Value of the CT “capsular sign” as a potential indicator of acute adrenal ischemia

Acute adrenal ischemia represents a rare cause of adrenal insufficiency which should be promptly diagnosed in order to preserve adrenal vitality and function. Our study aims to retrospectively evaluate the diagnostic accuracy of the CT capsular sign as an indicator of adrenal ischemia and its association with vascular involvement. Between January 2013 and January 2014, 69 consecutive patients (47 men, 22 women; mean age 46; range 22-67) with suspected adrenal insufficiency based on clinical and biochemical data underwent 320-row CT examination in our Emergency Department. Written informed consent was obtained for the CT examinations, and the institutional review board approval was obtained for our retrospective study. CT multi-planar images were retrospectively and independently analyzed by two radiologists searching for the patency of adrenal vessels, enlarged adrenals, the presence of the "capsular sign" represented by a peripheral subtle hyperdense line around a hypodense enlarged adrenal, and the presence of any periadrenal inflammatory changes. All CT findings were then compared with the surgical findings (n = 5), follow-up examinations (n = 20), or autopsy (n = 4). Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV), and negative predictive value (NPV) were calculated for the "capsular sign" and were further evaluated by ROC analysis. Acute adrenal ischemia occurred in 29/69 patients (42 %), unilateral in 20, and bilateral in 9. Forty of sixty-nine patients (58 %) had no evidence of adrenal disease on CT. Thrombosis of the main adrenal vein was found in 20/29 (69 %) and non-venous ischemia in 9/29 (31 %). The capsular sign was found in 24/29 patients (83 %). Sensitivity, specificity, DA, PPV, and NPV values of 83, 100, 93, 100, and 89 %, respectively, were obtained. The capsular sign represents a CT indicator of acute adrenal ischemia, with a specificity of 100 % and leading to a prompt diagnosis in the early phase of the disease

Isolated unilateral adrenal gland hemorrhage following motor vehicle collision: a case report and review of the literature

BACKGROUND: Adrenal gland trauma is a rare condition that typically stems from blunt force trauma, and is associated with multiple organ injuries. Alternatively, isolated adrenal gland trauma is extremely rare, accounting for only 1.5 to 4% of all adrenal trauma cases. While isolated adrenal trauma is a mostly self-limiting condition, it is potentially life-threatening, representing a significant cause of bleeding, and/or hypotension due to adrenal insufficiency and adrenal crisis. Due to its rare occurrence, there are no reported guidelines for monitoring and observing isolated adrenal trauma. CASE PRESENTATION: Here we report on an isolated adrenal hemorrhage from a blunt trauma without associated injuries. A 53-year-old white man presented with abdominal pain after a high-speed motor vehicle accident. An initial evaluation revealed minimal abdominal pain and negative focused assessment with sonography for trauma examination; computed tomography imaging revealed a significant fluid collection consistent with adrenal hemorrhage. He was observed in our intensive care unit for 24 hours, and had stable hemoglobin and vital signs, after which he was discharged. At 1-month follow-up, he reported persistent intermittent abdominal pain, which was completely resolved by the 4-month follow-up. CONCLUSIONS: This case report demonstrates isolated adrenal gland injury resulting from significant blunt trauma to the abdomen. There are no current guidelines for monitoring isolated adrenal hemorrhage. Recognizing possible adrenal injury in blunt trauma cases is important due to potentially severe adrenal hemorrhage; therefore, we recommend follow-up with serial abdominal computed tomography until the resolution of hemorrhage and symptoms

Imaging of the adrenal gland lesions

With the steep increase in the use of cross-sectional imaging in recent years, the incidentally detected adrenal lesion, or "incidentaloma", has become an increasingly common diagnostic problem for the radiologist, and a need for an approach to classifying these lesions as benign, malignant or indeterminate with imaging has spurred an explosion of research. While most incidentalomas represent benign disease, typically an adenoma, the possibility of malignant involvement of the adrenal gland necessitates a reliance on imaging to inform management decisions. In this article, we review the literature on adrenal gland imaging, with particular emphasis on computed tomography, magnetic resonance imaging, and photon-emission tomography, and discuss how these findings relate to clinical practice. Emerging technologies, such as contrast-enhanced ultrasonography, dual-energy computed tomography, and magnetic resonance spectroscopic imaging will also be briefly addressed