Interact CardioVasc Thorac Surg 2008;7:430-431. doi:10.1510/icvts.2007.170795
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Vascular general |
Unilateral adrenal haemorrhage following systemic thrombolysis
Tor Steensruda,*,
Lil-Sofie Ording Müllerb and
Dag Sørliea
a Department of Cardio-Thoracic and Vascular Surgery, University Hospital North Norway and Institute of Clinical Medicine, University of Tromsø, Breivika, P.O. Box 102/exp, N-9038 Tromsø, Norway
b Department of Radiology, University Hospital North Norway, Norway
Received 31 October 2007;
received in revised form 8 January 2008;
accepted 9 January 2008
*Corresponding author. Tel.: +47 77626000; fax +47 77628298.
E-mail address: tor.steensrud{at}unn.no (T. Steensrud).
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Abstract
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We report a case of unilateral adrenal bleeding, worsened or initiated by systemic thrombolytic therapy given for a suspected myocardial infarction. Initial clinical diagnosis was ruptured aortic aneurysm or aortic dissection. A preoperative contrast-enhanced computer tomography (CT) scan showed a possible bleeding from the left adrenal gland. An emergency left subcostal retroperitoneal approach revealed a ruptured and bleeding adrenal gland and its arteries were ligated.
Key Words: Adrenal haemorrhage; Thrombolysis; Complication
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1. Case report
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A 58-year-old man was admitted in a circulatory unstable condition. His symptoms were acute postprandial pain in the upper left quadrant of the abdomen. A chest X-ray and an electrocardiogram (ECG) were obtained, the ECG showed ST elevations and he was given systemic thrombolytic therapy for a suspected myocardial infarction. His condition worsened following the abrupt onset of haemorrhagic shock. Hence he was transferred to our department by helicopter; on arrival, his blood pressure was 90/60 mmHg and heart rate 150 beats/min. Initial suspected diagnosis was a ruptured aortic aneurysm or an aortic dissection. He had no history of trauma and was not on any regular medication. Previous medical history included a left kidney stone and an episode with a persistent nasal bleed. Physical examination did not reveal any palpable mass in an obese abdomen and the point of maximal tenderness was still in the upper left quadrant. Laboratory tests showed anaemia (haemoglobin: 8.5 g/dl) and normal electrolytes. The cause of bleeding was still uncertain after an abdominal ultrasound in the trauma room. Radiological imaging, CT scan with intravenous contrast, showed a retroperitoneal haematoma and a probable bleeding at the site of the left adrenal gland (Fig. 1). Because of ongoing bleeding the patient immediately underwent surgery with a left subcostal retroperitoneal approach. The adrenal gland was found ruptured. Visible adrenal gland tissue was removed and its bleeding arteries ligated. The patient recovered uneventfully and he continues to do well six months postoperatively (Fig. 2).
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Fig. 1. Computer tomography scan of the abdomen and pelvis, with intravenous contrast, arterial phase, coronal view, demonstrating extravasations of intravenous contrast (long arrow) and retroperitoneal haematoma (small arrows).
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Fig. 2. Computer tomography scan of the abdomen and pelvis, with intravenous contrast, arterial phase, sagital view, showing extravasations of intravenous contrast (long arrow) and retroperitoneal haematoma (small arrows). Cortical cyst in the upper pole of the left kidney (cy).
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2. Discussion
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Adrenal haemorrhage is an uncommon condition and diagnosis is commonly made at autopsy [1]. Classically it is associated with meningococcal septicaemia and disseminated intravascular coagulation (Waterhouse-Friderichsen syndrome), but also trauma, hypotension, tumours, complications of pregnancy, surgical stress or anticoagulation therapy may cause adrenal haemorrhage. Vella et al. have in 25 years at the Mayo clinic found 204 patients with adrenal haemorrhage. Of three associated with anticoagulant therapy one was found at autopsy and the other two after adrenal failure [2]. Kawashima et al. have in 1999 reviewed the imaging features of non-traumatic adrenal haemorrhage and classified the causes into (a) stress, (b) haemorrhagic diathesis or coagulopathy, (c) neonatal stress, (d) underlying adrenal tumours, and (e) idiopathic disease [3]. The incidence of adrenal haemorrhage associated with anticoagulation therapy has increased since Amdor in 1965 reviewed the literature and 4,000 autopsies (1949–1962) with 29 cases of adrenal haemorrhage, nine associated with heparin or warfarin therapy. He added one case of his own for a total of 10. O'Connell and Astand reviewed the literature in 1974 and in 50 patients with spontaneous adrenal haemorrhage undergoing anticoagulant therapy, three patients were diagnosed and treated antemortem. He reported two cases with bilateral adrenal haemorrhages that died despite therapy [4]. Rao showed in a review that anticoagulation or coagulopathy has become an increasingly recognised cause of adrenal haemorrhage [5]. Also, Ognibene and McBride [6] and Vedrell et al. [7] have published case reports of unilateral adrenal haemorrhage after anticoagulant therapy similar to our case in which systemic thrombolytic therapy was given for a suspected myocardial infarction. This most probably only worsened his condition. The vascular supply to the adrenals makes them predisposed to haemorrhagic necrosis since three adrenal arteries divide into about 50 small branches, and one vein collects blood from the sinusoids [2]. This anatomy can make the bleeding adrenals a rather difficult target for endovascular therapy.
An identifiable risk factor is the presence of antiphospholipid antibodies (APL), and patients with APL are more susceptible to develop AH when exposed to surgery, infection or anticoagulation [8]. The majority of patients with adrenal bleeding do not have any signs of adrenal insufficiency. The most common symptoms are hypotension, confusion, lethargy, nausea, vomiting, tachycardia and fever. More specific symptoms as abdominal pain; central and radiating to the flank are present in 45% [9]. These symptoms together with anticoagulants and an elderly or very young patient should raise clinical suspicion. The essential diagnostic tool is CT [10]. Acute adrenal insufficiency (Addison crisis) may occur when the bleeding is bilateral. Such anticoagulant related adrenal insufficiency is potentially life-threatening but can easily be treated with steroids [5].
In this case, the retroperitoneal approach was chosen after CT examination. An emergency angiographic coiling was discussed with the radiologist on call but was considered not possible on this particular weekend night both due to anatomic considerations of the bleeding site and to the response time of the interventional radiologist. Conventional open surgery may still be a valuable tool in such cases.
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References
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- Vella A, Nippoldt TB, Morris JC III. Adrenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc 2001;76:161–168.[Medline]
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- O'Connell TX, Aston SJ. Acute adrenal hemorrhage complicating anticoagulant therapy. Surg Gynecol Obstet 1974;139:355–357.[Medline]
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- Zissin R, Ellis M, Gayer G. The CT findings of abdominal anticoagulant-related hematomas. Semin Ultrasound CT MR 2006;27:117–125.[CrossRef][Medline]
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Abstract
1. Case report