adrenal haemorrhage

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Adrenal Haemorrhage By Andrew McGovern Image: Underwood (2006) e use of different imaging methods in:

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Adrenal Haemorrhage. The use of different imaging methods in:. By Andrew McGovern. Image: Underwood (2006). Introduction. PART 1. Adrenal haemorrhage: An overview Pathophysiology PART 2. Imaging in adrenal haemorrhage: Different imaging possibilities - PowerPoint PPT Presentation

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Page 1: Adrenal Haemorrhage

Adrenal Haemorrhage

By Andrew McGovern

Image: Underwood (2006)

The use of different imaging methods in:

Page 2: Adrenal Haemorrhage

Introduction

PART 1. Adrenal haemorrhage:• An overview• Pathophysiology

PART 2. Imaging in adrenal haemorrhage:

• Different imaging possibilities• Positive and negative aspects of each

type• Image examples

Page 3: Adrenal Haemorrhage

What is adrenal haemorrhage?• Uncommon, usually presents as bilateral

haemorrhage. (Light, 2006)

• Can occur at any age. (Light, 2006)

• Extensive necrosis of all three cortical layers and medulla. (Tritos, 2007)

• Can cause volume lossand shock in infantsand acute adrenalinsufficiency unlessrecognised andtreated properly.(Light, 2006)

Adrenal haemorrhage at autopsy Image: Underwood

(2004)

Page 4: Adrenal Haemorrhage

PathophysiologyCauses of adrenal haemorrhage:• Coagulopathies: causing thrombosis in

renal and adrenal veins.

• Waterhouse-Friderichsen syndrome: in children and young adults (occurring in 20% of meningitis cases).

• Trauma: found in 28% of severe trauma cases autopsy. (Sevitt, 1955)

• Asphyxia: in neonates – at birth the adrenal gland is very large and vascular.

• Also associated with adrenal tumours. (Light, 2006)

Page 5: Adrenal Haemorrhage

Imaging: Computed tomographyCT scanning is the preferred method for

identifying adrenal haemorrhage in all patients over 6 months old.

CT is rapid, widely available and accurate in diagnosis.

• Useful for the identification of an underlying neoplasm, tumour or large thrombosis.

• Allows examination of the adrenal glands in trauma patients with other imaging indications.

Adrenal haemorrhage is detected as a round or oval mass obliterating the normal chevron shape of the adrenal gland. (Light, 2006)

Page 6: Adrenal Haemorrhage

Imaging: Computed tomographyCT of normal adrenals several

months before the onset of haemorrhage.

CT two weeks after the onset of an acute haemorrhage.

Images excerpted from: Rao et al. (1989)

Page 7: Adrenal Haemorrhage

Imaging: Computed tomography

CT of acute bilateral haemorrhage. Image: Hentel (2008)

Page 8: Adrenal Haemorrhage

Imaging: Magnetic ResonanceIn general MRI identifies adrenal

abnormalities at a rate which is comparable to CT.

• Not as widely available as CT.• May be preferable in younger people due to CT

radiation risk:– 1 fatal cancer per 2000 scans. (FDA, 2007)

– 20% increased lifetime cancer mortality risk. (FDA, 2007)

– 5 fatal cancers per 6000 scans in under 15s.– May account for up to 2% of cancers in the US.

(Brenner, 2007)

• Evidence for these studies is 25,000 survivors of Hiroshima bombing. Not directly comparable?

(BRER, 2006)

Page 9: Adrenal Haemorrhage

Imaging: Magnetic Resonance

T1 weighted MRI displaying right adrenal infarction without haemorrhage, in a 42-year-old man with anti phospholipid syndrome. Image: Riddell and Khalili (2004)

Page 10: Adrenal Haemorrhage

Imaging: UltrasoundUS is the standard in neonates for

imaging adrenal masses.

• It is sensitive for enlargements of the adrenal glands.

• Can differentiate between causes of adrenal mass.

• Echogenicity is variable with the age of the haemotoma – can estimate age.

• Widely available.

• No ionising radiation.

• But US is operator dependant. (Light, 2006)

Page 11: Adrenal Haemorrhage

Imaging: Ultrasound

An adrenal haemorrhage as seen on ultrasound.Image: Hentel

(2008)

Page 12: Adrenal Haemorrhage

Imaging: Ultrasound

An adrenal haemorrhage as seen with Doppler ultrasound. This enables the avascular nature of the mass to be identified. Image: Hentel (2008)

Page 13: Adrenal Haemorrhage

Imaging: UltrasoundAdrenal

haemorrhage in a foetus at 34 weeks gestation caused by a neuroblastoma.

Image: Trop and Levine (2001)

Page 14: Adrenal Haemorrhage

Imaging: Other modalitiesPlain radiographs: Acute adrenal

haemorrhage is rarely detectable. It may cause mass effect in the upper abdomen. (Light, 2006)

Image: Kawashima et al. (1999)

Page 15: Adrenal Haemorrhage

Imaging: Other modalitiesNuclear medicine studies: Of very

little use as the main contrast agents used are not taken up by haematoma or normal adrenal tissue. (Light, 2006)

Image: Kawashima et al. (1999)

Page 16: Adrenal Haemorrhage

Summary

• Adrenal haemorrhage is an uncommon but serious condition which causes adrenal insufficiency.

• CT is the diagnostic method of choice.

• MRI should be considered as an alternative in children.

• Ultrasound should be used in neonates.

Page 17: Adrenal Haemorrhage

ReferencesBRENNER, D. J. (2007) Computed Tomography — An Increasing Source of Radiation Exposure. the New England

Journal of Medicine, 357 pp. 2277-2284.

BRER (2006) Health risks from exposure to low levels of ionizing radiation — BEIR VII, 1st ed. Washington, DC: The National Academies Press.

FDA (2007) What are the Radiation Risks from CT? [online]. Available from: http://www.fda.gov/cdrh/ct/risks.html [accessed: 28 Feb 2008].

HENTEL, B. (2008) Adrenal hemorrhage [online]. Available from: http://www.radswiki.net/main/index.php?title=Adrenal_hemorrhage [accessed: 23 Feb 08].

KAWASHIMA, A., SANDLER, C. M., ERNST, R. D., TAKAHASHI, N., ROUBIDOUX, M. A., GOLDMAN, S. M. et al. (1999) Imaging of Nontraumatic Hemorrhage of the Adrenal Gland. RadioGraphics, 19 pp. 949-963.

LIGHT, D. (2006) Adrenal Hemorrhage [online]. Available from: http://www.emedicine.com/radio/topic15.htm [accessed: 23 Feb 2008].

RAO, R. H., VAGNUCCI, A. H. and AMICO, J. A. (1989) Bilateral massive adrenal hemorrhage: early recognition and treatment. Annals of Internal Medicine, 110 (3), pp. 227-235.

RIDDELL, A. M. and KHALILI, K. (2004) Sequential Adrenal Infarction Without MRI-Detectable Hemorrhage in Primary Antiphospholipid-Antibody Syndrome. American Journal of Roentgenology, 183 pp. 220-222.

SEWITT, S. (1995) Post-traumatic adrenal apoplexy. Journal of Clinical Pathology, 8 (3), pp. 184-194.

TRITOS, N. A. (2007) Adrenal Hemorrhage [online]. Available from: http://www.emedicine.com/MED/topic3009.htm [accessed: 28 Feb 2008].

TROP, I. and LEVINE, D. (2001) Hemorrhage During Pregnancy Sonography and MR Imaging. American Journal of Roentgenology, 176 pp. 607-615.

UNDERWOOD, J. C. E. (Ed.) (2004) General and Systemic Pathology, 4th ed. London: Churchill Livingstone.