CT scanning and splenic pseudoaneurysms.

1. Page 1
The use of repeat CT scanning in patients with splenic
injuries
Raimundas Lunevicius MD, PhD, FRCS
KCH, 3 May 2012
South East London Trauma Network

2. Spleen is as the 2nd most frequently injured solid organ following ab trauma
Liver injuries: 36 %
SI: occuring in 32 % of injuries to solid organs of abd cavity
Renal injuries: 26 %
Most often: in blunt trauma
Agreements
Controversies
Smith J, Caldwell E, D’Amours S, et al. ANZ J Surg 2005; 75:790-94
Background Page 2

3. • Patient selection to SNOM vs who needed AE
• SNOM to specific subpopulations
• The role of CT & angio-embolisation has not yet fully evolved (ex:…)
• AAST based prediction of the outcome of SI not reliable
• Further SI management plan when a patient was not AE / laparotomized
The use of imaging studies in SNOM is a major concern of
controversy →
is there a rationale for PSA radiological diagnosis in
whole SI population ?
Current controversies in management of splenic trauma
Gomez D, Haas B, Al-Ali, et al. Injury 2012;43:55-61 Page 3

4. Not surprisingly → No consensus (in 43 centers of Am, Eu, Australasia)
• On the need for routine follow-up imaging before / after discharge (PSA)
• On the need for routine re-CT scans in specific subpopulations
• On the utility of repeated CT scans after mild clinical deterioration
• On the expansion of the SNOM algorithm to specific populations
Key question: why is that ?
Key answers:
Institutional barriers to implement evidence-based care: …
Knowledge translation strategies do not (must) include all stakeholders:..
Gomez D, Haas B, Al-Ali, et al. Injury 2012;43:55-61
The use of imaging studies in SNOM
is a major concern of controversy Page 4

5. Some doctors think that
the use of early repeated CT scanning in patients with nonoperatively
managed SI (and liver) for the early diagnosis of posttraumatic
pseudoaneurysm and it’s AE is reasonable / justifiable / necessary
Some of them think that
routine CT scan follow-up (both early and delayed) is not necessary
Literature… findings…
The need for routine follow-up imaging Page 5

6. NOM was successful in 92% (45/49) adults
62% follow-up abdoCT scans were obtained (30/49)
Key question: did it affect management plan ?
Key answer: info that affected management was only on 1 follow-up CT
Follow-up abdoCT scans are not routinely necessary
in patients with SI managed nonoperatively
Thaermet, et al. J Trauma 1997; 43:748-51
The need for routine follow-up imaging Page 6

7. No doubt:
The incidence of splenic pseudoaneurysms correlates with the severity of SI:
71% of PSA develop following grade 3-4 SI
26% of PSA develop following grade 1-2 SI
.
Schurr MJ, Fabian TC, Gavant M, et al. J Trauma. 1995;39:507-513
How often the develop ?
Rare
Most result from blunt trauma
Tessier DJ, Stone WM, Fowl RJ, et al. J Vasc Surg. 2003;38:969-974.
The need for routine follow-up imaging Page 7

8. In whole SI population?
In 26 patients (8%) of 344 a contrast blush identified on urgent CT-scan
confirmed as a parenchymal PSA on arteriography
PSA incidence is 8% in whole SI population
Davis KA, Fabian T, Croce MA, et al. J Trauma. 1998;44:1008-1015
How does incidence of contrast blush correlate with SI
gr?
How often - numbers ? Page 8

9. Contrast blush (n=324) Splenic injury grade
3.2% 1-2
11.8% 3
69.7% 4-5
Correlation of incidence of contrast blush/CT/ with SI gr.
Omert, et al. J Trauma 2001; 51: 272-78 Page 9
CB is not an absolute indication for an operative or angiographic intervention

10. 43 (48%) pts: SI managed conservatively
All of them had an initial CT
• 31 had no follow-up radiographic studies & had no complications
• 12 pts had follow-up studies before discharge:
10 pts had no change in their clinical status and showed no
significant change in the radiographic injury pattern to the spleen
2 pts had developed shock and they underwent splenectomies
Splenectomies would have been done without re-CT scan
Routine follow-up radiographic evaluations are not necessary in the
nonoperative management of stable patients with splenic injuries
The need for routine follow-up imaging: a short story
Uecker J, et al. Am Surg 2001;67:22-5 Page 10

11. More specific:
Follow-up imaging (either CT or US) can be omitted
in clinically stable patients with blunt splenic trauma grade I-III
because they do not influence management
Lyass S, et al. Follow-Up Imaging Studies of Blunt Splenic Injury: Do They Influence Management? IMAJ 2001; 3: 731-3
The need for routine follow-up imaging Page 11

12. The severity of the SI does not have predictive value for development of SAP
Yardeni, J Trauma 2004:404-7
The significance of a a contrast blush on CT is unknown
Contrast blush presence alone does not predict delayed rupture of PSA or
failure of NOM
Cloutier, et al. J Pediatr Surg 2004;39:969-71.
Children subpopulation:
the need for routine follow-up imaging Page 12

13. Incidence 5.4%
186 children had SI, and 10 (5.4%) developed pseudoaneurysms
They were associated with
gr. III → 3/39, 8%, SI
gr. IV → 7/41, 17%, SI
• In 7 patients, the PSA thrombosed spontaneously
• AE was required in 2 children
• One underwent emergency splenectomy for delayed hemorrhage
Safavi A. et al. J Pediatr Surg 2011;46:938-41
Children subpopulation:
the need for routine follow-up imaging Page 13

14. Of the 176 patients who had liver injuries, 3 (1.7%) developed
pseudoaneurysms
All they were associated with gr. IV liver injuries (3/11, 27%)
1 child underwent early embolization
2 developed delayed hemorrhage requiring emergent treatment
Routine screening of pts only with high-grade - 4 - splenic and liver
injuries before discharge from hospital may be warranted because of
the potential risk of life-threatening hemorrhage
Safavi A. et al. J Pediatr Surg 2011;46:938-41
Children subpopulation:
the need for routine follow-up imaging / liver Page 14

15. 1. A variety of different suggestions have been made about follow-up
CT scanning ranging from no follow-ups at all to follow-ups at
frequent intervals.
2. Most series indicate that follow-up CT scan is not necessary
3. If performed, the frequency with which follow up CT scan alter
management is extremely low
Recommendations:
1. Routine repeated CT scan is not necessary
2. To perform CT-scan only in pts who have persistent abdominal
signs and symptoms after a week of observation
3. No contact sports or other activities where pts might suffer a blow
to the torso for 6 months
Feliciano, Mattox, Moore.Trauma, 6th edition. 2008 Page 15

16. Take – homes
1. No need for routine follow-up CT
2. Consider imaging: grade 4 (5) SI
3. Consider imaging: symptomatic pts
Thank you:
Clinical profile and natural history of splenic pseudoaneurysm is not well defined yet
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