adrenal injuries after blunt abdominal trauma are very rare , but have been reported in 0.15% of patients in the literature . in 75%90% of cases , hemorrhages are unilateral and the most affected gland is the right adrenal . isolated adrenal injuries are very rare ( 4% ) and are often associated with other organ injuries . associated trauma includes injuries of the liver ( 43% ) , spleen ( 23% ) , lung ( 19% ) , and kidney ( 18% ) , as well as pneumothoraces / hemothoraces . also , skeletal injuries to the rib , clavicle , scapulae , pelvis , hip , and spine can be accompanied by adrenal gland trauma . in particular , adrenal insufficiency due to bilateral adrenal gland hemorrhage , if untreated , can be fatal . here , we present the cases of two patients with unilateral adrenal hemorrhage detected by using computed tomography ( ct ) and magnetic resonance imaging ( mri ) , together with the literature review . a 38-year - old male was admitted to the emergency department with a history of falling from a height of approximately 22.5  m. upon admission , he was awake and complained of a severe pain in his right arm and pelvis . the plain x - ray showed fractures in the right scaphoid bone and distal radius , as well as multiple fractures in the inferior pubic ramus . there was a slightly hyperdense ( 50 hu ) 44  mm    22  mm adrenal mass on the right with periadrenal fat stranding and minimal free fluid in morison 's pouch in the non - contrast abdominopelvic ct ( fig . there was also slight peripheral enhancement after contrast administration in the lesion ( fig . four days later , a dynamic abdominal mri ( signa hdx 1.5  t ; ge medical systems , milwaukee , wi , usa ) exam was performed after stabilization of the patient to rule out a hemorrhagic adrenal mass . multiplanar ( axial , coronal , and sagittal ) t1 and t2 weighted ( w ) images with and without fat saturation , t1w images in - phase and out - phase spoiled gradient - recalled - echo , and dynamic t1w images were performed . the mri revealed a 44  mm    22  mm hypointense lesion in t1 and t2w images . within the gland , a 10  mm    11  mm focal area of hyperintensity was seen . dynamic mr images revealed peripheral contrast enhancement in the lesion ( fig .  2 ) . in - phase , out - of - phase , and fat - suppressed sequences did not show suppression in the lesion . dynamic mri findings ruled out a hemorrhagic adrenal mass to the adrenal hematoma . according to mri findings , thirty days later , mr imaging showed the reduction of lesion size ( 14  mm    37  mm ) and signal intensity changes . a hyperintense lesion with a focal hypointense area is seen on t1w ( fig . 3a ) and 2d fast imaging employing steady - state acquisition sequences ( fig . again , there was no suppression in the lesion of in - phase and out - of - phase sequences . a 35-year - old male was admitted to the emergency department with a history of a fall from a height of about 1.50  m. on admission , he was conscious and hemodynamically stable . plain x - rays showed multiple fractures of the right 9th , 10th , 11th , and 12th ribs . multiple fractures of the right 9th , 10th , 11th , and 12th ribs , diffuse subcutaneous emphysema in the right anterior chest wall , and bilateral hemothorax and fracture of the right transverse process of the right l1 - 2 vertebrae were seen in the ct . a 24  mm    25  mm left hyperdense adrenal mass ( 70  hu ) and periadrenal fat stranding were seen in the ct ( fig . the incidence of adrenal hemorrhage in trauma patients is not fully known because some adrenal injuries are asymptomatic and may remain undiagnosed . in ct - based earlier studies regarding the incidence of adrenal gland injuries , adrenal hemorrhages were found in less than 2% of scans . adrenal hemorrhage from blunt trauma occurred unilaterally on the right side twice as often as on the left . liver and ipsilateral kidney injuries most often accompany right adrenal gland trauma . left adrenal gland trauma is less common than on the right and may be accompanied by injuries to the pancreas or spleen . unilateral traumatic adrenal hemorrhages are often asymptomatic and , even if symptoms do exist , they are nonspecific . these symptoms include abdominal pain , nausea , vomiting , hypotension or hypertension , low fever , agitation , and a decrease in hematocrit . rupture of the vessels in the adrenal medulla and loosely textured juxtamedullary cortex due to sudden compression and decompression can be a cause of the adrenal hemorrhage . the right adrenal gland is more susceptible to damage and can be associated with the different drainage course of the adrenal veins . the right adrenal vein directly enters the inferior vena cava , but the left adrenal vein drains into the left renal vein or inferior phrenic vein . therefore , severe compression of the inferior vena cava might be responsible for intraglandular hemorrhage due to increased adrenal venous pressure . in the present case report , there was a history of falls from heights with multiple bone fractures and unilateral adrenal hemorrhage without intra - abdominal solid organ injury . adrenal hemorrhage and bone fractures are on the right side in case 1 . however , in case 2 , adrenal hemorrhage was seen on the left side , despite right blunt trauma to the thorax . although ultrasonography is noninvasive , easily accessible , and relatively inexpensive , it is sometimes insufficient when evaluating the retroperitoneal organs . a ct scan is the best method for evaluating the retroperitoneum , especially under emergency conditions . some ct findings are diagnostic for adrenal hematoma , although others are indistinguishable with adrenal neoplasms . a ct scan can show solid , round , or oval masses in the adrenal gland . high density on precontrast ct scans , as well as diminished size or resolution of the lesion over time , is indicative of a hematoma , especially in trauma patients . ill - defined soft tissue stranding around the adrenal gland is caused by infiltration of blood through the retroperitoneal fat . retroperitoneal stranding is observed in approximately 90% of traumatic adrenal hemorrhage cases.1 , 6 hematoma with active bleeding is a rare but important pattern . adrenal hemorrhages may also be seen in the form of adreniform enlargement and amorphous solid mass . unilateral adrenal enlargement should be considered bilateral adrenal hemorrhage in the presence of a contralateral hematoma . subacute hemorrhages into and around the adrenal gland can be seen as an amorphous solid mass with soft - tissue density . in both of our two cases , unenhanced ct scans demonstrated a 50  hu , hyperdense solid lesion and periadrenal fat stranding , both of which are diagnostic of adrenal hemorrhages . , hemorrhages can be seen in different signals in the acute , subacute , and chronic stages . in acute hemorrhage ( less than 7 days ) , deoxyhemoglobin shows isointense or hypointense signal intensity in t1w images and hypointense signal intensity in t2w images . in the subacute stage of hemorrhage ( 7 days7 weeks ) , methemoglobin appears to be hyperintense on t1w images . afterward , lysis of the red cells disperses the methemoglobin homogeneously throughout the liquid hematoma and hemorrhage appears to be bright on t2w imaging . chronic hematomas ( lasting more than 7 weeks ) appear to be hypointense on both t1w and t2w images because of the presence of hemosiderin deposits . in here , there was a 44  mm    22  mm hypointense lesion in t1w and t2w images and a 10  mm    11  mm focal area of hyperintensity within the gland . thirty days later , an mri showed a hyperintense ovoid mass of 37  mm    14  mm in the adrenal region with a focal hypointense area of 7  mm    6  mm most likely a subacute hemorrhage with hemosiderin deposits . adrenal atrophy or a hemorrhagic adrenal pseudocyst a hemorrhagic adrenal pseudocyst is a chronic organized collection of hemorrhage that can be seen on ct as a nonenhancing , low - attenuation fluid collection with a well - defined thin wall . it is difficult to distinguish between a tumor - related adrenal hemorrhage and a nontumoral adrenal hemorrhage , especially in the acute phase . in addition , pheochromocytoma , adenoma , carcinoma , metastases , and myelolipoma should be considered in the differential diagnosis . on ct or mri , hemorrhagic adrenal masses of heterogeneous attenuation or signal intensity that demonstrate enhancement should be evaluated more carefully . in the differential diagnosis , detection of intralesional enhancement , calcifications , or hypermetabolic activity on positron emission tomography delayed replacement or misdiagnosis can be fatal for patients . according to the literature , 16%50% of patients with bilateral adrenal hemorrhage have been reported to have life - threatening adrenal insufficiency . bilateral adrenal hemorrhage with sepsis adrenal trauma should not be considered an incidental finding because it can lead to severe bleeding , which may require a blood transfusion . in addition , bilateral adrenal hemorrhage can cause potentially fatal hyponatremia , hyperkalemia , acidosis , hypotension , and lethargy associated with acute adrenal insufficiency . a ct scan is the preferred imaging modality in emergency departments because of its easily accessible and rapid scan time . a 5090  hu hyperdense adrenal lesion and periadrenal fat stranding should be considered an adrenal hemorrhage in unenhanced ct images , especially if there is a history of trauma . also , mri is the most sensitive and specific method for diagnosing adrenal hemorrhage . hyperintense adrenal masses of precontrast t1w images primarily indicate the acute hemorrhage in a patient with a history of trauma . in conclusion , therefore , adrenal glands should always be carefully evaluated in patients with a history of trauma with imaging methods . mri should be performed for differential diagnosis of high - density adrenal lesions detected on ct in patients presenting with trauma .
adrenal hemorrhage following blunt abdominal trauma is extremely rare . 
 most of the lesions are unilateral and right sided . 
 although often asymptomatic , life - threatening adrenal insufficiency may develop in the bilateral adrenal gland hemorrhage . 
 isolated adrenal injuries are very rare . 
 they are often associated with other organ injuries . 
 the mortality rates of patients range from 7% to 32% . in this report 
 , we present the computed tomography and magnetic resonance imaging findings of unilateral adrenal hemorrhages in two patients with a history of fall from a height .