Applied Radiology

Prepared by Andrew W. Morton, MD; Robin Boyd-Kranis, MD; Douglas M. Coldwell, MD, PhD, Department of Radiology, University of Maryland School of Medicine, Baltimore, MD.

CASE SUMMARY

A 17-year-old male presented to a Level-1 trauma center after sustaining multiple injuries in a head-on motor vehicle collision. Injuries included closed-head trauma, left pneumothorax, and blunt abdominal trauma. A CT scan of the abdomen was performed (figure 1), followed by angiography (figure 2).

DIAGNOSIS

Diffuse splenic injury, "Seurat" spleen

IMAGING FINDINGS

CT scan of the abdomen demonstrates multiple lacerations (Grade 4) within the spleen. There is a small amount of intraperitoneal blood around the spleen. No extravasation of contrast material or active hemorrhage is seen. Celiac angiogram and selective splenic artery angiogram show diffuse, small punctate pockets of contrast material throughout the spleen. Several small pseudoaneurysms are seen. No active bleeding was present at angiography. Embolization of the main splenic artery was performed.

DISCUSSION

Arteriographic findings have often been compared to famous works of art and the artists themselves. Splenic injuries with multiple, punctate pseudoaneurysms demonstrate a nice similarity with the pointilistic approach of George Seurat (1859-1891). ¹ Seurat, a 19th century French neo-impressionist, is remembered for his technique called "pointilism" that uses small dots or strokes of contrasting color to create subtle changes in form. A fine example of Seurat's work is "Sunday Afternoon on the Island of La Grande Jatte." The "Seurat" spleen pattern may be diffuse or involve focal areas within the injured spleen.

Splenic injury is a common sequela of blunt abdominal trauma. Non-operative management of hemodynamically stable patients with splenic injuries has become an increasingly more prevalent option than splenectomy. The benefits of splenic salvage in preventing the risk of overwhelming sepsis in postsplenectomy patients have been documented. ² Computed tomography is a widely accepted and reliable diagnostic procedure to image abdominal injury, identify hemoperitoneum, and stage splenic injury. ³ The inability of CT to reliably predict successful nonoperative management is also well recognized, ⁴ although several recent studies suggest that identification of an abnormal contrast blush on CT may be a useful predictor of failure of non-operative management. ⁵ Diagnostic arteriography is a frequently used to image and assess the extent of splenic injury. By accurately assessing the degree of splenic injury, a higher confidence level of predicting the success of non-operative management can be achieved. If active bleeding of the spleen is determined at arteriography, a therapeutic embolization can stop the hemorrhage.

Sclafani and colleagues ⁶ propose angio-graphically analyzing all splenic injuries diagnosed by CT scan as long as the patient remains hemodynamically stable. A celiac arteriogram is performed initially to evaluate the spleen and liver. A selective, two-view, splenic arteriogram is then performed to diagnose the presence of active bleeding. The absence of active bleeding at arterio-graphy predicts successful non-surgical management in most instances. The presence of a pseudo-aneurysm, arteriovenous fistula, or active contrast extravasation indicates ongoing hemorrhage that can lead to expansile hematoma formation, recurrent bleeding, and delayed splenic rupture in some patients.

Main splenic artery embolization of active bleeding is an effective method to achieve hemostasis in hemodynamically stable patients. Embolization temporarily reduces splenic blood flow and splenic arterial pressure and allows healing at the injury site. Main splenic embolization in the setting of trauma should be performed with stainless steel coils and not particulate embolization material. It is preferable to use larger coils than smaller coils, which have the potential to migrate into the distal splenic artery. After arterial occlusion is achieved by coil embolization, an angiogram is repeated to confirm the presence of collateral flow. Splenic perfusion is maintained via collateral vessels, preventing major splenic infarction. It is important to recognize that immediate complete hemostasis may not be accomplished as time is required to resolve the intrasplenic extravasastion.

Conservative management of splenic injuries has created an environment conducive to application of interventional radiological techniques for these patients. Diagnosis of splenic injury by CT and angiographic demonstration and treatment of active bleeding by transcatheter embolization permit successful nonoperative management of most splenic injuries occurring in hemodynamically stable patients.

REFERENCES

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