1. Adrenal Flashcards
Congenital absent kidneys will result to what adrenal?
Pancak adrenals
Flat
Straight
Discoid
Each adrenal gland gets arterial blood from these 3 arterial supplies
Superio - phrenic
middl - aorta
inferior - renal artery
There are 4 zones to the adrenal, each of which makes different stuff.
Zona Glomerulosa
Zona Fasiculata
Zona Reticularis
Medulla
Makes Aldosterone
Zona gromerulosa
Prolonged stimulation = hypertrophy
Makes cortisol
Zona Fasciculata
Makes Androgens
Zona Reticularis
Makes Catecholamines
Medulla
Age related trivia: The relative size of the adrenal changes as you age.
* Second Trimester:
* Third Trimester:
* Adulthood:
- Second Trimester: Adrenal is Half the Size of the Kidney
- Third Trimester: Adrenal is 1/3 the Size of the Kidney
- Adulthood: Adrenal is 1/13 the Size of the Kidney
In babies, the cortex is ____
the medulla is ____
Normal Adrenal -
Hypoechoic Cortex,
Hyperechoic Medulla,
Hypoechoic Cortex - like an Oreo, with a creamfilling.
If you see a Pediatric Adrenal Cases you should think about:
(a) normal
(b) congenital
(c) neuroblastoma
(d) hemorrhage
(e) hyperplasia
There are three classic congenital cases
Pancake (Discoid)
Horseshoe
Adrenal Cyst
This occurs when the limbs of the adrenal glands fuse in the midline, and is associated with asplenia (right isomerism)
Horseshoe adrenals
Remember, they can show you bilateral trilobed lungs, a horizontal midline liver, an absent spleen, malrotation, and congenital heart disease (total anomalous pulmonary venous return - most commonly) — all in association with this horseshoe adrenal gland.
in a newborn - an adrenal cyst usually get resected because you can’t tell them apart from ?
Neuroblastoma
they form in the adrenal medulla (usually), and typically look like an enlarged gland with a hyperechoic component.
Neuroblastoma
This occurs most commonly in the setting of trauma or stress (neonates).
What this typically looks like on ultrasound is an enlarged gland with an anechoic component.
Hemorrhage
Hemorrhage of the adrenal in the setting of M fulminant meningitis (from Neisseria Meningitidis).
Waterhouse-Friderichsen Syndrome
Adrenal Hyperplasia
So what does “looks like a brain ” mean ? That means the surface is wrinkled, like it has gyri and sulci.
Congenital adrenal hypertrophy is caused by
21-Hydroxylase Deficiency in 90% of the cases
21-Hydroxylase Deficiency clicial manifestation
Genital ambiguity (girls)
Salt losing pathology (boys) - life threatening
Limb > 4 mm
loss of centrl hyperechoic stripe
I say “Genital ambiguity”,
21-Hydroxylase Deficiency
bilateral adrenal gland hyperplasia =
overproduction o f ACTH
This is an overproduction ofACTH by a pituitary adenoma,
Cushing Disease = too much coritsol
This is actually the most common cause of excess cortisol (75%)
Cushing Disease
Cushing syndrome:
overproduction of ACTH by:
1. An ACTH secreting tumor - small cell tumor
2. Overproduction of ACTH via an adrenal adenoma
3. Straight up adrenal hyperplasia
+
Taking chronic high dose sterioid
Any way you end up with a fat moon face and big gross lines all over you belly counts as “syndrome.”
classic mimic of an adrenal mass on imaging.
Infradiaphragmatic extralobar sequestration
The ultrasound will show a heterogeneous suprarenal mass
CT picture clearly showing the blood supply from the aorta (or branches o f the aorta):
It is really hard to tell Infradiaphragmatic extralobar sequestration from an adrenal mass with out any “hints.”
Examples of hints:
Hx of history “male neonatal with respiratory distress and cyanosis. ”
Normal adrenal
Triple Stripe
- Hypoechoic Cortex,
- Hyperechoic Medulla
- Hypoechoic Cortex
- Smooth Surface
Hyperplasia:
Big
Longer than 20 mm
Looks like a “brain”
“Genital ambiguity”, = 21-OH Deficiency
Hemorrhage:
Big with an anechoic (or echogenic) component
Gets smaller over time
Seen with “stress” or trauma
Neuroblastoma
Big with an echogenic (or anechoic) component
Does NOT gets smaller over time
These things are easily the most common tumor in the adrenal gland
Adrenal Adenoma
Absolute washout result of adenoma
Relative washout result of adenoma
what is a mimic of adenoma washout?
Hypervascular mets
Portal venous HU values > 120 should make you think about a met.
Adrenal Adenoma
Signal drop out In and Out of Phase
Real Life = Mass in Adrenal =
Adenoma
If adnreal HU on PVP is > 120 =
MEts from RCC/HCC or pheo
Two different tumors that smash together to look like one mass.
“Collision Tumors”
usually one of them is an Adenoma
Syndrome of excessive aldosterone production. This is most commonly caused by a benign adenoma (70%).
Conn’s Syndrome
Pheochromocytoma
T2 bright. a heterogeneous mass with AVID ENHANCEMENT
if they show you HU measurements > 120 on arterial or portal venous phase =
you can NOT call the thing an adenoma.
Rule of 10s of pheocromocytoma
10% are extraadrenal (Organ of Zuckerkandl - usually at the IMA
10% are bilateral
10% are in children
10% are hereditary
10% are NOT active (no HTN)
Associated Syndrome of Pheochromocytoma
First
Von Hippel Lindau
then think MEN Ila and Ilb
Carney Triad
Extra-Adrenal Pheo
GIST
Pulmonary Chondroma (hamartoma).
Don’t confuse this with the Carney Complex
(Cardiac Myxoma, and Skin Pigmentation).
Benign tumor that contains bulk fat
Myelolipoma
Myelolipoma
> 4 cm, can bleed + retroperitoneal hemorrhage
Adrenal calcifications are often a result of ?
prior trauma + infection (TB)
Certain tumors (cortical carcinoma, neuroblastoma, myelolipoma) can have calcifications. Melanoma mets are known to calcify.
Bilateral enlarged calcified adrenals. It’s a fat metabolism error thing that kills before the first year of life.
Cortical Carcinoma
LARGE (4 cm -10 cm),
May be functional (Cushings)
Calcify in about 20% of cases
Bad news & met everywhere (direct invasion often first).
not likely to be less than 5 cm + often has central necrosis.
