AJR 2001; 177:357-358
© American Roentgen Ray Society
Inferior Vena Cava Thrombosis
A Mechanism of Posttraumatic Adrenal Hemorrhage
Clay R. Hinrichs1,
Amy Singer,
Pierre Maldjian,
Hani Abu-Judeh and
Aashish Dadarwala
1
All authors: Department of Radiology, University of Medicine and Dentistry,
University Hospital, C320, 150 Bergen St., Newark, NJ 07103-2406.
Received November 1, 2000;
accepted after revision January 30, 2001.
Address correspondence to C. R. Hinrichs.
Introduction
Posttraumatic adrenal hemorrhage is an uncommon finding on CT. In a series
of 1120 adult patients who underwent CT for blunt abdominal trauma, Burks et
al. [1] found adrenal
hemorrhage in 20 patients (2%). In the pediatric trauma population, Sivit et
al. [2] reviewed 1155 CT
examinations and found adrenal hemorrhage in 34 patients (3%). Approximately
85% of trauma-related adrenal hemorrhages occur in the right adrenal gland
[1,2,3,4].
In several cases found in the literature, inferior vena cava thrombosis was
seen concurrently with adrenal hemorrhage
[1,
5]. However, a cause-and-effect
relationship has not been clearly established. It was suggested that the
inferior vena cava thrombus and adrenal hemorrhage both result from direct
compression by adjacent organs
[1,
5]. In contrast, we present a
case in which inferior vena cava thrombus was detected in the suprarenal
inferior vena cava before an adrenal hemorrhage. Our case suggests that
outflow obstruction caused by traumatic inferior vena cava thrombosis may be a
mechanism of posttraumatic adrenal hemorrhage.
Case Report
A 45-year-old woman, who was an unrestrained passenger involved in a
collision with another vehicle, was brought to the emergency department. She
was ejected from her car and lost consciousness at the scene. Her vital signs
were blood pressure, 130 over 80 mm Hg; pulse, 100; respiration rate, 25/min;
and O2 saturation of room air, 85-90%. The initial trauma series
included a portable chest radiograph, and lateral cervical spine and pelvic
radiographs. The chest radiograph revealed bilateral pneumothoraces and a left
scapular fracture. After insertion of chest tubes bilaterally, the patient
underwent CT scans of the head, cervical spine, abdomen, and pelvis. All CT
examinations were performed on a Hi-Speed CT/i scanner (General Electric
Medical Systems, Milwaukee, WI). Body scanning was performed using 5-mm
collimation and a power injection of nonionic contrast medium (150 mL, 300
mg/mL, 1.5 mL/sec). The initial abdominopelvic CT revealed bilateral pleural
effusions, a filling defect in the inferior vena cava
(Fig. 1A), and pelvic
fractures.
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —45-year-old woman who was unrestrained front-seat passenger
involved in collision with another vehicle. Initial axial CT scan of abdomen
shows thrombus (arrow) in inferior vena cava and normal right adrenal
gland.
|
|
On further review of the trauma series, the radiologist identified left
first and second rib fractures. CT of the chest was then performed to evaluate
possible intrathoracic injury. This scanning process was completed
approximately 1 hr after the initial abdominopelvic CT. The images obtained
through the upper abdomen again revealed the filling defect in the inferior
vena cava (Fig. 1B) and a new
large round fluid collection in the right suprarenal area consistent with
interval formation of adrenal hemorrhage. The patient remained hemodynamically
stable throughout her hospitalization. No further workup was done for the
adrenal hemorrhage and inferior vena cava thrombus. The patient responded well
to treatment and was transferred to a nursing care facility for
rehabilitation.
View larger version (120K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —45-year-old woman who was unrestrained front-seat passenger
involved in collision with another vehicle. Axial CT scan obtained 1 hr after
A shows thrombus (arrow) inferior vena cava, with interval
formation of right adrenal hemorrhage (arrowhead).
|
|
Discussion
CT characteristics of adrenal hemorrhage have been well described in the
literature
[1,2,3,4].
Adrenal hemorrhage on CT usually appears as a round or oval well-delineated
mass, but occasionally the hemorrhage may be diffuse and irregular. Associated
findings include infiltration of the periadrenal fat and thickening of the
diaphragmatic crus. Adrenal hemorrhage is usually, but not always, associated
with other ipsilateral thoracoabdominal injuries such as rib and spine
fractures; pneumothoraces; lung contusions; and splenic, hepatic, and renal
injuries [5].
There are several hypotheses for the mechanism of adrenal hemorrhage
resulting from blunt abdominal trauma. One theory is that the injury is caused
by direct compression of the adrenal gland by the adjacent vertebra and
viscera
[1,2,3,4,5,6].
Another proposal is that sudden deceleration forces result in the rupture of
the small adrenal vessels, causing hemorrhage
[2,
3]. A third explanation is that
compression of the inferior vena cava from trauma causes an acute rise in
intraadrenal venous pressure, resulting in hemorrhage. This latter theory may
account for the much higher frequency of right adrenal hemorrhage because the
right adrenal vein drains directly into the inferior vena cava and is more
susceptible to sudden fluctuations in inferior vena cava pressure
[1,2,3,4,5,6].
A vascular cause may also be responsible for nontraumatic adrenal
hemorrhage in pediatric patients. The left adrenal gland is most frequently
affected in this population. It has been postulated that thrombosis of the
left renal vein, with secondary thrombosis of the adrenal vein, leads to
outflow obstruction and adrenal hemorrhage. Sonography has supported this
theory by showing echogenic inferior vena cava and renal vein thrombus in some
of these patients
[7,8,9].
Right and bilateral adrenal hemorrhages are uncommon in these patients unless
the thrombus extends into the inferior vena cava, in which it can obstruct
outflow from the right adrenal vein. We postulate a similar mechanism of
adrenal hemorrhage from outflow obstruction by inferior vena cava thrombus in
our patient.
Evidence for outflow tract obstruction causing adrenal infarction may also
be seen in patients undergoing adrenal venous hormone sampling. Catheter
placement in the small adrenal veins may result in stasis and venous
thrombosis, which has reportedly led to adrenal infarction. As a result,
systemic heparinization is administered to avoid adrenal vein thrombosis
[10].
In summary, we have discussed a case of posttraumatic adrenal hemorrhage in
which an initial CT scan showed an inferior vena cava thrombus with
normal-appearing adrenal glands. Approximately 1 hr later, a repeated study
showed right adrenal hemorrhage. This case suggests that outflow obstruction
from thrombus within the inferior vena cava may cause posttraumatic adrenal
hemorrhage.
References
-
Burks D, Mirvis S, Shanmuganathan K. Acute adrenal injury after
blunt abdominal trauma: CT findings. AJR
1992;158:503
-507[Abstract/Free Full Text]
-
Sivit C, Ingram J, Taylor G, et al. Posttraumatic adrenal
hemorrhage in children: CT findings in 34 patients.
AJR
1992;158:1299
-1302[Abstract/Free Full Text]
-
Murphy B, Casillas J, Yrizarry J. Traumatic adrenal hemorrhage:
radiologic findings. Radiology
1988;169:701
-703[Abstract/Free Full Text]
-
Wilms G, Marchal G, Baert A, et al. CT and ultrasound features of
post-traumatic adrenal hemorrhage. J Comput Assist
Tomogr 1987;11:112
-115[Medline]
-
Gomez R, McAninch J, Carroll P. Adrenal gland trauma: diagnosis and
management. J Trauma
1993;35:870
-874[Medline]
-
Scully R, Mark E, McNeely B. Case 38: case records of the
Massachusetts general hospital—weekly clinicopathological exercises.
N Engl J Med
1984;311:783
-790[Medline]
-
Orazi C, Fariello G, Malena S, et al. Renal vein thrombosis and
adrenal hemorrhage in the new-born: ultrasound evaluation of 4 cases.
J Clin Ultrasound
1993;21:163
-169[Medline]
-
Clark A, Saunders A, Bewick M, et al. Neonatal inferior vena cava
and renal venous thrombosis treated by thrombectomy and nephrectomy.
Arch Dis Child
1985;60:1076
-1077[Abstract/Free Full Text]
-
Cremin B, Davey H, Oleszczuk-Raxzke K. Neonatal renal venous
thrombosis: sequential ultrasonic appearances. Clin
Radiol 1991;44:52
-54[Medline]
-
Dunnick N, Doppman J, Gill J. Failure to ablate the adrenal gland
by injection of contrast material. Radiology
1982;142:67
-69[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. M. Firoved, G. F. Miller, M. Moayeri, R. Kakkar, Y. Shen, J. F. Wiggins, E. M. McNally, W.-J. Tang, and S. H. Leppla
Bacillus anthracis Edema Toxin Causes Extensive Tissue Lesions and Rapid Lethality in Mice
Am. J. Pathol.,
November 1, 2005;
167(5):
1309 - 1320.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Report
