imaging findings of splenic trauma

1. SLIDE SHOW
21ST JAN,2023
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2. THANK YOU
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3. • The spleen is the most commonly injured
abdominal organ and this may follow
accidental or non-accidental trauma.
• It can occur after blunt or penetrating trauma
or secondary to medical intervention (i.e.
iatrogenic).
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4. • Epidemiology
• In blunt trauma, the spleen can account for up
to 49% of abdominal organ injuries 2.
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5. • Clinical presentation
• Patients may present with left upper
quadrant, left chest pain, left shoulder tip pain
(referred from diaphragmatic irritation), and
signs of hypotension or shock.
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6. • Pathology
• The spleen may be injured after blunt or
penetrating trauma or may be iatrogenic (e.g.
colonoscopy).
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7. • Types
• laceration
• hematoma: subcapsular (more common) or
intraparenchymal
– Seurat spleen
• active hemorrhage
• pseudoaneurysm or AV fistulas (in ~15% of
splenic trauma 4)
• splenic infarct (rare) 7
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8. • The American Association for the Surgery of
Trauma (AAST) splenic injury scale, most
recently revised in 2018, is currently the most
widely used grading system for splenic
trauma.
• The 2018 update incorporates "vascular
injury" (i.e. pseudoaneurysm, arteriovenous
fistula) into the imaging criteria for visceral
injury 4.
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9. • Classification
• grade I
– subcapsular hematoma <10% of surface area
– parenchymal laceration <1 cm depth
– capsular tear
• grade II
– subcapsular hematoma 10-50% of surface area
– intraparenchymal hematoma <5 cm
– parenchymal laceration 1-3 cm in depth
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10. • grade III
– subcapsular hematoma >50% of surface area
– intraparenchymal hematoma ≥5 cm
– parenchymal laceration >3 cm in depth
– ruptured subcapsular or intraparenchymal
hematoma
• grade IV
– any injury in the presence of a splenic vascular
injury* or active bleeding confined within splenic
capsule
– parenchymal laceration involving segmental or
hilar vessels producing >25% devascularisation
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11. • grade V
– shattered spleen
– any injury in the presence of splenic vascular injury* with active bleeding
extending beyond the spleen into
• Additional points
• advance one grade for multiple injuries, each up to grade III
• "vascular injury" (i.e. pseudoaneurysm or AV fistula)
appears as a focal collection of vascular contrast which
decreases in attenuation on delayed images
• "active bleeding" - focal or diffuse collection of vascular
contrast which increases in size or attenuation on a delayed
(i.e. later) phase
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12. .
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13. • Associations
• Splenic trauma is associated with injuries to other
intra-abdominal organs 1:
• left hemidiaphragm
• left lobe of the liver
• left kidney
• left adrenal gland
• pancreatic tail
• In penetrating trauma, the spleen is more likely to
be injured than bowel
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14. • Complications
• Complications of splenic trauma include 2:
• delayed splenic rupture (~5% in non-surgically
treated patients)
• splenic pseudocyst (<1%)
• splenic abscess formation
• splenic artery pseudoaneurysm
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15. • .
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Plain X-rays may reveal indirect signs of splenic injury.
Loss of the normal splenic contour
Obliteration of the splenorenal ligament
Presence of free intraperitoneal fluid or gas.
Significant hemorrhage may appear as-
Blurring of the psoas muscle margin
Widening of the retroperitoneal space
Elevation of the diaphragm

16. • Radiographs can detect associated injuries to
adjacent organs and structures, such as the
liver, kidneys, and diaphragm.
• This information is crucial for determining the
appropriate management strategy
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17. • Radiographic Findings
• • Radiography 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”
• Chest radiography demonstrates associated injuries–
Lower left lobe atelectasis &/or consolidation
• – Left rib fractures, pneumothorax, pleural effusion
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• Radiographic features
• Ultrasound
• FAST scanning may be performed to determine the presence
of free fluid
– particularly in the upper abdomen
– fresh blood is usually characterized as echoes free
– absence of free fluid does not rule out splenic injury 1

19. • Splenic enlargement, a sonolucent rim of
subcapsular haematoma, heterogeneity of
splenic echotexture caused by a parenchymal
haematoma, linear or stellate lucencies
representing tears or lacerations and free
peritoneal fluid indicating haemoperitoneum
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20. • An acute haematoma may be hyperechoic to
the spleen then later become echopoor. A
splenic laceration may be missed by
ultrasound because haematomas may have
the same echogenicity as the spleen.
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21. • Ultrasonographic Findings
• • Subtle laceration may be missed, as ultrasound
is insensitive for parenchymal injury 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
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22. • CT Findings
• • NECT High-attenuation hemoperitoneum > 30 HU or perisplenic clot > 45 HU– Perisplenic, intraparenchymal, or
subcapsular hematoma Perisplenic hematoma: Located adjacent to spleen and implies disruption or rupture of
splenic capsule
• Intraparenchymal hematoma: Typically round, ovoid, or irregular in shape
• Subcapsular hematoma: Constrained by splenic capsule; crescentic in shape and compresses lateral margin of
parenchyma
• Sentinel clot sign: Highest density blood localizes adjacent to spleen (or any site of injury)– Indicates splenic injury
even in absence of demonstrable laceration
• Layered or lamellated clot if bleeding is intermittent
• • CECT 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
• Splenic fracture: Deep laceration extending from outer capsule through splenic hilum
• 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
• 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 Active extravasation (unlike pseudoaneurysm) changes in size and morphology between initial and
delayed phases
• 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
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23. • CT
• CT is the modality of choice for assessing splenic trauma:
• splenic parenchyma should be assessed in portal venous phase as the inhomogeneous splenic
enhancement (zebra or psychedelic spleen) seen on the arterial phase can mimic splenic
laceration/contusion; arterial phase scanning can be useful in detecting vascular injuries such as
pseudoaneurysm and AV fistula 3-5
• lacerations appear as linear or branching hypodensities (geographic pattern) 3
• subcapsular hematomas can be seen as low-density fluid adjacent to the spleen that distorts the
splenic architecture 2
• active hemorrhage appears as a high-density (80-95 HU) material due to the extravasation of
contrast media that increases in size on delayed imaging 2,3
• pseudoaneurysms and AV fistulas have a similar appearance to active hemorrhage on initial
scanning but do not increase in size on delayed phases 3 and follow the blood pool
• splenic clefts may be mistaken for a laceration 9
– these are due to persistent lobulation of the spleen after development
– in contrast to a laceration, a cleft is usually smooth with a rounded edge and is not associated with an
adjacent subcapsular hematoma or perisplenic fluid
– some larger clefts may contain fat
• Protocol advice Arterial phase images more sensitive for active extravasation or pseudoaneurysm
• Portal venous phase images more sensitive for parenchymal injury (i.e., laceration)
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24. • Angiographic Findings
• • Avascular parenchymal laceration with
amorphous parenchymal extravasation
• • Flattened lateral contour of spleen due to
subcapsular hematoma
• • Rounded contrast collections
(pseudoaneurysms)
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25. MRI
• Hematoma
• Splenic hematoma is usually secondary to trauma [18]. Like splenic
infarcts, the MR appearance is variable, depending on the age of
the lesion. On acute (1 to 2 days) and early subacute phase (2 to 7
days) hematomas show low signal intensity on T2-weighted images
and intermediate and increasingly higher signal intensity on T1-
weighted images, respectively. On late subacute phase (7 to 14–28
days), hematomas show hyperintensity on both T1- and T2-
weighted images (Figure 10). After 3 weeks (chronic), the
hematoma may have a cystic appearance, regarded as a
hyperintensity lesion on T2-weighted sequences with low signal
intensity on T1-weighted images [18]. Older hematomas appear
hypointense on both T1- and T2-weighted images, due to its fibrotic
component.
•
(c)
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26. • Magnetic resonance imaging (MRI):
– Similar findings to CT scans, but MRI can provide
better visualization of soft tissue injuries and
vascular structures.
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27. • .
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28. .grade I
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29. GRADE IV
• .
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30. Grade III
• .
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31. GRADE V
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32. (Left) Axial CECT in an 87-year-old woman who fell at a nursing home
demonstrates a splenic parenchymal laceration and intraperitoneal blood , as
well as a lentiform heterogeneous and higher attenuation collection
flattening the normal convex lateral splenic contour, representing a
subcapsular hematoma .
• .
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33. Right) Axial CECT in a 23-year-old man injured in a motor vehicle accident
shows a shattered spleen with a sentinel clot in the perisplenic region and
large hemoperitoneum .
• .
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34. ROLE OF INTERVENTIONAL
RADIOLOGY.
• Treatment and prognosis
• Most splenic injuries in haemodynamically-
stable patients are treated non-
surgically. Splenic artery embolization plays a
major role in treating high-grade splenic
injuries (both in haemodynamically-stable and
-unstable patients; practice varies from
institution-to-institution).
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