Incidence, Presentation, and Natural History of Adrenal Hemorrhage

Abstract

INTRODUCTION: Adrenal hemorrhage (AH) occurring within a normal gland or an adrenal tumor can be indistinguishable on imaging. Guidelines regarding appropriate follow-up of AH are lacking. METHODS: We identified patients with AH found on chest, abdominal, or spinal CT at our tertiary medical center from January 1, 2006, to October 5, 2021, and performed a retrospective cohort analysis. Follow-up imaging of patients without documented resolution of hemorrhage underwent dedicated review by an attending radiologist for evidence of underlying mass. RESULTS: Of 490,301 scans, 550 (0.11%) had evidence of AH. Mean age of patients with AH was 36.8 years and 34.7% were women. Most scans (n = 493, 89.6%) were performed during trauma evaluation. Two patients underwent intervention at the time of presentation: 1 embolization and 1 aspiration of hemorrhagic cyst. Of 126 (22.9%) patients with follow-up imaging at our institution, 92 (73.0%) demonstrated resolution of hemorrhage and 19 (15.1%) showed decreased size at medians of 8.1 and 1.6 months after index scan, respectively. Ten patients (7.8%) had evidence of an adrenal mass, confirmed on follow-up imaging (n = 7) and/or at adrenalectomy (n = 3), with 1 adrenal cortical carcinoma confirmed on pathology. Nontrauma scans with AH were significantly more likely to have an underlying mass (n = 7/35 [20%] nontrauma vs n = 3/96 [3.1%] trauma, p < 0.01). CONCLUSION: AH is a rare finding on CT imaging that may indicate the presence of an underlying mass, particularly when unrelated to trauma. Interval imaging follow-up at 6 months to 1 year should be considered to assess for resolution of hemorrhage and exclude underlying mass.