Transcatheter arterial embolization for traumatic adrenal hemorrhage with contrast extravasation: case series and literature review

Abstract

Purpose

To evaluate the feasibility, short-term clinical outcomes, and technical considerations of transcatheter arterial embolization (TAE) for traumatic adrenal hemorrhage with contrast extravasation on CT.

Materials and methods

This single-center retrospective study included consecutive patients with traumatic adrenal hemorrhage showing contrast extravasation on CT who underwent TAE. Technical success was defined as complete embolization of the bleeding artery with no contrast extravasation on post-embolization angiography. Clinical success was defined as effective control of adrenal hemorrhage during the index hospitalization, as evidenced by the absence of repeat embolization or surgery and no clinical or imaging evidence of persistent or recurrent bleeding.

Results

Eight patients (4 men; median age, 78 years) underwent TAE. Adrenal hemorrhage was unilateral in all patients, involving the right side in 6 (75%) and the left side in 2 (25%). Contrast extravasation was observed in all patients during angiography. Gelatin sponge particles were used in all procedures. Technical and clinical success were both 100% (8/8). Single-artery embolization was performed in 6 patients (75%). Embolization of the middle adrenal artery was performed in 6 patients, the superior adrenal artery in 2, and the inferior adrenal artery in 3. One intraprocedural injury to the right inferior phrenic artery occurred. No procedure-related mortality or overt clinical evidence of adrenal insufficiency was observed during hospitalization. One patient died on hospital Day 8 of complications unrelated to adrenal hemorrhage.

Conclusion

TAE appears to be a technically feasible hemostatic option in selected patients with traumatic adrenal hemorrhage and CT-detected contrast extravasation, with favorable short-term in-hospital hemostatic outcomes in this small case series. However, the necessity of embolization and its comparative benefit over conservative management remain unclear.

Graphical Abstract

Introduction

Adrenal injury is an uncommon consequence of trauma, with a reported incidence of 0.5% to 4% in previous series [1–3]. In contrast, traumatic adrenal hemorrhage has been identified in up to 26% of autopsy cases of patients who died from severe blunt trauma to the chest or abdomen [4]. This discrepancy suggests that adrenal hemorrhage is frequently underdiagnosed in clinical practice, likely due to its nonspecific presentation and the inherent diagnostic challenges. Traumatic adrenal hemorrhage has been associated with substantial overall injury burden, with mortality rates ranging from 10 to 33% in previous series [1, 2]. Active bleeding may result in hemodynamic instability and fatal outcomes if not promptly managed.

Transcatheter arterial embolization (TAE) has emerged as a minimally invasive and effective treatment for adrenal hemorrhage [5]. While its safety and efficacy have been demonstrated in case reports and small series, studies specifically addressing traumatic adrenal hemorrhage are limited. Furthermore, the complex and highly variable anatomy of the adrenal arteries makes embolization technically challenging and may increase the risk of procedural complications.

In this study, we report our institutional experience with TAE for traumatic adrenal hemorrhage and review the relevant literature, with particular emphasis on anatomical and technical considerations.

Materials and methods

Study design and population

This single-center retrospective observational study was conducted over a 194-month period, from December 2006 to February 2023. The study was approved by the Institutional Review Board of our institution, and the requirement for written informed consent was waived through an opt-out process. Eight consecutive patients with traumatic adrenal injury demonstrating active contrast extravasation on contrast-enhanced computed tomography (CT) who underwent TAE were included. One patient had been previously described in a case report from our institution [6], but the prior report did not focus on adrenal embolization; therefore, this patient was included as part of the present consecutive adrenal TAE cohort. In all cases, the indication for TAE was determined individually in the context of multisystem trauma, with consideration of hemodynamic trends, associated injuries, and the need for endovascular hemostatic management as part of the overall trauma treatment strategy. In patients requiring TAE for multiple traumatic injuries, the sequence of TAE was determined on a case-by-case basis based on the clinical priority of hemorrhage control, angiographic findings, and procedural accessibility.

Study endpoints

The primary endpoints were the technical and clinical success of TAE for traumatic adrenal hemorrhage. Technical success was defined as complete embolization of the bleeding artery with no residual contrast extravasation on post-embolization angiography. Clinical success was defined as in-hospital control of adrenal hemorrhage without additional hemostatic intervention, including repeat embolization or surgery, and without progressive anemia, hemodynamic instability, or clinical/imaging evidence of persistent or recurrent bleeding. Post-procedural follow-up was based on serial clinical and laboratory assessment, with imaging performed when clinically indicated; available follow-up images were reviewed by non-operator physicians. Secondary endpoints focused on adrenal arterial anatomy and the angiographic detectability of feeders relevant to embolization strategy. Laterality of the affected adrenal gland was also recorded.

Data collection

Collected data included patient demographics (age and gender), clinical parameters (hemoglobin levels, vital signs, laterality of adrenal injury, and hematoma size), trauma-related clinical variables, intraprocedural or post-procedural adverse events, including overt clinical evidence of adrenal insufficiency during hospitalization, procedural details (embolized vessels, embolic materials, and procedure duration), and treatment outcomes (technical and clinical success). Trauma-related clinical variables collected from the medical records included mechanism of injury, associated major injuries, Injury Severity Score, antithrombotic therapy, coagulation profile including platelet count, activated partial thromboplastin time, and PT-INR, electrolyte abnormalities including hyponatremia and hyperkalemia, transfusion requirement, vasopressor use, treatments performed for concomitant injuries, and overall clinical outcome. Adrenal insufficiency was assessed clinically on the basis of suggestive symptoms, routine laboratory findings, and the need for steroid replacement therapy during hospitalization, with consideration of trauma-related confounders. Anatomical characteristics of the adrenal arteries were analyzed using angiographic findings and thin-slice CT images to provide a detailed assessment of vascular anatomy relevant to embolization.

Procedure

Selective angiography of the adrenal artery considered most likely, based on contrast-enhanced CT findings, to be the bleeding source was performed first. When active extravasation was identified, embolization was performed immediately. Regardless of the initial angiographic findings, additional evaluation of possible adrenal feeders was performed, including selective angiography of the inferior phrenic and renal arteries and aortography, as needed. Vascular access was obtained via retrograde puncture of the common femoral artery using a 4-French or 5-French introducer sheath. A loop-shaped and/or Shepherd’s hook catheter (e.g., GHC-A; Hanako®, Osaka, Japan) was used as a diagnostic catheter. A microcatheter (e.g., Progreat λ17; Terumo®, Tokyo, Japan) was selectively advanced into the target artery for embolization (Figs. 1, 2, 3). Gelatin sponge particles were used as the primary embolic material in all cases. Additionally, n-butyl cyanoacrylate (NBCA; Histoacryl; B. Braun, Melsungen, Germany) mixed with ethiodized oil (Lipiodol; Guerbet, Villepinte, France) was used when deemed necessary by the operator, including for the management of procedure-related arterial injury.

Fig. 1.

Patient 1, a 78-year-old man. Axial computed tomography images in the unenhanced (A), arterial (B), venous (C), and delayed (D) phases show a right adrenal hematoma (white asterisk) with progressive contrast extravasation (white arrows), consistent with active bleeding. E Right renal arteriography demonstrates the inferior adrenal artery (black arrow). F Right inferior phrenic arteriography shows contrast extravasation from the middle adrenal artery (black arrow). G Selective angiography of the right middle adrenal artery confirms contrast extravasation (black arrow)

Fig. 2.

Patient 5, an 83-year-old woman with left adrenal hemorrhage. Axial computed tomography images in the unenhanced (A), arterial (B), venous (C), and delayed (D) phases show a left adrenal hematoma (white asterisk) with progressive contrast extravasation (white arrows), consistent with active bleeding. E Angiography shows contrast extravasation from the left middle adrenal artery arising from the aorta, with a 5-French GHC-A catheter positioned at its origin (dotted black arrow)

Fig. 3.

Patient 8, an 83-year-old man. Selective angiography of the left middle adrenal artery (black arrow), arising from the left gonadal artery (dotted black arrows), demonstrates contrast extravasation (arrowhead)

CT protocol

All patients underwent whole-body unenhanced and dual-phase contrast-enhanced CT examinations using a multidetector CT scanner as part of the institutional trauma imaging workflow in place during the study period. Automatic tube current modulation, combining z-axis and angular modulation based on patient size and body habitus, was used. Because the study spanned a long period, scanner hardware and detailed acquisition parameters were not identical in all cases. Representative acquisition parameters during the study period were as follows: tube voltage, 120 kVp; tube current, variable; noise index, 10.0 Hounsfield Unit (HU; 5-mm reconstruction thickness) using adaptive statistical Iterative Reconstruction–Veo (ASiR-V; GE Healthcare, Milwaukee, WI, USA) of 40%; detector configuration, 1.25-mm section thickness; beam collimation, 40 mm; rotation time, 0.4 s; pitch, 0.984:1; scan field of view, large body; display field of view, 36 cm; scan length, 620 mm; and total exposure time, 6.81 s. Breath-hold scans were acquired craniocaudally from the supraclavicular fossa to the pubic symphysis. Contrast-enhanced images were obtained after intravenous administration of iodinated contrast agent (370 mgI/mL; Iopamiron 370, Bayer AG, Leverkusen, Germany) at 100 mL and 4.0 mL/s using a power injector. Arterial- and venous-phase imaging was initiated at 5 and 120 s, respectively, after a bolus-tracking program (Smart-pre; GE Healthcare) detected a 100 HU threshold in the descending aorta at the level of the bronchial carina.

Results

Clinical outcomes

Eight patients with traumatic adrenal hemorrhage treated with TAE were included (4 men and 4 women; age range, 47–89 years; median age, 78 years). All patients demonstrated active contrast extravasation on pre-procedural contrast-enhanced CT, with a median maximum hematoma diameter of 43 mm (range, 37–78 mm). Right-sided adrenal hemorrhage was observed in six patients (75%), while the remaining two patients (25%) had left-sided involvement; no bilateral cases were identified. Patient demographics, clinical characteristics, vital signs, and outcomes are summarized in Table 1. All patients had multiple injuries, three required blood transfusions and two were receiving antithrombotic therapy. The median hospitalization duration was 13.0 days (range, 8–44 days). During hospitalization, follow-up CT was obtained in 7 of 8 patients, with 1 to 5 examinations per patient. These studies were independently reviewed by non-operator physicians and generally showed hematoma reduction or resorptive change without evidence of worsening active bleeding. Post-discharge follow-up was frequently continued at outside hospitals and was therefore not uniformly available for review. Mean pre- and post-procedural hemodynamic parameters were as follows: heart rate, 86 vs. 83 beats per minute; systolic/diastolic blood pressure, 138/78 vs. 123/61 mmHg; and hemoglobin, 12.3 vs. 10.3 g/dL. Post-procedural decreases in hemoglobin level should be interpreted cautiously in the context of the overall clinical course, as they may partly reflect hemodilution related to fluid administration rather than ongoing or recurrent bleeding.

Table 1.

Clinical characteristics and outcomes of the present cases

Variable		Value
Number of patients		8
Sex (male/female)		4 (50%)/4 (50%)
Age (median, years)		78.0 (range 47–89)
Side of injury (right/left)		6 (75%)/2 (25%)
Cause of injury (traffic accident/fall/falling tree)		5 (63%)/2 (25%)/1 (12%)
Multiple injuries		8 (100%)
Maximum hematoma diameter (median, mm)		43.0 (range 37–78)
Blood transfusion		3 (38%)
Antithrombotic therapy		2 (25%)
Procedure duration (median, min)		62.5 (range 45–113)
Technical success		8 (100%)
Clinical success		8 (100%)
Intraprocedural complications		1 (12%)
Adrenal insufficiency		0
Procedure-related mortality		0
Overall mortality		1 (12%)
Length of hospital stay (median, days)		13.0 (range 8–44)
Vital signs
	Pre-procedure	Post-procedure
Heart rate(/min)	86	83
Blood pressure (systolic/diastolic; mmHg)	138/78	123/61
Hemoglobin level (g/dL)	12.3	10.3

Trauma-related clinical variables are summarized in Table 2. Two patients were receiving antithrombotic therapy: Patient 3 was on rivaroxaban for paroxysmal atrial fibrillation, whereas Patient 8 was taking aspirin for a previous myocardial infarction. Treatment for associated injuries included additional embolization for renal, pelvic, and hepatic injuries, as well as chest tube placement, posterior pelvic fixation, hernia repair, distal radius/ulna fixation, below-knee amputation, and dialysis. Adrenal TAE was the only TAE procedure in three patients (Patients 1, 3, and 4). The remaining five patients underwent TAE for multiple traumatic bleeding sites as part of their overall trauma management. In these patients, adrenal TAE was performed after another TAE procedure in three patients (Patients 5, 7, and 8) and between other TAE procedures in two patients (Patients 2 and 6); adrenal TAE was not performed first in any of these five patients. One patient (Patient 8) died from complications unrelated to adrenal hemorrhage during hospitalization (Day 8). No pre-procedural or ongoing vasopressor support was required; vasopressors were used only during terminal deterioration in Patient 8. No overt clinical evidence of adrenal insufficiency was observed during hospitalization, and no patient required steroid supplementation. Although electrolyte abnormalities were observed in several patients during hospitalization, these findings were interpreted in the context of severe trauma, fluid resuscitation, and associated conditions rather than as definitive evidence of adrenal insufficiency.

Table 2.

Trauma-related clinical context of the present cases

Patient	Age/sex	Side	Cause	Associated major injuries	ISS	Antithrombotic therapy	Coagulation profile Plt(× 10 4 /μL) / APTT(s) / PT-INR	Electrolyte abnormality HypoNa / HyperK	Transfusion RCC/Plt/FFP (unit)	Vasopressors	Treatment for concomitant injuries	Overall outcome/remarks
1	78/M	R	Traffic accident	SAH/odontoid fracture/hemothorax with rib fractures/liver injury	22	No	9.9/30.3/1.15	No/No	0/0/0	No	Conservative management	Survived
2	71/M	R	Fall	Right renal injury/right hemopneumothorax	25	No	20.4/27.7/0.98	No/No	0/0/0	No	Renal TAE	Survived
3	89/F	R	Traffic accident	Pulmonary contusion/omental injury/iliopsoas hematoma	18	Yes; Rivaroxaban for PAF	19.9/24.5/1.06	No/No	0/0/0	No	Conservative management	Survived
4	47/M	R	Falling tree	Right hemopneumothorax/pulmonary contusion/traumatic abdominal wall hernia	19	No	28.4/21.9/0.92	Yes/No	0/0/0	No	Chest tube placement; hernia repair	Survived
5	83/F	L	Traffic accident	Pelvic fracture/left hemothorax/pulmonary contusion/occipital subcutaneous hematoma	34	No	10.4/54.4/1.53	Yes/No	18/30/28	No	Pelvic TAE; posterior pelvic fixation	Survived
6	85/F	R	Fall	Liver injury/right hemothorax/pubic fracture/distal radial fracture	27	No	13.8/30.6/1.09	Yes/Yes	6/0/0	No	Multivessel TAE; distal radius/ulna fixation	Survived
7	74/F	R	Traffic accident	Traumatic SAH/pulmonary contusion/liver contusion	29	No	22.1/22.7/0.97	Yes/No	0/0/0	No	Hepatic TAE (A7)	Survived
8	83/M	L	Traffic accident	Unstable pelvic fracture/acetabular fracture/liver injury/splenic injury/rib fractures	22	Yes; Aspirin for previous MI	5.7/50.8/1.29	Yes/Yes	16/70/26	Yes (terminal use)	Pelvic TAE; below-knee amputation; dialysis	Died from complications unrelated to adrenal hemorrhage

Abbreviations: M male, F female, R Right, L Left, ISS Injury Severity Score, Plt Platelet count, APTT Activated partial thromboplastin time, PT-INR Prothrombin time-international normalized ratio, HypoNa Hyponatremia (< 136 mEq/L), HyperK Hyperkalemia (> 5.1 mEq/L), RCC Red cell concentrate, FFP Fresh frozen plasma, TAE Transcatheter arterial embolization, SAH Subarachnoid hemorrhage, PAF = Paroxysmal atrial fibrillation, MI = Myocardial infarction

Patient 8 corresponds to a previously published case report (Miyake et al., 2020)

Procedural details and outcomes are summarized in Table 3. The median interval between contrast-enhanced CT and angiography was 89.5 min (range, 53–212 min). Extravasation of the contrast medium was confirmed in all patients during angiography. Gelatin sponge particles were used in all procedures. The median procedure time was 62.5 min (range, 45–113 min). Single-artery embolization was sufficient in six cases (75%), whereas two patients (25%) required embolization of multiple adrenal arteries. Middle adrenal artery (ADA) embolization was performed in six patients, superior ADA embolization in two, and inferior ADA embolization in three.

Table 3.

Embolization details and outcomes of the present case series

Patient	Side	No. of embolized ADAs	Embolized ADAs	Embolic material	Technical success	Clinical success	Intraprocedural complication	Overt clinical evidence of adrenal insufficiency	Procedure-related mortality
1	R	Single	M	GS	Yes	Yes	None	No	No
2	R	Multiple	M, I	GS	Yes	Yes	None	No	No
3	R	Single	I	GS	Yes	Yes	None	No	No
4	R	Multiple	S, M, I	GS	Yes	Yes	None	No	No
5	L	Single	M	GS	Yes	Yes	None	No	No
6	R	Single	S	GS	Yes	Yes	IPA perforation*	No	No
7	R	Single	M	GS	Yes	Yes	None	No	No
8	L	Single	M	GS	Yes	Yes	None	No	No

Abbreviations: R Right, L Left, ADA Adrenal artery, S Superior, M Middle, I Inferior, GS Gelatin sponge, IPA Inferior phrenic artery, NBCA n-butyl cyanoacrylate

^*Successfully embolized with 50% NBCA-Lipiodol mixture

One intraprocedural complication occurred: catheter-related perforation of the inferior phrenic artery, which was successfully treated with a 50% NBCA-lipiodol mixture.

No procedure-related mortality was observed. Technical and clinical success were achieved in all cases (100%, 8/8).

Anatomical patterns of the adrenal arteries

The anatomical patterns of detectable ADAs are summarized in Table 4 and Fig. 4. In our cohort, the inferior phrenic artery originated from the renal artery in three patients (38%), the aorta in two (25%), and the celiac trunk in three (38%). The superior ADA consistently arose from the inferior phrenic artery in all cases. The middle ADA arose from the aorta in two cases (25%), from the inferior phrenic artery in four cases (50%), and from the left gonadal artery in one case; it was not detected in one case (Fig. 3). The inferior ADA most commonly arose from the renal artery in four patients (50%), whereas it was not clearly visualized in the remaining four cases on angiography or contrast-enhanced CT.

Table 4.

Anatomical origins of inferior phrenic and adrenal arteries

Patient	Sex	Side	The origin of IPA	The origins of adrenal arteries
				S	M	I
1	M	R	RA	IPA	IPA	RA
2	M	R	RA	IPA	IPA	RA
3	F	R	CA	IPA	unknown	RA
4	M	R	RA	IPA	IPA	RA
5	F	L	Ao	IPA	Ao	unknown
6	F	R	Ao	IPA	Ao	unknown
7	F	R	CA	IPA	IPA	unknown
8	M	L	CA	IPA	GA	unknown

Abbreviations: M = Male, F = Female, R = Right, L = Left, S = Superior, M = Middle, I = Inferior, Ao = Aorta, CA = Celiac artery, IPA = Inferior phrenic artery, RA = Renal artery, GA = Gonadal artery, unknown = not identified on angiography or contrast-enhanced CT

Fig. 4.

Schematic representation of the anatomical patterns of detectable adrenal arteries in our cases

Discussion

Traumatic adrenal hemorrhage is a clinically important injury that may lead to life-threatening hemorrhage. While TAE has emerged as a valuable minimally invasive treatment option for selected patients with active contrast extravasation, its clinical utility and technical considerations remain insufficiently defined because of the rarity of this injury and the variability of the adrenal arterial anatomy. Therefore, we present a relatively large single-center case series of traumatic adrenal hemorrhage treated with TAE, with particular emphasis on in-hospital outcomes, angiographic anatomy, and embolization strategy, alongside a focused review of the literature. Traumatic adrenal hemorrhage is an uncommon injury, typically unilateral and predominantly affecting the right adrenal gland. Its low incidence likely reflects the protected retroperitoneal location and small size of the adrenal glands [3, 7]. Proposed mechanisms include direct compression, inferior vena cava-related venous hypertension, venous thrombosis or obstruction, and shear injury to small intraglandular vessels during deceleration [2, 4]. These anatomical and pathophysiological factors may also explain the right-sided predominance, as the right adrenal gland is particularly susceptible to compression between the liver and spine and drains directly into the inferior vena cava via a short vein, facilitating abrupt increases in venous pressure. Adrenal injury is associated with increased mortality, higher morbidity, and a greater burden of concomitant multi-organ injuries [2]. Given the rarity of this injury and the heterogeneity of mechanisms and clinical severity, optimal management remains controversial.

Currently, no consensus exists regarding the necessity or timing of intervention. Some authors advocate early treatment, whereas others report favorable outcomes with conservative management. Liao et al. [8] demonstrated that extravasation alone does not mandate intervention, while the need for treatment increases substantially when extravasation is accompanied by a mean arterial pressure (MAP) < 70 mmHg. However, several reports describe patients with MAP ≥ 70 mmHg who were initially managed conservatively but later required TAE [9–11], suggesting that MAP ≥ 70 mmHg may be insufficient as a standalone threshold. Persistent contrast extravasation may justify consideration of TAE even in initially hemodynamically stable patients. Accordingly, indications for TAE should be individualized based on hemodynamics and trends, concomitant injuries, transfusion requirements, and imaging findings. A thorough understanding of adrenal arterial anatomy, including potential access routes, is essential for patient selection and procedural planning.

Each adrenal gland is supplied by three principal arteries: the superior, middle, and inferior ADAs. These vessels show marked variability in origin, most commonly arising from the inferior phrenic artery (IPA), aorta, and renal artery, respectively [12–14]. Each ADA divides into numerous fine branches forming a dense capsular plexus, frequently resulting in multifocal bleeding from small feeders during hemorrhage [7, 12, 15, 16]. While the superior and inferior ADAs typically originate from the IPA and renal artery, respectively, the middle ADA demonstrates the greatest variability, potentially arising from the aorta or IPA or may be absent altogether. Rare variants—including branches from the celiac axis, intercostal, polar renal, gonadal, or even superior mesenteric arteries—necessitate a systematic angiographic search when initial selective studies are negative [12–14, 17].

Given their frequent involvement with the IPA, detailed knowledge of its branching patterns is critical. Aslaner et al. reported that a common IPA trunk is present in approximately 30% of patients, typically arising from the aorta [18]; otherwise, IPAs usually originate from the celiac axis. This distribution shifts in the presence of celiac axis variants, such as hepatosplenic or hepatomesenteric trunks, where IPAs more frequently arise from the aorta, left gastric artery, or renal artery. Consistent with this variability, we observed the right IPA originating from the right renal artery in three of eight patients. In these cases, the superior and middle ADAs arose from the IPA, and the inferior ADA originated directly from the right renal artery. This pattern suggests that early selective renal angiography should be considered to identify an IPA originating from the renal artery and its adrenal branches, particularly when conventional IPA or aortic origins are not visualized. Building on prior case reports and smaller series, our study provides a more structured description of adrenal feeder anatomy, the angiographic search strategy, and the technical implications of variable adrenal arterial supply for embolization planning in traumatic adrenal hemorrhage. The available English-language evidence on TAE for traumatic adrenal injury remains limited, consisting mainly of case reports and small series. For contextual comparison, we reviewed 10 relevant original articles and extracted data only for TAE-treated patients from studies including mixed treatment modalities [5, 9–11, 15, 19–23]. Across these published cases, the culprit arteries were variable, with frequent involvement of adrenal branches from the inferior phrenic and renal arterial territories. Some cases involved multiple bleeding sources or required multi-artery embolization, supporting the need for a systematic angiographic search strategy (Tables 5 and 6). A systematic angiographic approach—beginning with the IPA and renal arterial territories and extending to adjacent feeders if needed—may be critical for timely identification of bleeding sources and minimizing incomplete hemostasis or recurrent hemorrhage. Although embolization of multiple ADAs is sometimes required, adrenal insufficiency appears to be uncommon in unilateral injuries. However, adrenal insufficiency has been reported in bilateral adrenal trauma [24, 25], underscoring the need for vigilant endocrine follow-up in such patients. In our cohort, no patient received post-procedural steroid replacement therapy. Patient 8 presented with hyponatremia and hyperkalemia on admission, but these abnormalities were clinically attributed to trauma-related acute kidney injury secondary to rhabdomyolysis rather than definitive adrenal insufficiency. In the setting of severe polytrauma, electrolyte abnormalities may be multifactorial and should be interpreted cautiously. In addition, the 2017 SCCM/ESICM guidelines [26] for critical illness-related corticosteroid insufficiency suggest against routine corticosteroid use in major trauma and reserve corticosteroid therapy for selected critically ill patients, particularly those with refractory shock rather than hemodynamically stable trauma patients. Accordingly, even if trauma-related adrenal insufficiency is theoretically possible after adrenal hemorrhage or embolization, post-procedural hormone replacement should be approached cautiously in unilateral injuries without persistent biochemical, hemodynamic, or clinical findings strongly suggestive of adrenal failure.

Table 5.

Published reports of traumatic adrenal hemorrhage treated with transcatheter arterial embolization

Author (year)	Study type	No. of cases	Etiology	Side	Embolized ADA	Embolic material	TS	CS	Clinical outcome/remarks
Dinc et al. (2002) [19]	Case report	1	Blunt trauma	Right	Inferior	PVA	Yes§	Yes§	Initial conservative management; delayed instability/BP drop
Kish et al. (2004) [20]	Case series (mixed sites)	1/16	Fall (suicide)	NR	Inferior	NBCA	Yes§	Yes§	NBCA (1:4–1:5; case-specific ratio NR); occlusion microcatheter technique to prevent reflux
Ikeda et al. (2007) [9]	Case series	1*/7	Fall	Right	Inferior	Coil	Yes§	Yes§	An isolation technique with pushable and detachable microcoils
Agrawal et al. (2013) [21]	Case report	1	Blunt trauma	Right	Superior	Coils	Yes§	NR	Delayed detection of pseudoaneurysm; embolization effective
Liao et al. (2015) [5]	Retrospective cohort	4†/77	MVC	3 right/1 left	Inferior (all cases)	GS/coils	100%§	100%§	Renal artery–origin adrenal artery presumed to represent the inferior adrenal artery
Giurazza et al. (2019) [15]	Case series (mixed)	7‡/17	Blunt trauma	3 right/3 left/1 bilateral	1 superior/6 middle /1 superior & middle	GS/coils/microparticles/NBCA	94.1%¶	82.3%¶	Includes 7 “traumatic” cases; 2 were postoperative complications. Case-level identification not provided; subgroup analysis not feasible
Jegadeesan (2020) [10]	Case report	1	Traffic accident	Right	Superior	Coils	Yes§	Yes§	Initial conservative management: delayed instability/Hb drop
Sato (2023) [11]	Case report	1	MVC	Right	Middle	GS + coil	Yes§	Yes§	Initial conservative management: delayed instability/Hb drop
Kim et al. (2023) [22]	Case report	1	MVC	Right	Inferior	PVA	Yes§	Yes§	Required repeat TAE for recurrent bleeding. The right renal capsular artery was embolized using GS at first TAE
Perez-Sanchez et al. (2023) [23]	Case report	1	Fall	Right	Superior	NBCA	Yes§	NR	NBCA and Lipiodol dilution = 1:2

Abbreviations: TAE = Transcatheter arterial embolization, ADA = Adrenal artery, MVC =Motor vehicle collision, PVA = Polyvinyl alcohol, NBCA = N-butyl cyanoacrylate, GS = Gelatin sponge, TS = Technical success, CS = Clinical success, NR = Not reported, BP = Blood pressure, Hb = Hemoglobin

^*Ikeda et al. described a 7-case series, of which only one case was treated with TAE

^†Liao et al.: Among 77 patients, 4 underwent TAE

^‡Giurazza et al.: trauma-labeled subgroup (n = 7) includes 2 postoperative complications; case-level identification not provided

^§Adjudicated by the two reviewers according to the predefined definitions used in the present study when not explicitly stated in the original report. NR indicates insufficient information to adjudicate

^¶Reported TS/CS (94.1%/82.3%) are for all 17 cases (mixed etiologies); trauma-only outcomes not separable

Table 6.

Culprit arteries treated with TAE in published reports and the present case series

Author	Year	Number of patients	Cause	IPA involvement described	RA involvement described	Culprit ADAs
						Right			Left
						S	M	I	S	M	I
Dinc et al	2002	1	Blunt trauma	No	Yes	-	-	1	-	-	-
Kish et al	2004	1	Fall	No	No	-	-	NR*	-	-	NR*
Ikeda et al	2007	1	Fall	No	No	-	-	1	-	-	-
Agrawal et al	2013	1	Blunt trauma	Yes	No	1	-	-	-	-	-
Liao et al	2015	4	MVC	No	No	-	-	3	-	-	1
Giurazza et al	2019	7†	Blunt trauma (n = 5)/postoperative (n = 2)	No	No	1	3	-	1	4	-
Jegadeesan et al	2020	1	Traffic accident	Yes	Yes	1	-	-	-	-	-
Sato	2023	1	MVC	No	No	-	1	-	-	-	-
Kim et al	2023	1	MVC	Yes	Yes	-	-	1	-	-	-
Perez-Sanchez et al	2023	1	Fall	No	No	1	-	-	-	-	-
Present cases	—	8	Blunt trauma	Yes	Yes	2	4	3	-	2	-
Total		27	-	-	-	6	8	9*	1	6	1*

Abbreviations: TAE = Transcatheter arterial embolization, IPA = Inferior phrenic artery, RA = Renal artery, ADA = Adrenal artery, S/M/I = Superior/middle/inferior adrenal artery, MVC = Motor vehicle collision, NR = Not reported

^*Laterality not reported (Kish et al.); excluded from side-specific totals

^†Giurazza et al.: traumatic subgroup extracted (n = 7; includes two iatrogenic cases after nephrectomy)

This study has several limitations. First, the retrospective single-center design, small sample size, and absence of a comparator group limit generalizability. Second, treatment effectiveness was assessed primarily on the basis of short-term in-hospital hemorrhage control. Because all patients had multisystem trauma, changes in hemoglobin level, transfusion requirement, overall clinical course, and post-embolization electrolyte trends may have been influenced by associated injuries, fluid resuscitation, and other trauma-related factors rather than adrenal hemorrhage alone. Third, endocrine assessment was based mainly on clinical course and routine laboratory findings, and formal hormonal testing such as serum cortisol measurement or ACTH stimulation testing was not uniformly performed; therefore, subclinical adrenal insufficiency cannot be completely excluded. In addition, follow-up imaging was not protocolized, and post-discharge follow-up care was often provided at outside hospitals, limiting uniform evaluation of delayed rebleeding and late endocrine sequelae. In conclusion, TAE appears to be a technically feasible hemostatic option in selected patients with traumatic adrenal hemorrhage and CT-detected contrast extravasation; however, the necessity of embolization and its comparative benefit over conservative management remain unclear. Careful evaluation of the complex and variable adrenal arterial anatomy may facilitate identification of the culprit vessel and procedural planning. However, the small sample size, retrospective design, lack of a comparator group, and limited follow-up preclude definitive conclusions regarding comparative efficacy or long-term safety.

Authors’ contributions

All authors contributed to the study conception and design. Data were acquired, analyzed, and interpreted by the authors. All authors contributed to drafting and critical revision of the manuscript, and all authors approved the final version.

Funding

This study was not supported by any funding.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and ethical restrictions. De-identified data may be made available by the corresponding author upon reasonable request, subject to approval by the relevant institutional review board/institutions and, where applicable, a data use agreement.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of our institute. The requirement for informed consent was waived because of the retrospective observational design. An opt-out procedure was used in accordance with institutional policy and applicable regulations.

Consent for publication

Consent for publication was obtained for every individual person’s data included in the study.

Competing interests

The authors declare that they have no competing interests.