Postmortem Computed Tomography and Magnetic Resonance Imaging of an Abdominal Gunshot Wound.

The use of postmortem computed tomography (CT) has been described in many articles concerning gunshot injuries. Postmortem magnetic resonance imaging (MRI) for better assessment of soft tissue injuries has also been mentioned in the literature, albeit much less often. The use of postmortem MRI for abdominal gunshot wounds has not been previously presented in the literature. The present case report describes the findings of an abdominal gunshot wound detected by postmortem CT and MRI, followed by an autopsy. The main imaging findings on CT were a hyperdense ring at the entrance wound, which indicated the muzzle imprint mark, a hyperdense region beneath the skin, which was suggestive of combustion residue, gas cavities surrounding the bullet path, which might be related to the temporary cavity, and a fracture of the 13th rib on the left. Magnetic resonance imaging provided a clear depiction of defects in the muscle tissue and peritoneal fat, as well as an injury to the left kidney and a large volume of blood in the abdominal cavity. Computed tomography combined with MRI provided a descriptive presentation of the intracorporeal trajectory noninvasively. Autopsy confirmed the radiologic findings but additionally revealed further relevant findings, which were not detected radiologically, such as a duodenal perforation. Autopsy also detected subendocardial hemorrhages and shock kidney, which were consistent with severe blood loss.The imaging findings and their interpretations are discussed in this case report, as well as the role of CT and MRI in the assessment of abdominal gunshot wounds compared with autopsy.

Bilateral adrenal haemorrhage after a high energetic trauma: a case report and review of current literature.

Most adrenal injuries are asymptomatic. In traumatic events, adrenal haemorrhage is very likely to be accompanied by injuries to other organs. Isolated adrenal injury after trauma is very rare and mostly unilateral. We report a case of a 44-year-old male who suffered a major traffic accident with multiple trauma, including a bilateral adrenal haemorrhage. This caused a primary adrenal insufficiency, as proven with a cortisol stimulation test with synthetic corticotrophin. Bilateral adrenal haemorrhage is a very rare but potentially fatal disorder and should not be missed. This case illustrates that early diagnosis and prompt treatment with hydrocortisone may contribute to a beneficial outcome.

Adrenal gland injury due to gunshot.

Adrenal gland trauma is a rare phenomenon, due to the small size and retroperitoneal location of the organ. The majority of adrenal gland trauma is due to blunt force injury and is only rarely encountered due to the penetrating mechanisms. A 20-year-old male sustained a gunshot wound to the left abdomen. Upon exploration, he was found to have a through and through injury to the left adrenal gland, among other injuries. Injury to the adrenal gland due to penetrating trauma is exceptionally rare. The principles of management are to control bleeding from the gland with debridement and hemostasis rather than attempt to resect the entire organ. The management of a penetrating injury to the adrenal gland is straightforward and should not be a contributor to a patient's morbidity or mortality.

[Traumatic Adrenal Injury : A Single-Institution Experience].

Traumatic adrenal injury is quite rare. From January 2008 to March 2018, out of 287 patients with genitourinary trauma, 23 patients (8%) were diagnosed with traumatic adrenal injury at Kobe City Medical Center General Hospital. We retrospectively reviewed the medical records and assessed the traumatic category, image findings and outcome. All 23 patients were bluntly injured. The causes of traumatic adrenal injury were motor vehicle accident (11 patients : 48%) and falls (9 patients : 39%). The majority of injuries occurred on the right side (18 patients : 78%). Associated injuries occurred in all 23 patients, most frequently in the liver (57%) and ribs (57%). Extravasation of contrast materials was identified on computed tomography (CT) in 4 patients (17%). Although 22 patients (96%) were conservatively managed, only 1 patient was treated by transcatherter arterial embolization because of hypotension. One patient died of intraabdominal bleeding. To our knowledge, the present study is the largest on traumatic adrenal injury in Japan.

Adrenal Injuries: Historical Facts and Modern Truths.

BACKGROUND: Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors. METHODS: A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center's Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality. RESULTS: Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries. CONCLUSION: Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.

Adrenal gland trauma: is extravasation an absolute indication for intervention?

BACKGROUND: Adrenal gland trauma (AGT) is potentially devastating if unrecognized during the treatment of trauma patients. Because of the adrenal glands' rich vascularity, they often hemorrhage upon traumatic impact. However, there has been no conclusion about the indications for intervention in cases of hemorrhage after AGT. METHODS: We conducted a prospective collection with a retrospective review in a Level I trauma center in Taiwan. This study enrolled all of the patients who suffered from AGT from May 2008 to May 2013. We retrieved and analyzed the patient demographic data, clinical presentation, AGT grade, injury severity score, management, hospital stay, and mortality. RESULTS: The cohort consisted of 60 patients. The mean age was 31.0 ± 15.9 years. There were 32 patients (53.3 %) with extravasated AGT, which was associated with a high injury severity score, a high possibility of associated lung injury, and more than one accompanying trauma. Most of the patients could be treated conservatively. Five of these patients needed surgical hemostasis, and four of them needed angiographic embolization. Extravasation combined with a mean arterial pressure <70 mmHg was a predictor of the need for intervention (relative risk: 9.52, 95 % CI 1.64-55.56, p = 0.011). CONCLUSION: In conclusion, AGT is a rare injury with a good prognosis. Most AGT patients can be treated conservatively. Extravasation in AGT is not only a sign of hemorrhage, but also an indicator of severe associated injuries. However, extravasation in AGT does not always require further treatment. When intractable hypotension simultaneously occurs, further treatment should be considered.

Imaging of adrenal and renal hemorrhage.

Hemorrhage of the kidneys and adrenal glands has many etiologies. In the adrenal glands, trauma, anticoagulation, stress, sepsis, surgery, and neoplasms are common causes of hemorrhage. In the kidneys, reasons for hemorrhage include trauma, bleeding diathesis, vascular diseases, infection, infarction, hemorrhagic cyst rupture, the Antopol-Goldman lesion, and neoplasms. Angiomyolipoma and renal cell carcinoma are the neoplasms most commonly associated with hemorrhage in the kidneys and adrenal cortical carcinoma, metastases, and pheochromocytoma are associated with hemorrhage in the adrenal glands. Understanding the computed tomography and magnetic resonance imaging features, and causes of hemorrhage in the kidneys and adrenal glands is critical. It is also important to keep in mind that mimickers of hemorrhage exist, including lymphoma in both the kidneys and adrenal glands, and melanoma metastases in the adrenal glands. Appropriate imaging follow-up of renal and adrenal hemorrhage should occur to exclude an underlying malignancy as the cause. If there is suspicion for malignancy that cannot be definitively diagnosed on imaging, surgery or biopsy may be warranted. Angiography may be indicated when there is a suspected underlying vascular disease. Unnecessary intervention, such as nephrectomy, may be avoided in patients with benign causes or no underlying disease. Appropriate management is dependent on accurate diagnosis of the cause of renal or adrenal hemorrhage and it is incumbent upon the radiologist to determine the etiology.

Traumatic and non-traumatic adrenal emergencies.

Multiple traumatic and non-traumatic adrenal emergencies are occasionally encountered during the cross-sectional imaging of emergency department patients. Traumatic adrenal hematomas are markers of severe polytrauma, and can be easily overlooked due to multiple concomitant injuries. Patients with non-traumatic adrenal emergencies usually present to an emergency department with a non-specific clinical picture. The detection and management of adrenal emergencies is based on cross-sectional imaging. Adrenal hemorrhage, adrenal infection, or rupture of adrenal neoplasm require immediate detection to avoid dire consequences. More often however, adrenal emergencies are detected incidentally in patients being investigated for non-specific acute abdominal pain. A high index of suspicion is required for the establishment of timely diagnosis and to avert potentially life-threatening complications. We describe cross-sectional imaging findings in patients with traumatic and non-traumatic adrenal hemorrhage, adrenal infarctions, adrenal infections, and complications of adrenal masses.

Increased incidence of adrenal gland injury in blunt abdominal trauma: a computed tomography-based study from Pakistan.

OBJECTIVE: To determine the frequency of adrenal injuries in patients presenting with blunt abdominal trauma by computed tomography (CT). METHODS: During a 6 month period from January 1, 2011 to June 30, 2011, 82 emergency CT examinations were performed in the setting of major abdominal trauma and retrospectively reviewed for adrenal gland injuries. RESULTS: A total of 7 patients were identified as having adrenal gland injuries (6 males and 1 female). Two patients had isolated adrenal gland injuries. In the other 5 patients with nonisolated injuries, injuries to the liver (1 case), spleen (1 case), retroperitoneum (2 cases) and mesentery (4 cases) were identified. Overall 24 cases with liver injuries (29%), 11 cases with splenic injuries (13%), 54 cases with mesenteric injuries (65%), 14 cases (17%) with retroperitoneal injuries and 9 cases with renal injuries were identified. CONCLUSION: Adrenal gland injury is identified in 7 patients (11.7%) out of a total of 82 patients who underwent CT after major abdominal trauma. Most of these cases were nonisolated injuries. Our experience indicates that adrenal injury resulting from trauma is more common than suggested by other reports. The rise in incidence of adrenal injuries could be attributed to the mode of injury.

[Clinical characteristics of adrenal gland trauma].

OBJECTIVE: To explore the clinical characteristics of adrenal gland trauma. METHODS: A retrospective review was performed for 17 patients presenting with adrenal gland injury diagnosed by computed tomography (CT). There were 11 males and 6 females with an average age of 14-60 (38 ± 12) years. The injuries occurred as the consequence of motor vehicle crash (n = 13) and secondarily to a fall (n = 4). The average time from accident to admission was 5.0 ± 4.1 hours and the average injury severity score (ISS) 31.5 ± 10.3. Among 9 patients with throat injuries, there were pulmonary contusion, hematopneumothrax and rib fracture, followed by extremity fracture (n = 8) and pelvis fracture (n = 7). Additionally, 3 patients had injuries to vertebral column and 4 suffered closed cranial injury. There were 3 patients with liver injury, including subcapsular hematoma (n = 2) and laceration (n = 1). The urinary related injuries included renal contusion and laceration (n = 5) and urethral injury (n = 1). Among them, 15 had injuries to right adrenal glands and 2 to left ones. The CT findings of adrenal trauma were adrenal contusion and focal hematoma. All patients received conservative treatment. RESULTS: No patient died. The complications of urinary tract infection (n = 6) , deep vein thrombosis (n = 3), pneumonia (n = 3) and gastrointestinal ulceration (n = 2) improved with conservative treatment.Vital signs were all stable after 1 week treatment except for 1 patient operated for intracranial hematoma. The average follow-up period was 2.0- 12.0 (5.5 ± 2.7) weeks for 11 patients. The re-examination of CT showed a absorption of hematoma. And 2 cases had a complete absorption. CONCLUSIONS: Adrenal gland injury is rare and there is a right-sided preponderance.It is associated with high injury severity.For a lack of obvious clinical manifestations, missed diagnosis is frequently made. CT scan is the first-choice diagnostic tool for adrenal gland injury. Conservative treatment is often satisfactory and hormonal supplement unnecessary.

"Blunt adrenal injury does not affect outcomes in the pediatric population with isolated abdominal injury- a National Trauma Data Bank Review®."

BACKGROUND: The incidence of blunt abdominal injury (BAI) in the adult population has been estimated to be between 0.03% and 4.95%. However, the impact of BAI on the pediatric population remains unknown. METHODS: We conducted a retrospective review of National Trauma Data Bank datasets for the years 2017-2019. We included patients under the age of 18 who experienced blunt trauma and had suffered a blunt abdominal injury with an Abbreviated Injury Scale (AIS) severity score of 2 or higher. RESULTS: Out of the 8064 pediatric patients with isolated abdominal trauma, 134 patients also suffered from BAI. We found no difference in the outcomes of patients with blunt adrenal injury in terms of mortality, length of stay in the intensive care unit (ICU) and hospital, and the number of ventilator days. Within poly-trauma patients BAI was associated with worst patient outcomes. CONCLUSIONS: This study demonstrates that BAI has minimal clinical impact on patient outcomes in isolation. However it is associated with worst outcomes in poly trauma patients suggesting correlation with increased trauma burden. LEVEL OF EVIDENCE: III.

Adrenal artery embolization: anatomy, indications, and technical considerations.

OBJECTIVE: The purpose of this review is to describe adrenal arterial anatomy and to discuss the indications, outcomes, and technical considerations of adrenal artery embolization. CONCLUSION: Adrenal artery embolization can be used for management of adrenal tumors (palliative for pain relief, debulking, or hormone suppression) and treatment of acute bleeding from ruptured adrenal tumors, traumatic adrenal injury, and aneurysms. Variant arterial supplies, options for embolic agents, and potential complications are important considerations.

Adrenal trauma: medical and surgical emergency.

A 35-year-old man was admitted to hospital in a state of haemorrhagic shock after a road traffic accident. A right adrenal gland injury associated with a retroperitoneal haematoma was diagnosed by CT scan. Haemostatic surgery (without adrenal gland resection) was performed instead of angioembolisation because of an associated abdominal compartment syndrome. The outcome was favourable. The objective of this case report is to illustrate the importance of the early diagnosis of adrenal gland injuries after trauma which, though uncommon and frequently overlooked or discovered fortuitously by CT scan, can be life-threatening. Angioembolisation or surgery may be necessary in cases of uncontrolled bleeding or the development of abdominal compartmental syndrome.

Bedside ultrasound of acute adrenal hemorrhage.

Most complications from traumatic isolated adrenal hemorrhage are thought to be minor and do not require specific treatment. However, there are often additional intraabdominal organ injuries, such as liver and ipsilateral kidney, associated with adrenal injury. It is, therefore, important to identify these injuries as early as possible, preferably on initial assessment. We describe a case of a 43-year-old man who presented to the emergency department after sustaining blunt force trauma to the flank during a soccer match and was subsequently diagnosed with acute adrenal injury by use of bedside ultrasonography.

Imaging of traumatic adrenal injury.

Traumatic adrenal injury is a relatively rare event, reported in 0.15 to 4 % of blunt abdominal trauma cases. The location of the adrenal glands, protected deeply within the retroperitoneum, accounts for the rarity of adrenal trauma. These injuries are unilateral in 75 to 90 % of cases and most commonly afflict the right adrenal gland. While no specific clinical symptoms or signs point directly to adrenal injury, and isolated adrenal injury is rare, the presence of adrenal injury can be an indicator of severe trauma. In fact, mortality rates in series of adrenal injuries range from 7 to 32 %. The most common associated injuries affect the liver, ribs, kidney, or spleen. Three theories of adrenal injury from blunt trauma have been proposed: (1) acute rise in intra-adrenal venous pressure due to compression of the IVC during impact, (2) crushing between the spine and surrounding organs, and (3) deceleration forces shearing the small adrenal arterioles. The most common imaging features include a 2-3-cm oval hematoma, irregular hemorrhage obliterating the adrenal gland, periadrenal hemorrhage or fat stranding, and uniform adrenal swelling with increased attenuation. The differential diagnosis of adrenal abnormalities on trauma CT includes adenoma, carcinoma, myelolipoma, metastases, pheochromocytoma, and tuberculosis. Preexisting adrenal disorders can predispose the adrenal to injury with minor trauma. Most adrenal traumatic injuries are managed conservatively.

Adrenal injuries following blunt abdominal trauma in children: report of two cases.

Adrenal injuries following blunt abdominal trauma are uncommon. Adrenal hemorrhage in children associated with multiple organ injury, which has received little attention in the past, is an increasingly recognized phenomenon in modern trauma centers with the widespread use of abdominal computed tomography. Adrenal trauma occurs in the setting of multisystem organ injury. Isolated adrenal injury is exceedingly rare. We report two children with blunt adrenal trauma (one isolated and one with associated injuries), who were admitted during the last two years to our Pediatric Surgery Department after abdominal trauma. We determined the prevalence, management and general prognosis of blunt adrenal injury in the pediatric population. Traumatic adrenal hemorrhage appears to be an incidental and unsuspected finding that resolves on follow-up imaging.

Pediatric adrenal trauma in the 21st century: Children's Hospital of Atlanta experience.

PURPOSE: Adrenal trauma in children is rare and poorly characterized. To characterize these injuries better, we reviewed the contemporary experience at a large pediatric trauma center. MATERIALS AND METHODS: We queried the trauma registry of Children's Hospitals of Atlanta for all patients treated for adrenal trauma (ICD-9 codes 868.01 and 868.11) between January 1, 2000 and December 31, 2009. We performed a detailed chart review. RESULTS: Of 12,045 patients who were treated for trauma during the study period 42 children (0.35%) with adrenal injuries were identified. All injuries resulted from blunt trauma. Motor vehicle crash was the most common mechanism, responsible for 41% of injuries. A total of 41 cases (98%) were diagnosed by computerized tomography and 1 during exploratory laparotomy for associated vascular injury. Injuries were to the right adrenal gland in 36 cases (86%), left in 5 (12%) and bilateral in 1 (2%). The most common associated regions were the liver (55%), head or brain (33%) and skeleton (31%). Five patients (12%) experienced isolated adrenal injuries. One patient required treatment for adrenal insufficiency and none required adrenalectomy, adrenalorrhaphy or adrenal embolization. Of patients with isolated adrenal injuries 2 were hospitalized and 3 were treated as outpatients. All had an unremarkable course. CONCLUSIONS: Adrenal trauma in children is rare. Although typically associated with high morbidity, this outcome is likely from related injuries as an isolated adrenal injury generally portends a benign course.

Blunt adrenal gland injury: The impact of extra-abdominal injury.

BACKGROUND: Blunt adrenal gland injuries are considered uncommon. Moreover, the factors associated with the mechanisms of the injury following blunt trauma are unclear. In this study, we determined the factors associated with blunt adrenal gland injury (BAGI). MATERIALS AND METHODS: A total of 315 patients with blunt abdominal trauma were admitted to our institution during a 12-year period. After excluding 26 patients who were under 18 years old and 27 patients who were in cardiopulmonary arrest on arrival, 262 eligible patients were retrospectively reviewed. Patient characteristics, mechanism of injury, intervention, and associated organ injuries were compared between those with and without BAGI. RESULTS: Blunt adrenal gland injury was identified in 38 of 262 patients (14.5%). The right side was the predominant site of injury (68%). There were no differences in vital sign, in-hospital mortality, intervention, and concomitant abdominal organ injuries between those with and without adrenal gland injury. Patients with BAGI had a higher frequency of fall and motorcycle collision as mechanisms of injury. In addition, patients with BAGI had a higher injury severity score and a higher frequency of concomitant severe head, chest, and pelvic injuries. CONCLUSION: The results of the present study suggest that the deceleration injury leading to concomitant head, chest, or pelvic injuries with blunt abdominal trauma may be associated with the mechanism of BAGI. LEVEL OF EVIDENCE: Prognostic study, level IV.

Adrenal injury following blunt abdominal trauma.

BACKGROUND: Adrenal injury secondary to abdominal trauma is quite rare because the adrenal gland is located deep in the retroperitoneum and is well cushioned by surrounding soft tissues. This report presents our experiences of managing patients with adrenal injury following abdominal blunt trauma. METHODS: The medical records of 11 patients who had been treated for adrenal gland injury between January 1998 and June 2009 were retrospectively reviewed. RESULTS: Of the 11 patients, nine were male and two were female and the mean age was 31.5 years. The causes of trauma were motor vehicle accident (8 cases) and fall (3 cases). The majority of injuries occurred on the right side (8 cases), two were on the left side, and one patient had bilateral injury. Three cases presented as isolated adrenal gland injuries, and eight were combined with other internal organ injuries. The most common coinjured organ was the liver, followed by the kidney. The most useful diagnostic modality was computed tomography (CT). Ten cases were treated successfully using conservative management, while one required a left partial adrenalectomy and splenectomy due to active bleeding. CONCLUSIONS: Adrenal injury due to blunt abdominal trauma is extremely rare. The majority of cases can be diagnosed using CT. Most cases involve the right side and can be treated successfully using conservative management. Surgery is required only in cases of active bleeding.

Hemorrhagic adrenal myelolipoma after trauma to left adrenal gland: A case report.

Myelolipomas are rare benign tumors comprised of mature adipose tissue and hematopoietic elements. Adrenal myelolipomas associated with traumatic adrenal injury are relatively rare and less common on the left due to the limited size and well-protected position of the gland. A 59-year-old female admitted to the emergency department with intermittent left flank pain radiating to the left abdomen after falling from the bed six hours earlier. Her vital signs were stable, and she had tenderness over the left flank area and left abdomen. Her initial hemoglobin level was 12.9 g/dL. Bedside focused assessment with sonography for trauma revealed unclear left kidney margins. Contrast abdominal computed tomography (CT) revealed a space-occupying mass, 11.6×10.4×8.8 cm in dimension, in the left suprarenal region with active bleeding in the lower pole. Angiography did not reveal any active contrast medium extravasation. The CT-guided biopsy, was well performed concomitantly with angiography. Pathological assessment of the biopsy specimen revealed the presence of mostly adipose tissue with few erythrocytes and leukocytes. She was diagnosed with adrenal myelolipoma and admitted to the urology ward for left adrenalectomy with tumor resection. Traumatic adrenal injury, an unusual presentation of adrenal myelolipoma incidentally found in less than 5% of all abdominal blunt injuries, should be considered in cases of bleeding with trauma to the flank for prompt treatment.