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.
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).
Diffuse splenic injury, "Seurat" spleen
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.
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).
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
Computed tomography is a widely accepted and reliable diagnostic
procedure to image abdominal injury, identify hemoperitoneum, and
stage splenic injury.
The inability of CT to reliably predict successful nonoperative
management is also well recognized,
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.
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
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
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
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