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This is a case report on a young woman with a large idiopathic unilateral adrenal hematoma (AH). Only few cases of AH which were not associated with any trauma, previous surgery, coagulative or any other systemic disorders have been described. The mass was discovered by abdominal ultrasound which was performed for a recent flank pain. Magnetic resonance imaging (MRI) confirmed the presence of a 13-cm sized lesion in the right hemi-abdomen; T1 and T2 weighed imaging was compatible with subacute-to-chronic adrenal hematoma. The lesion dislocated the liver and right kidney. Positron emission tomography (PET) did not show any significant radiotracer uptake by the mass. Serum cortisol, aldosterone, renin activity and DHEA-S were normal. Urinary catecholamines and free cortisol excretion were within the normal range too. The lesion was removed by transabdominal laparoscopic adrenalectomy without any complication. The histological exam confirmed a large subacute-to-chronic organized AH. In conclusion, in the absence of known risk factors, differential diagnosis of a large AH may not be easy. The possibility of an underlying pheochromocytoma, malignant adrenal or metastatic tumor must always be considered. In our patient, computed tomography (CT) scan and MRI suggested the presence of a large subacute-to-chronic AH, and PET excluded metabolic activity of the mass. Laparoscopic adrenalectomy can be the surgical treatment of choice in organized symptomatic AH. The correct diagnosis, early recognition and treatment of complications including adrenal insufficiency may decrease patient morbidity and mortality.

The use of intercavernous sinus phlebography in the diagnosis of pituitary adenomas has enabled the collection of selective venous samplings of the inferior petrosal sinuses (IPS), where pituitary hormones can be measured before becoming excessively diluted in the systemic circulation. This approach has been particularly useful in patients affected by ACTH-secreting microadenomas, whose diagnosis and preoperative localization can be very difficult. Five female patients, 30–53 years old, suffering from hyperadrenocorticism have been studied. The basal and dynamic hormonal assessment indicated an ACTH-dependent hyperadrenocorticism, although the computed tomography of the sella turcica, performed in all the patients, was negative in 3 patients and doubtful in 2. The perihypophyseal phlebography showed a small left-sided intrasellar expansive process in patient no. 1 and a right-sided intrasellar mass in patients no. 2 and 3. The analysis of ACTH concentrations in the IPS and in the peripheral circulation showed the presence of a concentration gradient between the side of presumed adenoma and the contralateral side (2.7 times;p<0.01) and between the side of the presumed adenoma and the periphery (3.4 times;p<0.01). No significant difference was found between the ACTH concentration in the contralateral IPS and that of the periphery. Surgery confirmed the presumed diagnosis in all cases.

The use of intercavernous sinus phlebography in the diagnosis of pituitary adenomas has enabled the collection of selective venous samplings of the inferior petrosal sinuses (IPS), where pituitary hormones can be measured before becoming excessively diluted in the systemic circulation. This approach has been particularly useful in patients affected by ACTH-secreting microadenomas, whose diagnosis and preoperative localization can be very difficult. Five female patients, 30–53 years old, suffering from hyperadrenocorticism have been studied. The basal and dynamic hormonal assessment indicated an ACTH-dependent hyperadrenocorticism, although the computed tomography of the sella turcica, performed in all the patients, was negative in 3 patients and doubtful in 2. The perihypophyseal phlebography showed a small left-sided intrasellar expansive process in patient no. 1 and a right-sided intrasellar mass in patients no. 2 and 3. The analysis of ACTH concentrations in the IPS and in the peripheral circulation showed the presence of a concentration gradient between the side of presumed adenoma and the contralateral side (2.7 times;p<0.01) and between the side of the presumed adenoma and the periphery (3.4 times;p<0.01). No significant difference was found between the ACTH concentration in the contralateral IPS and that of the periphery. Surgery confirmed the presumed diagnosis in all cases. L'utilisation de la phlébographie sinusale intercaverneuse dans le diagnostic des adénomes hypophysaires permet de faire des prélèvements veineux des sinus pétreux inférieurs (SPI), et par conséquent de doser les hormones hypophysaires avant qu'elles ne se diluent dans la circulation systémique. Cette méthode est particulièrement intéressante chez le patient présentant un microadénome à ACTH, dont le diagnostic et la localisation préopératoires peuvent être extrêmement difficiles. Cinq femmes âgées de 30–53 ans, présentant un hypercorticisme, ont été explorées. Les dosages de base et dosages dynamiques ont mis en évidence un hypercorticisme ACTH dépendant, bien que l'examen tomodensitométrique de la selle turcique, pratiqué chez toutes les patientes, ait été négatif chez 3 d'entre elles et douteux chez les 2 autres. La phlébographie périhypophysaire a mis en évidence un petit processus expansif intracellaire à gauche chez une patiente (patiente 1) et une masse intrasellaire droite chez 2 autres patients (patientes 2 et 3). L'analyse des concentrations en ACTH dans les SPI et dans la circulation périphérique a démontré un gradient de concentration hormonale entre le côté présumé de l'adénome et le côté controlatéral (× 2.7;p< 0.01), et entre le côté présumé de l'adénome et la circulation périphérique (× 3.4;p <0.01). On n'a pas trouvé de différence significative entre la concentration en ACTH dans le SPI controlatéral et la circulation périphérique. La chirurgie a confirmé le diagnostic présumé dans tous les cas. El uso de la flebografía venosa intracavernosa en el diagnóstico de adenomas hipofisiarios ha hecho posible la recolección de muestras venosas selectivas de los senos petrosos inferiores (SPI), donde las hormonas hipofisiarias pueden ser medidas antes de quedar excesivamente diluídas en la circulation sistémica. Este aproche ha resultado particularmente útil en pacientes con microadenomas secretores de ACTH, cuyo diagnóstico y localizatción preoperatoria pueden ser bastante difíciles. Cinco pacientes femeninas, con edades entre 30 y 53 años, quienes padecían hiperadrenocorticalismo han sido estudiadas. Las determinaciones hormonales tanto basales como dinámicas indicaban hiperadrenocorticalismo ACTH dependiente, aunque la tomografía computadorizada de la silla turca, procedimiento que fue realizado en la totalidad de las pacientes, fue negativa en 3 casos y dudosa en 2. La flebografía perihipofisiaria demostró un pequeño proceso expansivo intraselar izquierdo en la paciente 1 y una masa intraselar derecha en las pacientes 2 y 3. El análisis de las concentraciones de ACTH en los SPI y en la circulacíon periférica demostró la presencia de un gradiente de concentración entre el lado de ubicación del presunto adenoma y el lado contralateral (2.7 veces;p<0.01) y entre el lado del presunto adenoma y la periferie (3.4 veces;p<0.01). No se halló diferencia significativa entre las concentraciones de ACTH en los SPI contralaterales y la periferie. La cirugía confirmó el diagnóstico en la totalidad de los casos.