CT and MRI features of adrenal hemangioma: A study of 21 cases from two centers

•AH is a rare tumor, and prone to misdiagnosis.•Small AHs are a few, and show homogeneous density or signal intensity with the typical enhancement pattern.•Most of AHs demonstrate large size, striking inhomogeneous density or signal intensity, and peripheral nodular enhancement without delayed central filling.•AH can also produce the cystic appearance. To retrospectively analyze the CT and MR imaging presentations of adrenal hemangioma (AH) and to strengthen the recognition for such tumors. This retrospective study enrolled 21 patients with 22 lesions histologically proven AH from two centers between October 2010 and November 2023. The clinical presentation and preoperative diagnosis were recorded. Two radiologists reviewed the CT and MR imaging features in consensus, including number, size, shape, boundary, attenuation, signal intensity, and dynamic enhancement pattern. The study included nine men and twelve women (mean age 55.6 ± 12.5 years, range, 35–77 years) without hormone production. AH was unilateral in 19 cases, bilateral in 2 cases. The maximum diameter was more than 3 cm in 19/22(86 %). AHs had oval (10/22,45 %), round (5/22, 23 %), or (7/22, 32 %) multilocular shape, and well-defined boundary (18/22,82 %). On unenhanced CT, 11/20 (55 %) displayed peripheral iso-density and central hypo-intensity, 3/20 (15 %) heterogeneously hyper-density, 6/20 (30 %) hypodensity, and 14/20 (70 %) contained speckled calcification. On T2-weighted images, 7/12 (58 %) exhibited nodular hyper-intensity peripherally, markedly hyper-intensity centrally, and hypo-intense fibrotic scar in between, 5/12 (42 %) hyperintensity. On T1-weighted images, 6/12 (50 %) displayed center hyper-intensity surrounded by peripheral hypo-intensity, 5/12 (41 %) hypo-intensity, 1/11 (9 %) hyperintensity. On DWI, 7/12 (58 %) demonstrated mixed hyper-intensity and hypo-intensity, 5/12 (42 %) hyper-intensity. CT and MR imaging findings were suggestive of cystic change and necrosis (19/22,86 %, 4 cystic tumors), hemorrhage (15/22,68 %), fat (7/22, 33 %) within the tumors. CT and MR enhanced images showed peripheral nodular enhancement with (3/22,14 %) or without (13/22, 59 %) delayed central filling, nodular peripheral and center enhancement with progressive partial fill-in (2/22,9%), capsular and/or septal mild enhancement (4/22, 18 %), and capsule (16/22,73 %). The solid part was significantly enhanced, similar to the abdominal aorta (AA) with no statistical difference between the two (P >