503

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Acute Adrenal Injury After Blunt

Abdominal Trauma: CT Findings

..

Dawn W. Burks1 During a 32-month period, adrenal injuries were diagnosed in 20 (2%) of 1 120 patients
Stuart E. Mirvis1’2 who had abdominal CT for assessment of blunt force trauma. Injuries were unilateral in
17 patients (12 right-sided and five left-sided) and bilateral in three (23 total adrenal
K. Shanrnuganathan1’2
injuries) and were accompanied by concurrent ipsilateral thoracic or abdominal Injuries
in all but one patient. Nineteen (83%) of the adrenal injuries appeared as discrete round
to oval hematomas expanding the adrenal gland, as diffuse irregular
two (9%) appeared
hemorrhage obliterating the gland, and two appeared
as uniform swelling of the
(9%)
adrenal gland. Associated CT findings included “stranding” of the penadrenal fat caused
by blood in 14 cases (61%) and posterior pararenal hemorrhage mimicking a thickened
diaphragmatic crus in nine cases (39%). In general, these injuries had no significant
medical sequelae, but acute adrenal insufficiency developed in one patient with bilateral
lesions; in another patient with an adrenal hematoma compressing the inferior vena
cava, caval thrombosis developed. The potential for delayed bleeding or infection within
the hemorrhagic gland exists, but these did not occur in any of our patients.
Our experience indicates that adrenal injury resulting from blunt trauma is more
common than suggested by previous reports and emphasizes the importance of careful
inspection of the adrenal glands in patients in whom lower thoracic or upper abdominal
injuries are detected by CT.

AJR 158:503-507, March 1992

Adrenal injury caused by blunt abdominal trauma has been reported infrequently
in the radiologic literature; only eight patients with this injury were described in two
recent reports [1 2], suggesting that this is a rare injury. At autopsy, adrenal injury
,

may be found in up to 28% of patients with significant abdominal trauma [3]. We

retrospectively reviewed all abdominal CT scans obtained at our trauma center
during a 32-month period for the evaluation of possible intraabdominal injury to
identify patients with adrenal injury. The varied CT appearances of adrenal injury,
associated injuries, and postulated mechanisms of injury are described.

Materials and Methods

A computer data-base search of records of 1 1 20 patients who had abdominopelvic CT

within 48 hr of admission to detect injury from blunt trauma during a 32-month period (October
1989 through June 1 991) identified 20 patients (2%) with adrenal injury. These 20 patients
Received August 19, 1991; accepted after revi-
sion October 10, 1991. included 1 2 men and eight women 20-67 years old (mean, 43). The mechanism of injury

‘Department of Diagnostic Radiology, lkiiversity

included motor vehicle trauma (1 4), pedestrian-vehicle accident (three), falls (two), and crush
of Mar1and Medical Center, 22 S. Greene St., injury to the thorax (one). No patient included in the series had a history of anticoagulant
Baltimore, MO 21201. Address reprint requests to therapy, carcinoma, or clinical adrenal disorder. The patients’ initial presentation, hospital
S. E. Mirvis. course, and outcome were determined by review of medical charts and surgical and pathologic
2S’Trauma Center, University of Maryland reports.
Medical Center, Baltimore, MO 21201. All patients had abdominal CT scans within 6 hr after their traumatic event and subsequent

0361 -803X/92/1 583-0503 admission to the trauma center. CT scanning was performed on a Somatom Hi-Q unit
© American Roentgen Ray Society (Siemens Medical Systems, Iselin, NJ). In our institution, contrast-enhanced CT is performed
 504 BURKS ET AL. MR:158, March 1992

as follows: IV contrast material (60%) is administered by a CT power had round to oval masses replacing the normal gland archi-
injector. A bolus of 80 ml is given at a rate of 2 mI/sec, 70
and then tecture (Fig. 5).
ml is given at a rate of 0.5 mI/sec for a total of 150 ml. Rapid scanning,
2 soc or less, is used routinely. The abdomen is scanned from the
lower bases to the iliac crest at 1 -cm
lung intervals and then through Periadrenal Manifestations
the pelvis with 1 -cm sections every 2 cm.
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The diagnosis of acute adrenal injury was confirmed by surgery in The most common periadrenal findings included strandlike
three patients and by partial resolution of the injury on follow-up CT hemorrhage infiltrating the adjacent fat and/or more focal
scans in 1 4 patients. In three patients, the diagnosis was based on hematoma. These were identified in 14 (61 %) of 23 adrenal
the CT appearance and clinical setting only and was not proved by injuries (Figs. 2 and 5). In addition, hemorrhage in the posterior
follow-up CT or pathologic examination. Follow-up CT scans were pararenal space was seen in nine adrenal injuries (39%)
obtained 2-56 days after injury, depending on the patient’s clinical mimicking a thickened diaphragmatic crus (Figs. 1 -3). Other
status. All CT scans were reviewed for this study, and findings were
less commonly associated manifestations included anterior
determined by consensus. Information recorded from the CT scan
included the appearance of the adrenal gland and adjacent tissues
pararenal space hemorrhage (three), compression of the in-
and associated intra- or retropentoneal injuries. The appearance of fenor vena cava (IVC) (three) (Figs. 6-8), psoas muscle he-
the adrenal gland on follow-up CT studies was also noted when matoma (two), anterior thickening of Gerota’s fascia (two)
available. (Fig. 4), and anterior displacement of the kidney (one).

Results Follow-up CT Appearance

A total of 23 adrenal injuries were identified in 20 patients. Follow-up abdominal CT scans obtained in 14 patients 2-
Twelve adrenal injuries were right-sided, five were left-sided, 56 days after initial trauma showed various degrees of reso-
and three were bilateral. In 1 7 of the 20 patients, the adrenal lution of adrenal injury. Patients with a round hematoma or
injuries were diagnosed during the last 9 months of the study mass replacing the normal gland had a decrease in both the
period. size and attenuation of the hematoma or mass (Figs. 6 and
7). In one patient, the adrenal hemorrhage showed a slight
initial increase in size 2 days after injury, but a decrease in
CT Appearance of Adrenal Injury size was seen on later scans. In another patient in whom
Nineteen adrenal injuries (83%) were seen as discrete, adrenal injury was seen as a uniformly enlarged gland, follow-
round or oval masses or hematoma occupying the adrenal up CT showed partial resolution of the abnormality.
region (Figs. 1 and 2). Occasionally, the splayed adrenal limbs
were observed surrounding a central hematoma. In one pa-
Associated Injuries
tient with a CT finding of a central adrenal hematoma, a
suprarenal hematoma was identified at surgery. Two patients In 19 (95%) of the 20 patients, the adrenal injury was
(9%) had irregular, diffuse suprarenal hemorrhage occupying accompanied by ipsilateral thoracic, abdominal visceral, or
the adrenal region and obliterating the adrenal gland entirely; retropentoneal injury. The most notable intrathoracic injuries
in both patients, diffuse suprarenal hemorrhage and adrenal included ipsilateral rib fractures (1 2), atelectasis (1 2), hemo-
lacerations were documented surgically (Fig. 3). Two patients thorax (seven), pneumothorax (six), and lung parenchymal
(9%) had a uniformly enlarged adrenal gland with indistinct contusions (six). Intraabdominal and retroperitoneal injuries
margins (Fig. 4). All three patients with bilateral adrenal injury mostly involved the spleen (eight) (Figs. 4 and 8), kidney (six)

Fig. 1.-Adrenal hematoma. CT scan shows

ovoid mass replacing normal configuration of right
adrenal gland. Note that slightly hyperintense ad-
renal limbs are spread by lower attenuation central
hematoma. Hemorrhage into posterior pararenai
space tracks along diaphragm, mimicking a thick-
ened diaphragmatic crus (arrow). Hemorrhage cx-
tended caudad along right psoas muscle (not
shown).

Fig. 2.-Adrenal hematoma. CT scan shows

oval mass obscuring normal morphology of right
adrenal gland. Adrenal limbs appear slightly hy-
perintense relative to nonenhancing central he-
matoma. in addition, foci of Increased-density
hemorrhage are observed in periadrenal fat pos-
tenor to gland; hemorrhage in posterior pararenal
space mimics a thickened diaphragmatic crus. He-
moperitoneum is seen adjacent to spleen. Both
hepatic and splenic injuries were noted in this
patient.
 AJR:158, March 1992 CT OF POSTTRAUMATIC ADRENAL INJURY 505
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Fig. 3.-Extensive adrenal hemorrhage. CT Fig. 4.-Adrenal contusion. CT scan in 33- Fig. 5.-Bilateral adrenal hematomas. CT
scan reveals complete disruption of left adrenal year-old woman after a motor vehicle accident scan in a 35-year-old man after a motor vehicle
gland with replacement by an irregular hemor- reveals thickened, slightly indistinct left adrenal accident shows discrete oval bilateral central
rhagic mass (arrowheads). Right adrenal gland limbs. Right adrenalgland(not shown) appeared adrenal hematomas expandIng slIghtly denser
appears normal. Concurrent homorrhage in pos- normal. Gland maintains “adreniform” configu- adrenal limbs. Minimal strandilke hemorrhage
terior pararenal space mimics a thickened crus. ration. Image also shows blood tracking along Infiltrates fat posterlorto left adrenal gland. Lac-
Other major visceral injuries (not shown) included anterior Gerota’s fascia, producing apparent eration of liver was observed on a rostral image
transection of tail of pancreas, multiple splenic thickening and peripheral lateral splenic lacera- (not shown). No sequelae resulted from bilateral
lacerations, and renal contusions. A lacerated left hon. adrenal injury.
adrenal gland was found at surgery.

Fig. 6.-Resolution of adrenal hematoma with complicating inferior vena cava (IVC) thrombus in a 46-year-old man after a motor vehicle accident
A, CT scan reveals large ovoid mass replacing normal adrenal structure. Considerable compression of IVC (arrowhead) is observed.
B, CT scan 4 weeks later reveals consIderable decrease In size and attenuation of adrenal hematoma and less compressIon of IVC.
C, More caudal CT scan reveals thrombus In IVC that was confirmed by venography and treated by placement of IVC fIlter from above.

(Fig. 8), liver (five), and lumbar spine (five). Singles cases of a right-sided adrenal hematoma compressing the IVC. Follow-
pancreatic transection, gastric perforation, mesenteric con- up examination 1 week later showed persistent hematoma of
tusion, and ruptured hemidiaphragm were seen also. the right adrenal gland and persistent compression of the
IVC. Thrombus in the infrarenal IVC necessitated prophylactic
Cllnical Manifestations
placement of a Bird’s Nest filter (Fig. 6). In two additional
patients, IVC compression was caused by adrenal hematoma,
In two patients, significant complications developed that but venous thrombosis did not develop (Figs. 7 and 8).
could be related to adrenal injury. Most importantly, one of
the three patients with bilateral adrenal hemorrhage (Fig. 8)
Discussion
had evidence of acute adrenal insufficiency and showed dra-
matic clinical improvement after administration of corticoster- Traumatic adrenal hemorrhage was first described in 1863
oids. In another patient, the initial abdominal CT scan showed [4], but subsequently few cases have been reported. In 1955,
 506 BURKS ET AL. AJR:158, March 1992
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Fig. 7.-Traumatic adrenal hematoma vs preexisting neoplasm in a 45-year-old woman Fig. 8.-Bilateral adrenal injury resulting in acute
involved in a motor vehicle accIdent adrenal insufficlency in a 25-year-old man who was
A, InItial CT scan reveals mass In right adrenal gland. No other injury on right side of body struck by a car. CT scan shows bilateral injury of adrenal
and no ancillary findings of perladrenal hemorrhage were present to support a diagnosis of glands. Inferior vena cava is flat because of compres-
traumatic adrenal hematoma. Mass compresses inferior vena cava (IVC). sian from right adrenal hematoma and/or hypotension.
B, CT scan 8 weeks after A shows partial resolution of mass with decreased mass effect on Nonenhancing left upper renal pole is seen (posterior to
IVC, supporting a diagnosis of adrenal hematoma. Adrenal gland had a more normal form on adrenal gland). Splenic lacerations and posterior pole
other images. infarction are observed. At surgery, devascularization
of left kidney and avulsion of left renal vein were found.
Marked clinical improvement occurred after administra-
hon of corticosterolds, supporting a presumptive diag-
nosis of adrenal cortical insufficiency.

Sevitt [3] reported 14 cases in a series of 50 consecutive [3] that adrenal hemorrhage after blunt trauma arises centrally
autopsies performed in a trauma center, nearly doubling the within the gland, occupying a part or all of the medulla,
number of cases in the literature at that time. His study surrounded by a narrow, sometimes thinned and stretched
suggested that the prevalence of associated adrenal hemor- adrenal cortex.
rhage in patients with closed thoracoabdominal injuries was The two patients with more severe injuries had diffuse
much higher than indicated in previous reports. irregular hemorrhage replacing identifiable adrenal architec-
More recently, injury to the adrenal gland after blunt trauma ture. This appearance corresponded well to the surgical find-
has been diagnosed by CT scanning [1 2, 4]. Still, relatively
, ings of complete disruption or laceration of the gland with a
few cases of adrenal injury from blunt trauma found on CT large amount of hemorrhage into the periadrenal space. The
have been reported; only four patients were described in each mild to moderate uniform enlargement of the adrenal gland
of two reports [1 2]. , with slightly indistinct borders seen in two patients may
The higher frequency of adrenal injury after blunt trauma represent adrenal gland edema or adrenal contusion without
detected in our series may be the result of several factors: significant hemorrhage. Follow-up CT studies can distinguish
the increased use of CT scanning instead of peritoneal lavage traumatic adrenal swelling from adrenal hyperplasia by show-
for assessment of the peritoneal cavity, the use of CT in more ing an interval resolution to normal gland thickness.
severely injured patients because of its increased availability Among the 1 9 adrenal injuries seen as a discrete mass or
and speed, the better technical quality of CT scans produced hematoma, 14 (74%) had strands of high-density material
with more rapid scan times and power injection of IV contrast (hemorrhage) or more focal areas of hemorrhage in the per-
material, and the increased awareness of the potential for iadrenal fat. Sevitt [3] found that central adrenal hemorrhage
adrenal injury and greater scrutiny of the adrenal glands after stretched the cortex, frequently invaded it, and sometimes
trauma. We believe the last factor is most likely responsible resulted in focal cortical rupture, leading to hemorrhage or
for the increased recognition of this injury during the latter bruising of the penadrenal tissues. These observations may
part of our study period. explain the CT findings of strandlike hemorrhage infiltrating
We found a variety of CT manifestations of adrenal gland the penadrenal fat and more focal areas of hemorrhage in the
and periadrenal injury. Most patients (83%) had round or oval adjacent tissues. As noted in our series, thickening of the
hematomas occupying the adrenal area. In several cases, the diaphragmatic crus has been associated with traumatic ad-
splayed adrenal limbs could be visualized around the hema- renal injury [2]. This finding was observed in nine (39%) of 23
toma, particularly on follow-up CT examinations (Fig. 6). This adrenal injuries in our series. On close inspection, this abnor-
appearance supports the original autopsy findings of Sevitt mality actually appears to be due to hemorrhage in the
 AJR:158, March 1992 CT OF POSTTRAUMATIC ADRENAL INJURY 507

adjacent posterior pararenal space paralleling the diaphrag- blunt force injury play a key role in the development of
matic crus, thus mimicking a thickened crus. posttraumatic adrenal hemorrhage. The right adrenal gland is
Distinction between an adrenal mass resulting from blunt more prone to be damaged than the left one, possibly because
trauma and a preexisting, unsuspected adrenal mass has much of its anterior surface is closely opposed to the liver
obvious clinical implications. Although lack of history of anti- [6]; also, the right adrenal gland is more susceptible to high
venous pressures because its central vein drains directly into
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coagulant therapy, carcinoma, or adrenal disorder favors a

traumatic cause for an adrenal mass found in the setting of the IVC. These two factors may account for the higher
acute trauma, associated CT findings in the penadrenal soft prevalence of hemorrhage in the right adrenal gland, both in
tissues lend further support to a traumatic cause for such a our series and in previous reports [1 -3]. Severe stress related
mass. This is true particularly when strandlike hemorrhage to surgery, septicemia, burns, or hypotension is associated
infiltrating the fat or a thickened crus sign is identified. In fact, with bilateral massive adrenal hemorrhage that may lead to
the presence of these two associated periadrenal manifesta- acute adrenal insufficiency [5, 6]. Stress increases secretion
tions can be used to confidently diagnose adrenal hemorrhage of adrenocorticotropic hormone, leading to increased adrenal
in the setting of acute trauma. The only differential diagnostic blood flow and a rise in adrenal venous pressure, which in
problem involves distinguishing between hemorrhage into a turn may lead to venous hemorrhage [5].
preexisting tumor [1] and primary adrenal hemorrhage, but Fortunately, adrenal injuries have limited clinical signifi-
this can be adequately determined by follow-up CT scans cance, particularly when they are unilateral. Nevertheless, it
showing resolution of the adrenal mass. The presence of a is important to document these lesions, as they could be
discrete adrenal mass after blunt trauma, without associated sources of delayed hemorrhage, particularly in patients re-
CT findings of adrenal injury or concurrent ipsilateral nonad- ceiving anticoagulant prophylaxis for deep venous thrombo-
renal injuries, mandates follow-up CT to evaluate for potential sis, and possibly they should be considered a relative con-
neoplasm (Fig. 7). traindication to acute anticoagulation therapy. In addition,
In the recent radiologic literature, isolated adrenal injuries adrenal hematomas, as with any hematoma, should be con-
from blunt trauma were described in two series [1 2] of four
, sidered as a source of possible infection in posttraumatic
patients each. In our experience, which correlates more sepsis, although this complication did not occur in the current
closely with the autopsy findings of Sevitt [3], adrenal injury series. Patients with adrenal hematomas that significantly
was associated with ipsilateral thoracic, abdominal, or retro- compress the IVC may be at increased risk for formation of
peritoneal injury in 95% of cases. Thus, careful inspection of IVC thrombus due to slowed venous flow, as occurred in one
the ipsilateral adrenal gland is warranted when significant of our patients. Patients with posttraumatic adrenal hemor-
injury of adjacent structures is present, particularly in the rhage bilaterally are at increased risk for development of acute
lower chest, liver, spleen, and kidneys. The discrepancy be- adrenal insufficiency [6-8], as occurred in one of three pa-
tween the findings in our series and those in the recent tients in our series, and should be closely monitored for this
literature may reflect differences in the referral of patients; complication.
most patients referred to our institution have major multisys-
tern injuries.
REFERENCES
The exact mechanism of adrenal injury after blunt trauma
is unclear. Adrenal blood vessels are vulnerable to hemor- 1. Wilms G, Marchal G, Beart A, Adisoejoso B, Mangkuwerdojo S. CT and
rhage [5]. Three or more suprarenal arteries pass through the ultrasound features of post-traumatic adrenal hemorrhage. J compt Assist
Tomogr 1987;11:112-115
adrenal capsule, divide into a sinusoidal network within the
2. Murphy J, Casillas J, Yrizarry J. Traumatic adrenal hemorrhage: radiologic
Cortex, and drain via a single central vein. The central vein findings. Radiology 1988;169:701-703
empties directly into the IVC on the right and the renal vein 3. Sevitt S. Post-traumatic adrenal apoplexy. J cl/n Pathol 1955;8: 185-194
on the left [3]. Pathologic studies show that adrenal hemor- 4. Scully RE, Mark EJ, McNeely BU. Case 38, case records of the Massa-
rhage occurs in the spongy medulla and loosely textured chusetts General Hospital: weekly clinicopathological exercises. N EngI J
Med 1984;31 1:783-790
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mainly sinusoids and venules [3]. Sudden compression and early recognition and treatment. Ann Intern Med 1989;110:227-235
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ture these vessels and produce hemorrhage [3]. Alternatively, acute adrenal insufficiency in the adult. AiR 1985;142:311-314
7. Swift 0, Overholt E, Travelli R. Methods of diagnosis of acute adrenal
central adrenal hemorrhage may follow an acute rise of in-
hemorrhage complicating anticoagulant therapy-abdominal CT scanning.
traadrenal venous pressure caused by sudden and severe Wis Med J 1981;80:25-28
compression of the IVC during abdominal compression [3]. 8. Ling 0, Korobkin M, Silverman PM, Ounnick NR. CT demonstration of
Both theories suggest that compressive effects of severe bilateral adrenal hemorrhage. AIR 1983;141 :307-308