Cortical rim sign (kidneys)

Last revised by Yahya Baba on 30 Jul 2023

The cortical rim sign describes the thin, viable rim of subcapsular cortex seen on contrast-enhanced CT or MRI in major renal vascular compromise including:

This occurs because the blood supply to the outer aspect of the cortex is derived from perforating branches of the renal capsular artery which is an early branch of the renal artery.

It is, therefore, useful in distinguishing lobar nephronia / acute pyelonephritis from a segmental renal infarct on contrast-enhanced CT or MRI.

In the setting of lobar nephronia / acute pyelonephritis, the areas of abnormally reduced enhancement typically involve a complete wedge of renal parenchyma, extending from medulla peripherally to the capsule. The imaging appearance is thought to correspond to a combination of edema and ischemia.

By contrast, segmental renal infarcts may result in wedge-shaped areas of abnormal renal parenchymal hypoenhancement with relative sparing of the cortex where perfusion may be preserved to a thin rim (2-4 mm) of cortex which enhances normally.

Unfortunately, the cortical rim sign is only seen in approximately half of renal infarcts and it may be partial or total depending on the level of vascular occlusion.

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Cases and figures

  • Case 1: renal infarction
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  • Case 2
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  • Case 3
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  • Case 4
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