661

Adrenal Hemorrhage in Abused

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Children: Imaging and Postmortem

Findings

Katherine Nimkin1 OBJECTIVE. Adrenal hemorrhage associated with child abuse has received little
Susan Teeger1 attention in published reports. We review imaging studies or pathologic findings of
Michael T. WaIIach2 adrenal hemorrhage in five cases of proved child abuse.
SUBJECTS AND METHODS. The imaging findings in three children with adrenal
John C. DuVally3
hemorrhage were analyzed retrospectively. All three had abdominal CT scans and
Melissa R. Spevak1
skeletal radiographs. One also had abdominal sonograms and MR images. The patho-
Paul K. Kleinman1 logic findings in two other abused children with adrenal hemorrhage who died of
head injuries were also studied. In all five cases, a history of trauma was not initially
known; child abuse was later confirmed.
RESULTS. Unilateral hemorrhage in the right adrenal gland was found in all patients.
Enhanced CT scans of the abdomen showed a low-attenuation, oval mass separating
the limbs of the adrenal gland. Sonograms in one case showed a small, heterogeneous
mass in the right adrenal gland. MR images obtained 3 weeks later showed an area of
high signal intensity within the right adrenal gland on both Ti- and T2-welghted
images, consistent with subacute hemorrhage. In both deceased children, autopsy
showed hemorrhage in the right adrenal gland, mainly within the medulla with some
extension beyond the capsule in one case. All five children had associated abdominal
visceral injuries or rib fractures or both, on the same side as the hemorrhage.
CONCLUSION. Imaging findings of adrenal hemorrhage are similar to those previ-
ously described in patients with accidental trauma. Pathologic sections of the gland
reveal predominantly medullary involvement with hemorrhage. The presence of adre-
nal hemorrhage in a child should prompt a search for other associated injuries and
raise the possibility of unsuspected trauma.

AJR i994;i62:66i-663

The imaging characteristics of adrenal hemorrhage in neonates and, more

recently, in children with accidental injuries have been well described [1]. Adrenal
hemorrhage associated with child abuse has received little attention in published
reports [2]. We present nadiologic or pathologic findings of adrenal hemorrhage in
five cases of proved child abuse.

Received September 20, 1993; accepted after Subjects and Methods

revision November 16, 1993.
1 Department of Radiology, University of Massa-
We retrospectively analyzed the features of adrenal hemorrhage noted on imaging studies of
three abused children. The children, all boys, were 4-36 months old (mean, 15 months). All three chil-
chusetts Medical Center, 55 Lake Ave., N.,
Worcester, MA 01 655. Address correspondence to dren had abdominal distension and skin bruises or lacerations. Contrast-enhanced abdominal CT
K. Nimkin. scans and skeletal radiographs were available for all three; one child also had abdominal sonograms

2Department of Radiology, Rhode Island Hospi- and MR images. In two children, CT findings were typical of adrenal hemorrhage; these cases were
tal, 593 Eddy St., Providence, RI 02903. not proved histoIogicaH In one child, findings were confirmed at laparotomy. In two other abused
3Department of Pathology, Sturdy Memorial children who died of head trauma, autopsy showed adrenal hemorrhage, which was studied histolog-
Hospital, 211 Park St., Attleboro, MA 02703. belly. History oftrauma was not initially evident in ailfive cases; abuse was proved later.
0361-803X/94/1 623-0661 Contrast-enhanced axial CT scans of contiguous 5-mm slices from the diaphragm through the
© American Roentgen Ray Society pubic symphysis were obtained. Contrast medium (iohexol, Omnipaque 240, Winthrop, New
 662 NIMKIN ETAL. AJA:162, March 1994

York) was administered IV at a dose of 1 mI,Ib (2.2 mVkg) body weight. liven and spleen separating the limbs of the adrenal gland (Fig.
Unenhanced axial Ti -weighted (600/20 [TRITE]), proton density- iA). The maximal dimension of the right adrenal gland on CT
weighted (2000/20), and T2-weighted (2000/80) spin-echo MR images scans was 2-3 cm. In one case, sonognams showed a small
were obtained on a 1 .5-T unit. A 3-mm slice thickness, a 256 xi28
heterogeneous mass in the night adrenal gland (Fig. i B). Both
acquisition matrix, and a 20- to 24-cm field of view were
two excitations,
Ti - and T2-weighted MR images (Figs. 1C and 1 D) obtained 3
used. Unenhanced coronal Ti -weighted images were also obtained.
weeks later showed an area of high signal intensity within the
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Sonograms were obtained with a 5.0-MHz linear-array transducer.

night adrenal gland, consistent with subacute hemorrhage.
Four children had rib fractures; these were on the same
Results side as the adrenal hemorrhage in two cases. The location
Unilateral hemorrhage of the right adrenal gland was found of the nib fractures was different in each case; anterior, lat-
in all patients. Contrast-enhanced CT scans of the abdomen eral, and posterior fractures were noted. Other associated
revealed an oval mass with decreased attenuation relative to findings included laceration of the liver (Fig. 2), renal contu-

Fig. 1 .-Right adrenal hemorrhage in a 4-

month-old boy with abdominal distension, skin
bruises, and lethargy. There was no known his-
tory of trauma; child abuse was later confirmed.
A, Contrast-enhanced CT scan shows mass
(arrow) with predominantly low density within
right adrenal gland.
B, Sagittal sonogram of right suprarenal
area shows a heterogeneous mass (arrows) in
right adrenal gland.
C and D, Ti-weighted (C) and T2-welghted
(D) MR images show a high-signal-intensity
mass (arrows) within right adrenal gland, con-
sistent with subacute hemorrhage. Perladre-
nal hemorrhage is also present.

Fig. 2.-Right adrenal hemorrhage with liver

laceration in a 1 6-month-old boy with vomiting,
diarrhea, and abdominal distension. Abuse
was later proved. Contrast-enhanced CT scan
of upper abdomen shows extensive laceration
of liver (arrowheads), perihepatic fluid, and
low-density mass splaying limbs of right adre-
nal gland (arrow).

Fig. 3.-Adrenal hemorrhage confined to

medulla of gland.Histologic section of right ad-
renal gland of 36-month-old boy who died of in-
flicted head trauma. Hemorrhage is confined to
medulla of gland (white arrow) with sparing of
cortex (black arrow).
 AJR:i62, March i994 ADRENAL HEMORRHAGE IN ABUSED CHILDREN 663

sion, mesenteric hemorrhage, and chylous ascites (proved children had no other evidence of abdominal visceral injury at
at laparotomy). Only one child had fractures of the long autopsy, despite the presence of multiple rib fractures. The
bones. Two children died of head trauma; hemorrhage of the second deceased child had small-bowel mesenteric
right adrenal gland was confirmed at autopsy. Fresh or sub- hematoma as the only other abdominal injury. Sivit et al. [1]
acute hemorrhage was noted mainly within the medulla of found that adrenal hemorrhage caused by trauma was usually,
the gland (Fig. 3), with some extension beyond the capsule but not always, associated with ipsilateral abdominal visceral
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in one case. One of these children showed no other evi- injury. Therefore, adrenal hemorrhage may be the only evi-
dence of abdominal visceral injury at autopsy. The other dence of previous abdominal trauma in some cases.
child had an associated mesentenic hematoma as the only An abused child may have abdominal visceral injury with-
other abdominal finding. out external signs of trauma or obvious clinical findings [iO].
Typical radiographic findings of child abuse may also be
absent [2]. Only one of these five patients had the typical
Discussion long-bone fractures seen in child abuse.
Proposed mechanisms of adrenal hemorrhage have In summary, adrenal hemorrhage can be seen in young
included direct trauma, an acute rise in intraadrenal venous children and is usually associated with ipsilateral visceral
pressure, and shearing of small vessels perforating the and skeletal injuries. The CT appearance of adrenal hemor-
adrenal capsule with deceleration forces [1 , 3]. It is likely that rhage in our cases is similar to that described in previous
the adrenal hemorrhage in these cases was associated with reports of accidental trauma. Pathologic data confirm the
blunt trauma to the gland. All five cases had ipsilateral rib predominant medullary location of the hemorrhage. In cases
fractures or associated visceral injuries or both. The possibil- of suspected abuse, the suprarenal area should be carefully
ity that a sudden rise in venous pressure was a factor in inspected on imaging studies. The presence of adrenal hem-
these cases cannot be excluded. The predominance of hem- orrhage in a child without a history of trauma should alert the
orrhage in the right adrenal gland is similar to the findings in radiologist to the possibility of inflicted injury.
other reports. This may be related to venous drainage of the
right adrenal gland directly into the inferior vena cava; sud-
ACKNOWLEDGMENTS
den increased pressure in the inferior vena cava would pref-
erentially affect the right adrenal gland [1 , 3, 4]. We thank Kathy Delongchamp for her assistance in manuscript
CT findings in all cases showed mainly low-attenuation preparation and Theodore J. Burke, Iowa City, IA, for the clinical
hemorrhage within the adrenal gland. Sivit et al. [1] described data and pathologic material in one case.
similar findings. Several reviews [3-8] of adrenal hemorrhage
in adults describe masses with relatively high attenuation
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