1. Clinical Hook

A 39-year-old woman presented with acute generalized abdominal pain and vomiting. Her previous history included abdominal hernia surgery and a prior episode of intestinal obstruction, making an intra-abdominal surgical or gastrointestinal process an understandable initial consideration.

The CT examination, however, revealed something considerably more consequential: both adrenal glands were enlarged and heterogeneous, with abnormal changes in the surrounding fat.

That observation changes the clinical question.

The important question is no longer simply:

What is causing this patient's abdominal pain?

It becomes:

Could bilateral adrenal injury be causing or contributing to acute adrenal insufficiency?

This distinction matters because unilateral adrenal hemorrhage is often clinically silent or self-limited, whereas extensive bilateral adrenal injury can destroy sufficient cortical tissue to produce primary adrenal insufficiency and, in severe cases, adrenal crisis.

The supplied case illustrates a classic radiologic principle: an unexpected finding on an abdominal CT can become the most clinically important finding on the entire examination.

Bilateral adrenal hemorrhage is uncommon. In a 2024 Mayo Clinic series of 363 radiologically confirmed adrenal hemorrhage cases, 338 were unilateral and 25 were bilateral, corresponding to approximately 7% bilateral involvement. Bilateral disease was associated with substantially greater concern for coagulopathy and primary adrenal insufficiency.

For the radiologist, therefore, laterality is not a descriptive detail.

Laterality is a risk marker.

2. Learning Objectives

After reading this article, the reader should be able to:

Recognize the characteristic CT appearance of acute bilateral adrenal hemorrhage.
Understand why bilateral adrenal injury can cause acute primary adrenal insufficiency.
Distinguish hemorrhage from bilateral adrenal metastases, lymphoma, infection, and hemorrhagic adrenal tumors.
Understand the complementary roles of CT and MRI in characterizing adrenal hemorrhage.
Interpret interval imaging changes and distinguish resolving hematoma from persistent adrenal neoplasm.
Understand how radiologists can use AI-assisted imaging tools without allowing automated interpretation to replace clinical judgment.

3. Anatomy Review

The adrenal glands are paired retroperitoneal endocrine organs located superior to the kidneys.

Each gland consists of an outer cortex and an inner medulla.

The adrenal cortex produces glucocorticoids, mineralocorticoids, and adrenal androgens. The medulla produces catecholamines.

From an imaging perspective, the adrenal glands are relatively small structures, but their vascular anatomy is disproportionately complex. Multiple arterial branches supply each gland, while venous drainage is comparatively limited. This vascular arrangement has been proposed as one reason the adrenal glands may be vulnerable to venous congestion, thrombosis, ischemia, and hemorrhagic infarction during severe systemic stress or coagulation disorders.

This vascular physiology provides an important conceptual bridge between systemic disease and imaging.

A patient may have no direct abdominal trauma, yet develop bilateral adrenal hemorrhage because the initiating event is actually systemic.

Examples include:

sepsis,
disseminated intravascular coagulation,
heparin-induced thrombocytopenia,
antiphospholipid syndrome,
anticoagulation,
severe physiologic stress,
postoperative states,
vascular thrombosis,
and adrenal neoplasms.

Figure 1. Adrenal Anatomy and the Mechanism of Bilateral Hemorrhagic Injury

Schematic illustration of the bilateral adrenal glands demonstrating the adrenal cortex and medulla, rich arterial supply, venous drainage, and the proposed relationship between venous thrombosis, vascular congestion, ischemia, hemorrhagic infarction, and adrenal tissue destruction.

4. Case Presentation

History

A 39-year-old woman presented to the emergency department with approximately one day of generalized abdominal pain accompanied by vomiting. Her medical history included previous abdominal hernia surgery and intestinal obstruction.

The clinical presentation could easily direct attention toward gastrointestinal pathology.

The important radiologic lesson is that previous abdominal surgery can establish an initial diagnostic bias. A radiologist who concentrates exclusively on the bowel may overlook a subtle but clinically critical abnormality outside the gastrointestinal tract.

Symptoms

The dominant symptoms were:

acute abdominal pain,
nausea and vomiting,
systemic weakness,
and, depending on the clinical course, manifestations compatible with hemodynamic compromise.

Bilateral adrenal hemorrhage does not have a pathognomonic symptom complex. Abdominal, flank, or back pain may occur, but patients can also present with nonspecific weakness, fever, hypotension, dizziness, or shock.

Physical Examination

The supplied case emphasizes the abdominal presentation rather than providing a complete standardized physical examination dataset.

In clinical practice, however, blood pressure and volume status become particularly important once bilateral adrenal hemorrhage is identified.

A patient with bilateral adrenal injury should be assessed promptly for:

hypotension,
orthostatic symptoms,
dehydration,
altered mental status,
fever,
signs of shock,
and electrolyte abnormalities.

Clinical Question

The imaging question initially appears to be related to acute abdominal pain and vomiting.

After CT demonstrates bilateral adrenal enlargement, the clinical question must expand:

Is this hemorrhage, infarction, infection, infiltrative disease, or neoplasm—and is adrenal cortical function compromised?

5. Laboratory Evaluation

The case material emphasizes the need to connect imaging with endocrine evaluation rather than treating the adrenal abnormality as an isolated radiologic diagnosis.

When adrenal insufficiency is suspected, laboratory assessment should include appropriate evaluation of:

serum cortisol,
ACTH,
sodium,
potassium,
glucose,
renal function,
blood pressure and hemodynamic status,
and, when appropriate, renin and aldosterone.

The Endocrine Society recommends diagnostic testing for primary adrenal insufficiency in acutely ill patients with otherwise unexplained features such as volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain, or hypoglycemia. When adrenal crisis is suspected, treatment should not be delayed while waiting for diagnostic confirmation.

6. Final Diagnosis

The imaging pattern and clinical context support:

Bilateral adrenal hemorrhage with concern for adrenal insufficiency.

The key radiologic evidence consists of bilateral adrenal enlargement, heterogeneous internal appearance, and surrounding inflammatory fat changes, followed by interval reduction in adrenal size and surrounding abnormalities on follow-up CT.

7. Pathophysiology

Why Does Bilateral Adrenal Hemorrhage Occur?

The pathophysiology is more complex than simple vessel rupture.

A useful conceptual model is:

Systemic stress or hypercoagulability → adrenal venous congestion/thrombosis → microvascular ischemia → hemorrhagic infarction → adrenal tissue destruction → adrenal insufficiency.

This mechanism is particularly relevant in systemic thrombotic disorders.

Sepsis

Severe systemic infection can produce endothelial injury, coagulation activation, vascular dysfunction, and disseminated microthrombosis.

The classic association between meningococcemia and bilateral adrenal hemorrhage is Waterhouse–Friderichsen syndrome.

Heparin-Induced Thrombocytopenia

HIT is especially instructive because thrombocytopenia can paradoxically coexist with thrombosis.

PF4-heparin antibodies activate platelets and promote a profound prothrombotic state. Adrenal venous thrombosis and hemorrhagic infarction can subsequently occur.

Bilateral adrenal hemorrhage is a recognized, potentially catastrophic manifestation of HIT.

Antiphospholipid Syndrome

APS creates another mechanistic pathway.

Thrombosis involving the adrenal microvasculature can produce infarction followed by hemorrhage. In patients with otherwise unexplained bilateral adrenal injury, a systemic thrombotic disorder should therefore remain in the differential diagnosis.

Recent literature continues to emphasize the strong association between APS/SLE-spectrum disease, bilateral adrenal injury, adrenal hemorrhage, and adrenal insufficiency.

Anticoagulation

Anticoagulant therapy increases bleeding risk. The medication history is therefore an essential part of the imaging interpretation.

Tumor-Associated Hemorrhage

An adrenal tumor may bleed internally.

This creates a critical diagnostic trap:

The visible hematoma may not be the underlying disease.

A hemorrhagic adrenal mass can conceal pheochromocytoma, adrenocortical carcinoma, metastasis, or another neoplasm. Persistent enhancement, calcification, metabolic activity, or failure to regress should raise suspicion for an underlying mass.

Figure 2. Pathophysiologic Continuum of Bilateral Adrenal Hemorrhage

Diagram showing the progression from systemic stress or hypercoagulability through adrenal venous thrombosis and microvascular ischemia to hemorrhagic infarction, cortical destruction, cortisol/aldosterone deficiency, hypotension, electrolyte disturbance, and adrenal crisis.

8. Epidemiology

Adrenal hemorrhage is uncommon and heterogeneous.

The 2024 Mayo Clinic analysis provides one of the most useful contemporary datasets. Among 363 radiologically confirmed cases, approximately 93% were unilateral and 7% bilateral. Bilateral cases carried greater clinical concern for coagulation abnormalities and primary adrenal insufficiency.

Table 1. Epidemiologic and Clinical Profile of Adrenal Hemorrhage

Parameter	Clinical Interpretation
Overall frequency	Rare compared with other abdominal emergencies
Laterality	Predominantly unilateral
Bilateral involvement	Approximately 7% in a large 2024 series
Age	Broad range; depends on underlying etiology
Sex	No single dominant sex pattern
Major systemic risks	Sepsis, coagulopathy, HIT, APS, anticoagulation
Traumatic hemorrhage	Usually unilateral
Bilateral disease	Strong warning for adrenal insufficiency
Major endocrine complication	Primary adrenal insufficiency/adrenal crisis
Important radiologic issue	Exclude underlying neoplasm
Follow-up	Important to document interval evolution

The epidemiology also illustrates why bilateral adrenal enlargement should not be dismissed as an incidental finding.

9. Clinical Presentation and Red Flags

The symptoms are deceptively nonspecific.

Common manifestations include:

abdominal pain,
flank or back pain,
nausea,
vomiting,
fatigue,
weakness,
fever,
dizziness,
hypotension,
dehydration,
altered consciousness,
and shock.

The most important clinical combination is:

Abdominal pain + bilateral adrenal enlargement/hemorrhage + hypotension.

This should immediately raise concern for adrenal crisis.

Additional red flags include:

unexplained hyponatremia,
hyperkalemia,
hypoglycemia,
unexplained volume depletion,
recent heparin exposure,
known thrombosis,
APS,
severe infection,
anticoagulant use,
recent surgery,
or a known malignancy.

10. Imaging Features: The Core Radiology Discussion

Why CT Matters

CT is often performed first because the clinical presentation resembles other acute abdominal conditions.

The adrenal glands should therefore be consciously inspected even when the primary clinical concern is bowel obstruction, pancreatitis, biliary disease, or another abdominal emergency.

In acute adrenal hemorrhage, CT may demonstrate:

bilateral adrenal enlargement,
heterogeneous attenuation,
loss of the normal adrenal configuration,
periadrenal fat stranding,
hemorrhagic components,
altered enhancement,
vascular abnormalities,
and, on follow-up, reduction in adrenal size.

Figure 3. Initial Axial Contrast-Enhanced CT

Axial contrast-enhanced abdominal CT demonstrating bilateral adrenal enlargement with heterogeneous internal appearance and surrounding periadrenal inflammatory fat changes. The bilateral distribution is a critical diagnostic clue in the setting of acute abdominal symptoms.

Radiologist Interpretation:
The adrenal glands are bilaterally enlarged and morphologically abnormal. Their internal heterogeneity is compatible with hemorrhagic tissue change. Associated periadrenal fat stranding supports an acute inflammatory/hemorrhagic process rather than a stable incidental adrenal mass.

The key observation is not simply “enlarged adrenal glands.”

It is:

Acute bilateral adrenal enlargement with heterogeneous morphology and surrounding tissue reaction.

That pattern should prompt consideration of hemorrhage and hemorrhagic infarction.

The supplied case specifically emphasizes that bilateral adrenal enlargement with surrounding fat abnormalities should lead to consideration of bilateral adrenal hemorrhage.

11. Why the Bilateral Pattern Matters

An isolated adrenal hematoma can occur after trauma or local vascular injury.

Bilateral disease suggests a different biological process.

The radiologist should therefore ask:

Is there systemic coagulopathy?
Is the patient septic?
Has the patient received heparin?
Is there a history of thrombosis?
Is APS possible?
Is there anticoagulant use?
Is there an underlying adrenal tumor?
Is adrenal insufficiency clinically apparent?

This converts a descriptive imaging finding into a clinically actionable interpretation.

12. Coronal CT: The Importance of Multiplanar Evaluation

Figure 4. Coronal Contrast-Enhanced CT

Coronal contrast-enhanced CT demonstrates bilateral adrenal enlargement and surrounding periadrenal inflammatory change. Multiplanar comparison facilitates recognition of the bilateral distribution and provides a more global assessment of adrenal morphology.

Radiologist Interpretation:
Coronal reconstruction is particularly helpful because the adrenal glands are obliquely oriented structures. Comparing the right and left glands on the same plane improves recognition of symmetry, enlargement, contour distortion, and surrounding inflammatory change.

Multiplanar imaging is not merely a technical convenience.

It is a diagnostic safeguard.

13. CT Versus MRI

MRI becomes particularly useful when the patient is clinically stable, and the principal question shifts from emergency detection to characterization.

Blood products evolve over time as hemoglobin changes between oxyhemoglobin, deoxyhemoglobin, methemoglobin, and hemosiderin-containing stages.

This produces temporal changes in MRI signal.

A T1-hyperintense adrenal lesion in the appropriate clinical setting can strongly support hemorrhage. Acute and subacute hemorrhage can therefore acquire a characteristic MRI appearance, while chronic hemorrhage may evolve into a thin-walled pseudocyst or atrophic gland.

Multimodal Imaging Comparison

Modality	Strength	Limitation	Clinical Value
CT	Rapid, widely available, excellent acute abdominal survey	Radiation; hemorrhage age less precisely characterized	First-line emergency assessment
MRI	Superior tissue characterization and blood-product characterization	Less practical in unstable patients	Problem solving and follow-up characterization
T1 MRI	Detects blood-product-related high signal	Signal varies with hemorrhage age	Supports hemorrhage diagnosis
T2 MRI	Helps characterize tissue and blood products	Temporal evolution complicates interpretation	Complementary characterization
DWI/ADC	May provide tissue cellularity/infarction information	Not specific for hemorrhage	Adjunctive assessment
SWI/GRE	Sensitive to susceptibility from blood products	Not routinely necessary for every adrenal case	Useful when hemorrhagic products need confirmation
Contrast MRI	Evaluates enhancing residual tissue or tumor	Contrast considerations	Helps detect underlying neoplasm

14. The Most Important Follow-Up Finding

The one-month follow-up CT demonstrated a reduction in bilateral adrenal size and decreased surrounding tissue changes.

This is a powerful diagnostic clue.

A lesion that decreases in size after an acute event is behaving differently from a growing malignant mass.

Axial
Coronal

Figure 5. One-Month Follow-Up CT

Follow-up axial and coronal CT approximately one month after treatment demonstrating interval reduction in bilateral adrenal enlargement and decreased periadrenal inflammatory change, consistent with partial resolution of the hemorrhagic process.

Radiologist Interpretation:
There is interval reduction in adrenal enlargement and associated periadrenal inflammatory change. The temporal evolution supports resolving adrenal hemorrhage rather than progressive neoplastic disease.

However, one important caution must be emphasized:

Radiologic improvement does not automatically mean endocrine recovery.

The supplied case explicitly highlights this distinction. Imaging improvement should therefore be accompanied by appropriate endocrine assessment.

15. Hemorrhage Versus Adrenal Tumor

A hemorrhagic adrenal lesion can mimic a mass.

The radiologist should compare:

prior CT examinations,
lesion size,
enhancement,
calcification,
contour,
surrounding invasion,
PET metabolic activity when clinically appropriate,
hormonal function,
and interval evolution.

Acute hemorrhage can subsequently organize into a pseudomass. Chronic hemorrhage may leave a low-attenuation lesion or calcified pseudocyst.

Findings that should increase concern for an underlying tumor include:

persistent enhancing components,
nodular enhancement,
calcification in an unusual pattern,
persistent or enlarging mass,
hypermetabolism on PET,
a known primary malignancy,
or biochemical evidence of a functioning adrenal neoplasm.

The 2023 ESE guideline emphasizes individualized assessment of adrenal masses according to malignancy risk, hormone excess, imaging phenotype, patient characteristics, and clinical context.

16. Imaging Differential Diagnosis

Table 2. Differential Diagnosis of Bilateral Adrenal Enlargement

Diagnosis	CT	MRI	Pathologic/Clinical Clue	Major Differentiating Point
Bilateral adrenal hemorrhage	Enlarged, heterogeneous glands; periadrenal stranding	Variable signal; T1 hyperintensity may occur	Hemorrhage/infarction	Interval regression
Metastases	Bilateral masses, often enhancing	Variable	Known malignancy	Persistent/progressive disease
Lymphoma	Bilateral homogeneous enlargement	Restricted diffusion may occur	Lymphoid infiltration	Associated lymphadenopathy/systemic disease
Infection	Enlargement, inflammatory change, possible necrosis	Variable	Infection/inflammation	Clinical infectious context
Pheochromocytoma with hemorrhage	Hemorrhagic mass, enhancement	Variable blood products	Catecholamine excess	Enhancing residual tumor
Adrenocortical carcinoma with hemorrhage	Large heterogeneous mass	Necrosis/hemorrhage	Malignancy	Invasion/persistence
Traumatic hematoma	Usually unilateral	Blood-product evolution	Trauma	Clinical history
Adrenal infarction	Enlargement or altered enhancement	Variable	Ischemic injury	Vascular/thrombotic context

Bilateral adrenal masses should be evaluated systematically rather than automatically labeled as hemorrhage. A recent clinical review specifically emphasizes that bilateral adrenal masses encompass hemorrhage, metastases, lymphoma, pheochromocytoma, adenomas, myelolipomas, and other conditions.

17. Radiologist Reading Report

Findings

There is bilateral adrenal enlargement with heterogeneous internal attenuation and surrounding periadrenal inflammatory fat stranding. The bilateral distribution and acute clinical presentation are suspicious for bilateral adrenal hemorrhage/hemorrhagic infarction.

No definitive underlying enhancing adrenal neoplasm is identified on the available examination.

Clinical correlation for adrenal insufficiency is recommended, particularly if hypotension, electrolyte abnormalities, volume depletion, or systemic weakness is present.

Impression

Bilateral adrenal enlargement with heterogeneous appearance and surrounding inflammatory fat stranding, suspicious for bilateral adrenal hemorrhage.

Given bilateral adrenal involvement, prompt clinical assessment for adrenal insufficiency is recommended.

On follow-up imaging, interval decrease in bilateral adrenal enlargement and surrounding inflammatory change would support resolving adrenal hemorrhage.

18. Treatment Strategy

Treatment is determined by two parallel questions:

Is the patient hemodynamically stable?

and

Is adrenal insufficiency present or strongly suspected?

The treatment of bilateral adrenal hemorrhage is therefore not simply a surgical problem.

Glucocorticoid Replacement

When adrenal crisis is suspected, treatment should be initiated promptly.

The Endocrine Society recommends immediate parenteral hydrocortisone in suspected adrenal crisis rather than waiting for diagnostic confirmation. The guideline specifies an initial 100-mg IV hydrocortisone dose followed by approximately 200 mg over 24 hours, together with appropriate fluid resuscitation.

Mineralocorticoid Replacement

Patients with established primary adrenal insufficiency and aldosterone deficiency may require fludrocortisone during long-term management.

The supplied case reports treatment with hydrocortisone and fludrocortisone.

The clinical context matters: fludrocortisone is a treatment for mineralocorticoid deficiency in primary adrenal insufficiency, not a universal treatment for every form of adrenal insufficiency.

Fluid Resuscitation

Hypotension and volume depletion require prompt hemodynamic management.

Electrolytes and Glucose

Sodium, potassium, glucose, renal function, and acid-base status should be monitored.

Treat the Cause

The hemorrhage is an endpoint, not necessarily the primary disease.

The clinician must investigate:

HIT,
APS,
sepsis,
DIC,
anticoagulant-associated bleeding,
trauma,
postoperative states,
and adrenal neoplasia.

19. Does Adrenal Hemorrhage Require Surgery?

No.

“Adrenal hemorrhage = surgery” is an incorrect generalization.

Stable patients without uncontrolled hemorrhage can often be managed conservatively with appropriate endocrine and clinical support.

Interventional radiology or surgery may become necessary in selected circumstances, including:

active bleeding,
hemodynamic instability,
massive hemorrhage,
hemorrhagic shock,
suspected malignant tumor,
persistent or enlarging mass,
or deterioration despite conservative management.

Recent reviews similarly describe management ranging from observation to embolization and adrenalectomy according to hemodynamic stability, ongoing hemorrhage, and suspicion of malignancy.

20. Prognosis

The prognosis depends less on the mere presence of blood within the adrenal glands than on the extent of adrenal cortical destruction and the underlying cause.

Three factors are particularly important:

Early recognition
Rapid treatment of adrenal insufficiency
Identification and treatment of the underlying systemic disorder

Imaging may improve substantially over time. Some patients demonstrate complete or partial radiologic resolution, while others develop persistent adrenal atrophy or residual pseudocystic change.

Functional recovery is variable.

This creates an important distinction:

Radiologic recovery and endocrine recovery are not synonymous.

21. The Time Course of Adrenal Hemorrhage on Imaging

A useful radiologic model is:

Acute enlargement → heterogeneous hemorrhagic appearance → organization/resorption → size reduction → possible residual low-attenuation pseudomass or calcification.

The supplied case demonstrates this principle particularly well because the follow-up CT shows reduced adrenal size and decreased surrounding inflammatory changes.

A residual lesion should therefore not automatically be interpreted as recurrent tumor.

The critical diagnostic variable is trajectory.

22. Artificial Intelligence Perspective

AI could potentially improve recognition of adrenal hemorrhage, but this application illustrates why medical AI must be integrated into clinical workflow rather than treated as an autonomous diagnostic oracle.

Figure 6. AI-Assisted Bilateral Adrenal Hemorrhage Workflow

Conceptual enterprise AI workflow connecting CT acquisition, automated adrenal localization, bilateral comparison, segmentation, attenuation analysis, hemorrhage-pattern detection, temporal comparison, radiology reporting, clinical decision support, and endocrine alerting through PACS and interoperable clinical systems.

What Would AI Look For?

A specialized imaging model could potentially detect:

bilateral adrenal enlargement,
asymmetry,
heterogeneous attenuation,
hyperdense hemorrhagic components,
periadrenal fat stranding,
contour distortion,
active extravasation,
and interval size change.

Radiomics

Radiomics could quantify:

first-order intensity distributions,
texture heterogeneity,
shape,
spatial relationships,
and temporal change.

These features might help distinguish hemorrhage from neoplastic or infiltrative disease, although radiomics remains highly sensitive to acquisition parameters, reconstruction algorithms, segmentation quality, and external validation.

Foundation Models

Large medical vision models could theoretically integrate:

CT appearance,
prior examinations,
clinical history,
laboratory data,
and longitudinal imaging.

This is more clinically meaningful than detecting a single abnormal pixel pattern.

Vision-Language Models

A vision-language system might translate an imaging pattern into an actionable statement such as:

“Bilateral adrenal enlargement with heterogeneous attenuation and interval regression is compatible with resolving adrenal hemorrhage; correlate clinically for adrenal insufficiency.”

But the model should not independently decide whether adrenal crisis exists.

Clinical Decision Support

This is a fundamentally different concept from simply highlighting the adrenal glands.

AI Workflow, PACS, HL7, and FHIR

AI Limitations

AI may fail when:

the adrenal glands are poorly visualized,
hemorrhage is subtle,
prior examinations are unavailable,
there is unusual anatomy,
the hemorrhage resembles a mass,
artifacts obscure the adrenal glands,
the model was trained on a different scanner population,
or the underlying cause is outside the model's intended task.

More importantly, imaging alone cannot reliably determine the degree of adrenal endocrine failure.

A model may correctly identify bilateral adrenal hemorrhage and still fail to recognize the patient's impending adrenal crisis if it has no access to blood pressure, sodium, potassium, cortisol, ACTH, medication history, or clinical deterioration.

That is the central limitation of image-only AI.

Future of Precision Medicine

Diagnostic Imaging Pearls

Always inspect both adrenal glands on abdominal CT.
Bilateral adrenal enlargement is more clinically significant than isolated unilateral enlargement.
Heterogeneous adrenal morphology in an acute setting should raise suspicion for hemorrhage.
Periadrenal fat stranding supports an acute inflammatory or hemorrhagic process.
Bilateral hemorrhage should immediately trigger consideration of adrenal insufficiency.
HIT is a particularly important thrombotic cause.
APS should remain in the differential when bilateral adrenal injury is otherwise unexplained.
Anticoagulant medication history is essential.
A hemorrhagic adrenal lesion may conceal an underlying tumor.
Interval regression strongly supports an evolving hematoma rather than progressive neoplasm.
MRI can help characterize blood products and hemorrhage age.
Persistent enhancement should raise concern for residual tumor.
Imaging improvement does not prove endocrine recovery.
Adrenal crisis is a clinical emergency and treatment should not await definitive testing when strongly suspected.
The radiology report should explicitly communicate the possibility of adrenal insufficiency when clinically appropriate.

Quiz

Question 1

A 39-year-old woman presents with acute abdominal pain and vomiting. CT demonstrates bilateral adrenal enlargement with heterogeneous internal appearance and periadrenal fat stranding. Which diagnosis is most appropriate?

① Bilateral adrenal adenomas
② Bilateral adrenal hemorrhage
③ Bilateral renal infarction
④ Uncomplicated adrenal incidentalomas
⑤ Isolated adrenal hyperplasia

Answer: ② Bilateral adrenal hemorrhage

Explanation: Acute bilateral adrenal enlargement with heterogeneous morphology and surrounding inflammatory change is highly suggestive of bilateral adrenal hemorrhage in the appropriate clinical setting.

Question 2

Which clinical complication is most important to consider after identifying bilateral adrenal hemorrhage?

① Hyperthyroidism
② Primary adrenal insufficiency
③ Diabetes insipidus
④ Hyperparathyroidism
⑤ Acromegaly

Answer: ② Primary adrenal insufficiency

Explanation: Extensive bilateral adrenal cortical injury can impair cortisol and aldosterone production and lead to adrenal crisis.

Question 3

One month after treatment, CT demonstrates reduced bilateral adrenal size and decreased periadrenal inflammatory change. What is the best imaging description?

① Complete resolution
② Partial resolution
③ Progressive disease
④ New adrenal metastases
⑤ Stable malignant mass

Answer: ② Partial resolution

Explanation: The lesion has decreased but has not completely disappeared. The supplied case specifically identifies this interval change as partial resolution.

Question 4

Which condition is particularly associated with bilateral adrenal hemorrhage through a thrombotic mechanism?

① Osteoarthritis
② HIT
③ Migraine
④ GERD
⑤ Hyperlipidemia alone

Answer: ② HIT

Explanation: HIT produces a powerful prothrombotic state and has been reported as a cause of bilateral adrenal hemorrhage.

Question 5

Which imaging finding should increase suspicion for an underlying hemorrhagic adrenal tumor?

① Progressive reduction in lesion size
② Absence of enhancement
③ Persistent nodular enhancement within the hematoma
④ Resolution of periadrenal stranding
⑤ Symmetric decrease in adrenal size

Answer: ③ Persistent nodular enhancement within the hematoma

Explanation: Persistent enhancing tissue may represent viable tumor hidden within the hemorrhagic component. Enhancement, calcification, and persistent or progressive mass effect warrant further evaluation.

Frequently Asked Questions

1. Is bilateral adrenal hemorrhage dangerous?

Yes. The principal danger is destruction of sufficient adrenal cortex to produce primary adrenal insufficiency and potentially adrenal crisis.

2. What is the most useful initial imaging test?

In an acutely ill patient with abdominal symptoms, CT is generally the most practical initial imaging examination.

3. Can MRI diagnose adrenal hemorrhage?

Yes. MRI is particularly useful for characterizing blood products and the temporal evolution of hemorrhage. T1 hyperintensity can be an important clue.

4. Does bilateral adrenal enlargement always mean hemorrhage?

No. Metastases, lymphoma, infection, infiltrative disease, hemorrhagic tumors, and other conditions must be considered.

5. Does adrenal hemorrhage always require surgery?

No. Many patients can be managed conservatively if they are stable and the hemorrhage is controlled.

6. When is embolization considered?

Embolization may be considered in selected patients with active bleeding or hemodynamic compromise when interventional control of hemorrhage is appropriate.

7. Can adrenal function recover?

It can, but recovery is variable. Radiologic improvement does not guarantee endocrine recovery.

8. Why is HIT important?

HIT can produce severe thrombosis despite thrombocytopenia and may cause adrenal hemorrhage through adrenal vascular thrombosis and hemorrhagic infarction.

9. Can adrenal hemorrhage mimic cancer?

Yes. Organized hemorrhage may form a pseudomass, while hemorrhage can also occur within a pre-existing adrenal tumor.

10. What should a radiologist mention in the report?

When clinically appropriate, the report should describe the bilateral adrenal abnormality, suggest hemorrhage, and explicitly recommend clinical correlation for adrenal insufficiency.

Clinical Correlation

This case illustrates why adrenal imaging should be interpreted in the context of clinical physiology and longitudinal change.

Imaging + physiology + time provide three complementary perspectives.

Imaging identifies the structural abnormality and establishes the pattern of adrenal injury. Clinical and laboratory assessment determines whether the bilateral adrenal involvement has resulted in functional impairment, particularly adrenal insufficiency. Serial imaging then shows whether the abnormality is resolving, remaining stable, or progressing.

In this case, the reduction in bilateral adrenal size and the associated decrease in surrounding inflammatory change on follow-up imaging provide an important temporal clue supporting the evolution and partial resolution of adrenal hemorrhage.

This longitudinal perspective is particularly valuable when distinguishing an evolving hematoma from an underlying adrenal neoplasm. A lesion that progressively decreases in size over time behaves differently from a persistent or enlarging mass, although imaging follow-up alone cannot completely exclude an underlying tumor when suspicious enhancing tissue remains.

Conclusion

Bilateral adrenal hemorrhage is an uncommon diagnosis with disproportionately important clinical consequences.

The radiologic diagnosis often begins with a simple observation:

Both adrenal glands are enlarged.

But expert interpretation does not stop there.

The radiologist should determine whether the glands are heterogeneous, whether surrounding fat is abnormal, whether there is evidence of active bleeding or vascular disease, whether an underlying mass is present, and whether previous imaging demonstrates interval evolution.

Most importantly, bilateral adrenal hemorrhage should trigger a clinical question that extends beyond radiology:

Is the patient developing adrenal insufficiency?

Current endocrine guidance supports immediate treatment when adrenal crisis is suspected rather than waiting for diagnostic confirmation.

The most useful radiology report is therefore not merely:

“Bilateral adrenal enlargement.”

It is an interpretation that connects anatomy to physiology:

“Bilateral adrenal enlargement with heterogeneous appearance and surrounding inflammatory change, suspicious for bilateral adrenal hemorrhage. Given bilateral involvement, clinical correlation for adrenal insufficiency is recommended.”

That sentence can change clinical management.

In the era of AI, this principle becomes even more important. An algorithm can detect bilateral adrenal enlargement, calculate volume, compare prior examinations, and identify temporal regression. But the ultimate clinical value comes from integrating that finding with the patient's blood pressure, electrolyte profile, medication history, thrombotic risk, and endocrine status.

The future of radiology is therefore not simply automated image recognition.

It is clinically connected intelligence.

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Final Expert Perspective

The most important lesson from this case is not simply that bilateral adrenal hemorrhage can be identified on CT. It is that radiologic pattern recognition should lead to physiological reasoning and timely clinical action.

Recognizing bilateral adrenal enlargement identifies the structural abnormality. Recognizing hemorrhage identifies the acute pathological process. But recognizing bilateral adrenal hemorrhage and communicating the potential risk of adrenal insufficiency connects imaging findings directly to patient safety.

This is an important responsibility of modern radiology. The value of medical imaging does not end with identifying an abnormality; it lies in understanding its clinical significance and communicating findings that may alter immediate patient management.

As clinical AI becomes increasingly integrated into radiology, the same principle should apply. AI may help detect subtle abnormalities, compare examinations over time, and prioritize potentially important findings, but the ultimate clinical value comes from connecting imaging findings with the patient's physiology, history, laboratory data, and clinical context.

Medical imaging should not merely tell us what is abnormal. It should help us understand what matters next.

Bilateral Adrenal Hemorrhage on CT: Imaging Diagnosis, Adrenal Insufficiency, and Emergency Management