CT scan shows a right adrenal mass. Note the area of low attenuation (arrow). (b) Axial T2-weighted spin-echo MR image (3,000/80) shows a hyperintense mass with an area of low signal intensity (arrow). This finding and demonstration of the blooming effect on a gradient-echo MR image (not shown) were consistent with hemosiderin.

View larger version (146K): [in a new window]   Figure 8b.  Proved pheochromocytoma in a 37-year-old man with von Hippel-Lindau disease. (a) Enhanced CT scan shows a right adrenal mass. Note the area of low attenuation (arrow). (b) Axial T2-weighted spin-echo MR image (3,000/80) shows a hyperintense mass with an area of low signal intensity (arrow). This finding and demonstration of the blooming effect on a gradient-echo MR image (not shown) were consistent with hemosiderin.

View larger version (152K): [in a new window]   Figure 9.  Proved adrenal adenoma with intratumoral hemorrhage in a 48-year-old woman. CT scan obtained after excretory urography shows a large cystic mass with a fluid-fluid level within it. Note the flecks of calcification in the wall (arrow).

View larger version (165K): [in a new window]   Figure 10a.  Hemorrhagic adrenal metastasis in a 60-year-old woman with acute onset of right flank pain and hemoptysis. (a) Nonenhanced helical CT scan through the right suprarenal region shows a large mass of mixed increased and decreased attenuation with high-attenuation stranding around the mass, findings consistent with hemorrhage. (b) Sagittally reformatted image generated from enhanced helical CT data shows the relationship of the right adrenal mass (M) to the right kidney and liver. Note the extension of the hemorrhage to the perinephric space around the upper pole of the right kidney. Chest radiographs and CT scans (not shown) revealed a lobulated mass in the right upper lobe of the lung. Percutaneous needle biopsy of the right adrenal mass yielded undifferentiated adenocarcinoma.

View larger version (187K): [in a new window]   Figure 10b.  Hemorrhagic adrenal metastasis in a 60-year-old woman with acute onset of right flank pain and hemoptysis. (a) Nonenhanced helical CT scan through the right suprarenal region shows a large mass of mixed increased and decreased attenuation with high-attenuation stranding around the mass, findings consistent with hemorrhage. (b) Sagittally reformatted image generated from enhanced helical CT data shows the relationship of the right adrenal mass (M) to the right kidney and liver. Note the extension of the hemorrhage to the perinephric space around the upper pole of the right kidney. Chest radiographs and CT scans (not shown) revealed a lobulated mass in the right upper lobe of the lung. Percutaneous needle biopsy of the right adrenal mass yielded undifferentiated adenocarcinoma.