Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic c
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REVIEW
Can we differentiate neoplastic and non‑neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation Ali Devrim Karaosmanoglu1 · Aycan Uysal2 · Sevtap Arslan1 · Cenk Sokmensuer3 · Canberk Leblebici3 · Deniz Akata1 · Mustafa Nasuh Ozmen1 · Musturay Karcaaltincaba1 Received: 10 July 2020 / Revised: 24 August 2020 / Accepted: 3 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.
Introduction
Pathophysiology
Non-traumatic bleeding in the adrenal glands is a rare clinical event and diagnosis may be difficult due to non-specific nature of the symptoms. Early diagnosis and intervention are critical as fatality rate has been reported to be as high as 16% to 50% due to life-threatening adrenal insufficiency [1, 2]. Historically, ante mortem diagnosis was rare due to non-specific nature of the process, however with the ever expanding use of cross-sectional imaging the diagnosis may be frequently made before death in current practice [3]. Vomiting, hypotension, flank pain, low-grade fever, agitation, and abdominal pain have been reported as common presenting symptoms [4]. Medullar portion is usually the source of the bleeding [5].
Adrenal glands may be particularly vulnerable to bleeding due to their unique circulation. There are around 50–60 small arteries that supply each adrenal gland and these vessels originate from inferior phrenic artery, the renal artery, and the aorta. The subcapsular plexus of the adrenal cortex is mainly supplied by these vessels and this plexus subsequently drains into few veins at the corticomedullary junction. This anatomic phenomenon is called as the “vascular dam” [6]. In addition to this anatomic challenge, the draining single adrenal vein has thick longitudinal muscle bundles in their walls which creates even more resistance to the venous outflow of the gland [4]. Based on the aforementioned uniqueness of the adrenal circulation, any clinical condition that results in increased arterial and venous circulation in the adrenal vessels may result in hemorrhage [4]. In case of systemic hypotension and decreased arterial inflow, reperfusion injury after restoration of arterial pressure may also cause adrenal bleeding [7]. The innate propensity of the adrenal vein to form platelet
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