The hollow adrenal gland sign: a newly described enhancing pattern of the adrenal gland on dual-phase contrast-enhanced CT for predicting the prognosis of patients with septic shock

  • Yang Peng
  • Qiuxia Xie
  • Huanjun Wang
  • Zhi Lin
  • Fan Zhang
  • Xuhui ZhouEmail author
  • Jian GuanEmail author
Emergency Radiology



To investigate the incidence, CT appearance, and implication for prognosis of the hollow adrenal gland sign (HAGS).


A total of 194 patients with septic shock and 24 patients with hemorrhagic shock (as control group) were retrospectively included in this study and the patients with septic shock were further divided into four subgroups (digestive tract diseases, DTD, n = 49; biliary and pancreatic diseases, BPD, n = 41; postsurgical infection, PI, n = 64; and other diseases, OD, n = 40). All patients underwent a dual-phase contrast-enhanced CT within 1 week after diagnosis. CT findings and clinical records were reviewed. If in the arterial phase the central zone of adrenal gland showed temporally much lower attenuation than the peripheral zone, it was defined as HAGS positive. The incidence of the HAGS in patients with septic shock and hemorrhagic shock, the demographic features, and mortality between HAGS-positive and HAGS-negative patients in each group were respectively compared.


The incidence of the HAGS in the septic shock group was nearly 30%, while it was 0 in the hemorrhagic shock group. There was no significant difference in age or gender between HAGS-positive and HAGS-negative patients in all groups, while the mortality of HAGS-positive patients was significantly higher than that of HAGS-negative patients in each group (p < 0.05). The concordance correlation coefficient value showed excellent reproducibility of the two observers (κ = 0.977).


The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.

Key Points

• The hollow adrenal gland sign (HAGS) newly described in this study is a special enhancing pattern of adrenal gland on dual-phase contrast-enhanced CT in patients with septic shock.

• The HAGS is characterized by the much lower-attenuated central zone of the adrenal gland in arterial phase and it showed excellent reproducibility between different observers.

• The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.


Shock, septic Shock, hemorrhagic Prognosis Tomography, X-ray computed Retrospective studies 



Biliary and pancreatic diseases


Computed tomography


Digestive tract diseases


Hollow adrenal gland sign


Hounsfield unit


Intensive care unit


Other diseases


Odds ratio


Postsurgical infection


Relative adrenal insufficiency



The authors state that this work was funded by National Natural Science Foundation of China (No.81701747, Huanjun Wang).

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Jian Guan.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of RadiologyThe First Affiliated Hospital of Sun Yat-Sen UniversityGuangzhouPeople’s Republic of China
  2. 2.Department of RadiologyThe Eighth Affiliated Hospital of Sun Yat-Sen UniversityShenzhenPeople’s Republic of China

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