Splenic Trauma

Published on 20/07/2015 by admin

Filed under Radiology

Last modified 20/07/2015

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 Perisplenic hematoma: Located adjacent to spleen and implies disruption or rupture of splenic capsule

image Intraparenchymal hematoma: Typically round or irregular in shape
image Subcapsular hematoma: Constrained by splenic capsule and crescentic in shape
• Sentinel clot sign: Highest density blood localizes adjacent to spleen (or any site of injury)

image Indicates splenic injury even without demonstrable laceration
• Parenchymal laceration: Irregular linear, branching, or stellate area of nonenhancing low attenuation
• Splenic fracture: Deep laceration extending from outer capsule through splenic hilum
• Splenic infarction: Unusual (< 2% of cases) in the setting of trauma, and can be segmental or complete
• Active arterial extravasation: High-attenuation focus isodense with aorta, surrounded by lower attenuation clot or hematoma

image Distinction between active extravasation and pseudoaneurysm using delayed phase images

TOP DIFFERENTIAL DIAGNOSES

• Splenic cleft
• Splenic abscess
• Splenic infarct
• Splenic cyst
• Lymphoma and splenic tumors

CLINICAL ISSUES

• Most commonly injured solid abdominal organ in blunt trauma and most common abdominal organ injury requiring surgery
• Prone to develop delayed hemorrhage, but excellent prognosis with early intervention (surgery/embolization)
• Identification of active arterial extravasation or pseudoaneurysm best predictor of need for surgery and failure of nonoperative management
image
(Left) Axial CECT in an 87-year-old woman who fell at a nursing home demonstrates a splenic parenchymal laceration image and intraperitoneal blood image, as well as a lentiform heterogeneous and higher attenuation collection flattening the normal convex lateral splenic contour, representing a subcapsular hematoma image.

image
(Right) Axial CECT in a 23-year-old man injured in a motor vehicle accident shows a shattered spleen with a sentinel clot image in the perisplenic region and large hemoperitoneum image.
image
(Left) Axial CECT in a 19-year-old man who was an unrestrained passenger in a motor vehicle accident shows marked upper abdominal hemoperitoneum image, a shattered spleen with intrasplenic high-attenuation pseudoaneurysms image, and a focus of active arterial extravasation lateral to the spleen within the peritoneal cavity image.

image
(Right) Axial CECT in the same patient shows the active arterial extravasation image extending into the left paracolic gutter with surrounding hemoperitoneum image.

TERMINOLOGY

Synonyms

• Splenic laceration or splenic fracture

Definitions

• Splenic parenchymal injury ± capsule disruption

IMAGING

General Features

• Best diagnostic clue

image Low-attenuation splenic laceration with high-density active bleeding
• Morphology

image Lacerations: Linear or jagged edges
image Fracture: Laceration extending from outer cortex to hilum
image Subcapsular hematoma: Flattened contour of splenic parenchyma

Radiographic Findings

• Radiography

image Abdominal radiography

– Left upper quadrant soft tissue mass
– Signs of intraperitoneal fluid with widening of distance between flank strip and descending colon
– Fluid in pelvis with prominent pelvic “dog ears”
image Chest radiography demonstrates associated injuries

– Lower left lobe atelectasis &/or consolidation
– Left rib fractures, pneumothorax, pleural effusion

CT Findings

• NECT

image High-attenuation hemoperitoneum > 30 HU or perisplenic clot > 45 HU

– Perisplenic, intraparenchymal, or subcapsular hematoma

image Perisplenic hematoma: Located adjacent to spleen and implies disruption or rupture of splenic capsule
image Intraparenchymal hematoma: Typically round, ovoid, or irregular in shape
image Subcapsular hematoma: Constrained by splenic capsule; crescentic in shape and compresses lateral margin of parenchyma
image Sentinel clot sign: Highest density blood localizes adjacent to spleen (or any site of injury)

– Indicates splenic injury even in absence of demonstrable laceration
image Layered or lamellated clot if bleeding is intermittent
• CECT

image Parenchymal laceration: Irregular linear, branching, or stellate area of nonenhancing low attenuation within parenchyma

– May extend to splenic capsule resulting in capsular tear
– Should become less conspicuous on follow-up imaging
image Splenic fracture: Deep laceration extending from outer capsule through splenic hilum
image Splenic infarction: Unusual (< 2% of cases) in setting of trauma

– Can be segmental or complete
– Wedge-shaped area of hypoattenuation
– Due to arterial thrombosis after intimal injury
– Risk of delayed rupture or abscess formation
image Active arterial extravasation: High-attenuation focus isodense with aorta, surrounded by lower attenuation clot or hematoma

– May be linear (spurting vessel) or rounded (pseudoaneurysm): Distinction is made using delayed phase images

image Active extravasation (unlike pseudoaneurysm) changes in size and morphology between initial and delayed phases
image Although delayed images are not routinely included in most trauma protocols, addition of delayed images can be helpful if there is site of suspicion noted on initially acquired portal venous phase images

Ultrasonographic Findings

• Subtle laceration may be missed, as ultrasound is insensitive for parenchymal injury

image Lacerations can be hypoechoic or isoechoic to splenic parenchyma and can be very difficult to detect with US
• Free intraperitoneal fluid with low-level echoes representing hemoperitoneum and echogenic perisplenic clot
• Hematoma should be avascular

Angiographic Findings

• Avascular parenchymal laceration with amorphous parenchymal extravasation
• Flattened lateral contour of spleen due to subcapsular hematoma
• Rounded contrast collections (pseudoaneurysms)

Imaging Recommendations

• Best imaging tool

image CECT
• Protocol advice

image Arterial phase images more sensitive for active extravasation or pseudoaneurysm

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