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(Radiology. 2000;217:75-82.)
© RSNA, 2000

Emergency Radiology

Nonsurgical Management of Blunt Splenic Injury: Use of CT Criteria to Select Patients for Splenic Arteriography and Potential Endovascular Therapy1

Kathirkamanathan Shanmuganathan, MD, Stuart E. Mirvis, MD, Robin Boyd-Kranis, MD, Tatsuyoshi Takada, MD, PhD and Thomas M. Scalea, MD

1 From the Department of Radiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201 (K.S., S.E.M., R.B.K.; the Shock Trauma Center, Baltimore, Md (K.S., S.E.M., R.B.K., T.M.S.); and the Department of Emergency and Critical Care Medicine, Kansai Medical University, Osaka, Japan (T.T.). Received September 3, 1999; revision requested October 8; final revision received February 22, 2000; accepted February 23. Address correspondence to K.S. (e-mail: kshan@radi.ummc.umaryland.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To determine if contrast material–enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization.

MATERIALS AND METHODS: During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome.

RESULTS: There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment.

CONCLUSION: Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.

Index terms: Computed tomography (CT), clinical effectiveness, 775.12112 • Computed tomography (CT), comparative studies, 775.1244, 775.12112 • Spleen, injuries, 775.411, 775.412


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Nonsurgical management is preferred for splenic injuries in children who are hemodynamically stable (1–4). The advantages of conservative therapy for splenic injury include the preservation of splenic immune function to prevent overwhelming postsplenectomy sepsis, a reduction in the number of nontherapeutic laparotomy procedures performed for splenic injury, and the avoidance of immediate and late complications associated with laparotomy (5–9). Although the nonsurgical management of stable blunt splenic injuries in adults has gained popularity in recent years, the initial choice of surgical versus nonsurgical management remains controversial (10–16). This controversy has been attributed to the relatively high failure rate of nonsurgical management (10%–31%) and to the potential to miss other intraabdominal injuries that require laparotomy (11,13,17,18). The failure of nonsurgical management of blunt splenic injuries in adults creates the potential for delayed rupture or progression of injury that may require urgent transfusion or emergency splenectomy and thus limits techniques to preserve splenic tissue (immune function), such as application of hemostatic agents, partial splenectomy, or splenorrhaphy (11–13,18).

During the past decade, conventional computed tomography (CT) with power injection of intravenous contrast material has been shown to be highly accurate (98%) in diagnosing acute splenic injuries (14,15,19–28). However, the various CT-based grading systems for splenic injury are not reliable for selecting patients who are likely to be treated successfully with conservative therapy (14,15,19–28). Sclafani et al (29,30) and Hagiwara et al (31) have shown that splenic arteriography can be used to diagnose and embolize traumatic splenic vascular lesions and have reported a 93%–97% success rate in patients with all grades of blunt splenic injury whose injuries were diagnosed with CT and treated nonsurgically. In retrospective studies by Gavant et al (32) and Federle et al (33), it has been reported that arterial contrast material extravasation or vascular abnormalities in the spleen at contrast material–enhanced conventional and spiral CT is associated with a high failure rate in patients with nonsurgically managed blunt splenic injuries. In these two studies, splenic arteriography was not performed to confirm or treat the splenic lesions seen at CT. The purpose of our prospective study was to determine the accuracy of contrast-enhanced spiral CT criteria in selecting patients with all grades of blunt splenic injury for splenic arteriography and for possible endovascular treatment.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
During a 15-month period, 195 patients (132 men, 63 women), aged 14–94 years (mean age, 35.3 years), were admitted to the Shock Trauma Center at the University of Maryland Medical Center, a level I trauma center, and received a diagnosis of blunt splenic injury. Contrast-enhanced spiral CT scans were obtained in 166 (85.1%) of these patients. Seventy-eight (40.0%) patients who were hemodynamically stable and required no immediate surgery underwent technically successful contrast-enhanced spiral CT followed by splenic arteriography and formed the study group. Arteriography of the spleen was not performed in 86 (41.1%) patients, who, in the opinion of the admitting surgeon, were considered to be hemodynamically unstable or to have other injuries that required urgent surgical treatment. Two patients had technically inadequate CT examinations and were not included in the study. The most common mechanism of injury was motor vehicle collision; other mechanisms included motorcycle collision, assault, falls, and pedestrian-vehicular collision.

Contrast-enhanced spiral CT scans were obtained by using a Somatom Plus 4 scanner (Siemens Medical Systems, Iselin, NJ) after the intravenous administration of 150 mL of 240 mg of iodine per milliliter of contrast material (iohexol, Omnipaque 240; Nycomed Amersham, New York, NY) at 3 mL/sec by means of a mechanical power injector (Mark IV; Medrad, Pittsburgh, Pa). A uniphasic injection with a scanning delay of 60 seconds from the initiation of contrast material injection was performed. Scans were obtained from the level of the diaphragm to the symphysis pubis by using a collimation of 8 mm and a table speed of 8 mm (pitch of one). All patients received oral contrast material that consisted of 600 mL diatrizoate sodium (2% Hypaque; Nycomed Amersham) in water, which was administered orally or through a nasogastric tube in two doses. The first dose of 300 mL was given 30 minutes before scanning, and the second dose was given in the scanning suite.

The contrast-enhanced spiral CT scans were interpreted prospectively by either of two radiologists (S.E.M. or K.S.) without knowledge of the arteriographic results. The criteria of the organ injury scale for splenic injuries (Table 1) were applied to all scans obtained prior to digital splenic arteriography to establish a CT grade for the splenic injury (34). CT scans obtained at admission were evaluated prospectively for intraparenchymal, subcapsular, or intraperitoneal splenic vascular contrast material extravasation or for vascular lesions, which included posttraumatic pseudoaneurysms and traumatic arteriovenous fistulas. Splenic vascular contrast material extravasation was defined as CT evidence of an irregular collection of intra- or extrasplenic contrast material enhancement, with an attenuation similar to or greater than that of the aorta or an adjacent major artery (32,35,36). A posttraumatic pseudoaneurysm or arteriovenous fistula in the spleen was defined as a well-circumscribed intrasplenic focus of increased attenuation that was higher than that of the surrounding enhancing splenic parenchyma (37). These two contrast-enhanced spiral CT findings were considered to be predictors of vascular injury that indicated the need for confirmatory splenic arteriography and possible endovascular therapy. The presence or absence of either of these CT criteria was correlated with the results of splenic arteriography in all 78 patients.


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  		TABLE 1. AAST Splenic Injury Scale (1994 Revision)
 
Digital arteriography of the spleen was performed by initially obtaining an anteroposterior celiac arteriogram. Additional anteroposterior and oblique projections of the spleen were obtained after selective catheterization of the main splenic artery. Indications for transcatheter splenic embolization included evidence of intraparenchymal, subcapsular, or intraperitoneal bleeding, posttraumatic pseudoaneurysm, or arteriovenous fistulas at splenic arteriography. Transcatheter embolization was performed with subselective placement of absorbable gelatin sponge (Gelfoam; Upjohn, Kalamazoo, Mich) and/or microcoils (Pharmacia and Upjohn, Kalamazoo, Mich) into the injured splenic branches. If the injured intrasplenic branch vessel could not be selected or if the parenchymal injury involved more than half of the spleen, the main (proximal) splenic artery was embolized with coils. The end point for selective transcatheter embolization was the occlusion of the injured intrasplenic arterial branch or the stasis of contrast material flow in the main splenic artery after proximal occlusion. Informed consent was obtained from all patients before arteriography and embolization.

Medical records were reviewed to determine demographic data, which included arteriographic findings, the number of patients treated with transcatheter embolization, and the outcome in patients whose blunt splenic injuries were managed nonsurgically. The clinical outcome and the contrast-enhanced spiral CT and arteriographic findings were categorized as true-positive, true-negative, false-positive, or false-negative (Table 2) to determine the sensitivities, specificities, positive and negative predictive values, and accuracies of contrast-enhanced spiral CT criteria as indicators for splenic arteriography. The standard of reference was considered to be splenic arteriographic findings in the nonsurgically treated patients and was considered to be surgical findings in the patients who underwent splenic surgery.


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  		TABLE 2. Categorization of Findings of Clinical Examination, Contrast-enhanced Spiral CT, and Angiography
 

   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Table 3 summarizes the results of splenic injury grading when the American Association for the Surgery of Trauma (AAST) splenic injury grading system was applied to the 78 admission contrast-enhanced spiral CT scans obtained prior to splenic arteriography (34). The frequency distribution of the contrast-enhanced spiral CT grade of splenic injury and the need for transcatheter splenic therapy or surgery is shown in Table 3. Transcatheter splenic embolization or splenic surgery was required in 17 (42%) of 41 patients with high-grade splenic injuries (grades III–V) and in six (16%) of 37 patients with low-grade splenic injuries (grade I or II).


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  		TABLE 3. Contrast-enhanced Spiral CT Grade and Need for Splenic Endovascular Treatment or Splenic Surgery
 
Comparison of Contrast-enhanced Spiral CT and Splenic Arteriographic Findings
The contrast-enhanced spiral CT studies and splenic arteriograms did not show evidence of splenic vascular contrast material extravasation or posttraumatic vascular lesions in 48 (62%) of 78 patients. Contrast-enhanced spiral CT showed evidence of intraparenchymal, subcapsular, or intraperitoneal splenic vascular contrast material extravasation in seven (9%) patients (Fig 1). Vascular lesions such as pseudoaneurysms (Fig 2) or arteriovenous fistulas (Fig 3) were seen in 19 (24%) patients (Table 4). All seven patients with splenic vascular contrast material extravasation underwent transcatheter embolization (n = 6) or splenectomy (n = 1) for bleeding. The patient in this group who needed splenectomy initially was treated nonsurgically, as splenic arteriography did not show evidence of bleeding (Fig 4). However, within 12 hours of arteriography, splenectomy was performed for ongoing splenic hemorrhage. The presence of splenic vascular contrast material extravasation at admission CT at had 100% sensitivity (seven of seven patients; 95% CI: 59%, 100%) in predicting the need for splenic arteriography with subsequent endovascular treatment or splenic surgery.



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  		Figure 1a. Active splenic vascular contrast material extravasation in a 77-year-old patient with blunt trauma. (a, b) Transverse contrast-enhanced spiral CT images show a grade III splenic injury, with subcapsular (straight arrow in a), intraparenchymal (arrowheads), and intraperitoneal (open arrow in b) vascular contrast material extravasation. Some free intraperitoneal fluid (curved arrow) is seen adjacent to the liver. (c) Anteroposterior celiac-axis arteriogram shows active bleeding (arrow). Transcatheter splenic embolization arrested the bleeding.

 


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  		Figure 1b. Active splenic vascular contrast material extravasation in a 77-year-old patient with blunt trauma. (a, b) Transverse contrast-enhanced spiral CT images show a grade III splenic injury, with subcapsular (straight arrow in a), intraparenchymal (arrowheads), and intraperitoneal (open arrow in b) vascular contrast material extravasation. Some free intraperitoneal fluid (curved arrow) is seen adjacent to the liver. (c) Anteroposterior celiac-axis arteriogram shows active bleeding (arrow). Transcatheter splenic embolization arrested the bleeding.

 


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  		Figure 1c. Active splenic vascular contrast material extravasation in a 77-year-old patient with blunt trauma. (a, b) Transverse contrast-enhanced spiral CT images show a grade III splenic injury, with subcapsular (straight arrow in a), intraparenchymal (arrowheads), and intraperitoneal (open arrow in b) vascular contrast material extravasation. Some free intraperitoneal fluid (curved arrow) is seen adjacent to the liver. (c) Anteroposterior celiac-axis arteriogram shows active bleeding (arrow). Transcatheter splenic embolization arrested the bleeding.

 


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  		Figure 2a. Splenic pseudoaneurysm in a 33-year-old patient who was admitted after a motor vehicle collision. (a) Transverse contrast-enhanced spiral CT scan shows a grade IV splenic laceration with multiple pseudoaneurysms (arrowheads in a and b). Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (b) Multiplanar coronal reformation image in the upper abdomen shows that only the lower half of the spleen was involved by vascular injuries and correlates well with the selective splenic arteriogram. Pseudoaneurysms cannot be differentiated from active contrast material extravasation on this image. Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (c) Selective splenic arteriogram shows multiple bleeding pseudoaneurysms (solid arrows) with intraparenchymal bleeds (open arrows). These vascular injuries were embolized successfully.

 


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  		Figure 2b. Splenic pseudoaneurysm in a 33-year-old patient who was admitted after a motor vehicle collision. (a) Transverse contrast-enhanced spiral CT scan shows a grade IV splenic laceration with multiple pseudoaneurysms (arrowheads in a and b). Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (b) Multiplanar coronal reformation image in the upper abdomen shows that only the lower half of the spleen was involved by vascular injuries and correlates well with the selective splenic arteriogram. Pseudoaneurysms cannot be differentiated from active contrast material extravasation on this image. Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (c) Selective splenic arteriogram shows multiple bleeding pseudoaneurysms (solid arrows) with intraparenchymal bleeds (open arrows). These vascular injuries were embolized successfully.

 


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  		Figure 2c. Splenic pseudoaneurysm in a 33-year-old patient who was admitted after a motor vehicle collision. (a) Transverse contrast-enhanced spiral CT scan shows a grade IV splenic laceration with multiple pseudoaneurysms (arrowheads in a and b). Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (b) Multiplanar coronal reformation image in the upper abdomen shows that only the lower half of the spleen was involved by vascular injuries and correlates well with the selective splenic arteriogram. Pseudoaneurysms cannot be differentiated from active contrast material extravasation on this image. Free intraperitoneal blood (arrows) is seen around the spleen, liver, and right paracolic gutter. (c) Selective splenic arteriogram shows multiple bleeding pseudoaneurysms (solid arrows) with intraparenchymal bleeds (open arrows). These vascular injuries were embolized successfully.

 


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  		Figure 3a. Posttraumatic splenic arteriovenous fistula in a 19-year-old patient admitted after being assaulted. (a) Transverse contrast-enhanced spiral CT image shows a grade II splenic laceration (arrow) without free intraperitoneal blood. Areas of high attenuation (arrowheads) are seen within and represent a posttraumatic vascular lesion. (b) Selective splenic arteriogram shows an arteriovenous fistula (arrow) in the midpole of spleen, which was embolized successfully with microcoils.

 


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  		Figure 3b. Posttraumatic splenic arteriovenous fistula in a 19-year-old patient admitted after being assaulted. (a) Transverse contrast-enhanced spiral CT image shows a grade II splenic laceration (arrow) without free intraperitoneal blood. Areas of high attenuation (arrowheads) are seen within and represent a posttraumatic vascular lesion. (b) Selective splenic arteriogram shows an arteriovenous fistula (arrow) in the midpole of spleen, which was embolized successfully with microcoils.

 

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  		TABLE 4. Correlation of Contrast-enhanced Spiral CT, Transcatheter Treatment, and Splenic Surgery
 


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  		Figure 4a. Images in a 34-year-old patient admitted after a motor vehicle collision. (a) Transverse contrast-enhanced spiral CT image shows a grade III splenic injury with active vascular contrast material extravasation (arrow) and with a large perisplenic hematoma (arrowheads) displacing the spleen (S) medially. (b) Selective splenic arteriogram shows the spleen as medially displaced from the ribs (arrows) as a result of the perisplenic hematoma. No active bleeding was seen in the spleen on multiple arteriographic views. Delayed splenectomy for splenic hemorrhage was performed 12 hours after arteriography.

 


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  		Figure 4b. Images in a 34-year-old patient admitted after a motor vehicle collision. (a) Transverse contrast-enhanced spiral CT image shows a grade III splenic injury with active vascular contrast material extravasation (arrow) and with a large perisplenic hematoma (arrowheads) displacing the spleen (S) medially. (b) Selective splenic arteriogram shows the spleen as medially displaced from the ribs (arrows) as a result of the perisplenic hematoma. No active bleeding was seen in the spleen on multiple arteriographic views. Delayed splenectomy for splenic hemorrhage was performed 12 hours after arteriography.

 
Vascular lesions including pseudoaneurysms and arteriovenous fistulas were seen at contrast-enhanced spiral CT in 19 patients with splenic injuries (Table 4). In nine patients, the lesions were confirmed at splenic arteriography and were embolized. In the other 10 patients, arteriography demonstrated irregular splenic parenchymal staining but no focal vascular injury; these patients did not meet the arteriographic criteria for transcatheter embolization. Delayed splenectomy was performed for hemorrhage in one of the 10 patients who received a diagnosis of splenic pseudoaneurysm at admission contrast-enhanced spiral CT but who had a splenic arteriogram that was negative for vascular injury.

Four other patients had evidence of posttraumatic pseudoaneurysm (n = 1) and/or arteriovenous fistulas (n = 3) that was demonstrated only at arteriography and was treated with splenic embolization. At retrospective review of the splenic arteriograms of two of the four patients treated with transcatheter splenic embolization for posttraumatic arteriovenous fistulas, arteriographic findings were believed to represent early filling of the splenic veins, which was considered to be physiologic shunting resulting from hyperdynamic circulation. The other two patients had low-grade splenic injuries (grades I and II), and splenic arteriography demonstrated a posttraumatic arteriovenous fistula (n = 1) and pseudoaneurysms (n = 2) that required transcatheter embolization (Fig 5). One patient had both a posttraumatic pseudoaneurysm and an arteriovenous fistula. The finding of a splenic vascular lesion at contrast-enhanced spiral CT was 83% (10 of 12 patients; 95% CI: 52%, 98%) sensitive in predicting the need for splenic arteriography and subsequent endovascular therapy or splenic surgery.



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  		Figure 5a. Images in a 58-year-old patient admitted after a motor vehicle collision. (a) Contrast-enhanced spiral CT image obtained at admission shows a minimal amount of free fluid (arrowheads) adjacent to the spleen. (b) Selective and (c) subselective splenic arteriograms of the lower pole lesion show intraparenchymal bleeding (straight arrow in b) in the upper pole and an arteriovenous fistula (curved arrow in b), with early filling of the splenic vein (arrow in c) in the lower pole of the spleen. Both lesions were embolized with absorbable gelatin sponge and microcoils.

 


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  		Figure 5b. Images in a 58-year-old patient admitted after a motor vehicle collision. (a) Contrast-enhanced spiral CT image obtained at admission shows a minimal amount of free fluid (arrowheads) adjacent to the spleen. (b) Selective and (c) subselective splenic arteriograms of the lower pole lesion show intraparenchymal bleeding (straight arrow in b) in the upper pole and an arteriovenous fistula (curved arrow in b), with early filling of the splenic vein (arrow in c) in the lower pole of the spleen. Both lesions were embolized with absorbable gelatin sponge and microcoils.

 


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  		Figure 5c. Images in a 58-year-old patient admitted after a motor vehicle collision. (a) Contrast-enhanced spiral CT image obtained at admission shows a minimal amount of free fluid (arrowheads) adjacent to the spleen. (b) Selective and (c) subselective splenic arteriograms of the lower pole lesion show intraparenchymal bleeding (straight arrow in b) in the upper pole and an arteriovenous fistula (curved arrow in b), with early filling of the splenic vein (arrow in c) in the lower pole of the spleen. Both lesions were embolized with absorbable gelatin sponge and microcoils.

 
Contrast-enhanced Spiral CT Findings as an Indication for Splenic Arteriography
The correlation of the contrast-enhanced spiral CT criteria, the arteriographic findings, and the clinical outcome were categorized as true-positive (17 patients), true-negative (48 patients), false-positive (nine patients), or false-negative (four patients), as shown (Fig 6). The two contrast-enhanced spiral CT criteria, contrast material extravasation from the spleen and focal intrasplenic vascular abnormality, had an overall sensitivity of 81% (17 of 21 patients; 95% CI: 58%, 95%), a specificity of 84% (48 of 57 patients; 95% CI: 72%, 93%), negative and positive predictive values of 92% (48 of 52 patients; 95% CI: 82%, 98%) and 65% (17 of 26 patients; 95% CI: 44%, 83%), respectively, and an accuracy of 83% (65 of 78 patients; 95% CI: 73%, 91%) in predicting the need for splenic arteriography and subsequent endovascular therapy or surgery. These criteria were applied to all grades of blunt splenic injury initially managed nonsurgically.



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  		Figure 6. Chart shows the utility of contrast-enhanced spiral CT (CESCT) in predicting the need for splenic embolization or splenectomy. Angio = angiography, TP = true-positive, FP = false-positive, TN = true-negative, FN = false-negative, # = splenectomy, and * = normal physiologic shunting in the spleen.

 
Failure of Nonsurgical Management
Splenectomy was performed for delayed splenic hemorrhage in all five (6%) of the 78 patients whose initial nonsurgical treatment failed. The contrast-enhanced spiral CT and splenic arteriographic results in these five patients are shown in Table 5. Neither contrast-enhanced spiral CT nor digital splenic arteriography showed evidence of vascular injuries in two patients whose nonsurgical treatment failed. Two other patients whose nonsurgical treatment failed had evidence of one of the two contrast-enhanced spiral CT criteria for embolization, which included splenic vascular contrast material extravasation (n = 1) (Fig 4) and posttraumatic pseudoaneurysm (n = 1). Transcatheter embolization was not performed in these two patients, since splenic arteriography did not demonstrate a focal vascular injury. One patient had a pseudoaneurysm and areas of vascular contrast material extravasation at admission contrast-enhanced spiral CT and arteriography (Fig 2). Although these splenic lesions were embolized, the patient required delayed splenectomy for splenic bleeding that continued for 5 days after arteriography.


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  		TABLE 5. Unsuccessful Nonsurgical Management: Contrast-enhanced Spiral CT and Angiographic Findings
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Nonsurgical management is becoming the preferred treatment method for adult patients who are hemodynamically stable and have blunt splenic injuries. To attempt nonsurgical management, it is important to identify and characterize not only the splenic injury but also any concurrent injury to the solid viscera, mesentery and bowel, or retroperitoneum that may require surgery (31,32,38). Investigators in most prior studies (10–12,14–18) who supported the nonsurgical management of blunt splenic injury have not used splenic embolization as part of the treatment approach. Sclafani et al (29,30) and Hagiwara et al (31) performed transcatheter splenic embolization, which resulted in an improved success rate for nonsurgical management, as compared with that in earlier series (39–41). In these three studies, the authors found that contrast-enhanced conventional CT was accurate in diagnosing splenic parenchymal injury but did not demonstrate splenic arterial contrast material extravasation or other posttraumatic vascular abnormalities. However, the authors acknowledge the use of suboptimal CT contrast material enhancement techniques, which include the use of small volumes of intravenous contrast material, low contrast material infusion rates, and slow scanning and scanning repetition times.

In the current study, all patients who are hemodynamically stable and have evidence of splenic injuries diagnosed at contrast-enhanced spiral CT, without respect to the grade of the splenic injuries or to contrast-enhanced spiral CT findings of vascular injuries, underwent splenic arteriography. Although splenic embolization was based on the arteriographic findings in this study, this method permitted correlation of the contrast-enhanced spiral CT criteria that might be used to directly predict the need for splenic arteriography and potential endovascular treatment by using splenic arteriographic results. Among seven patients with vascular contrast material extravasation at admission contrast-enhanced spiral CT, six patients had evidence of bleeding at arteriography and underwent embolization successfully. One patient did not demonstrate splenic hemorrhage or vascular injury at arteriography. However, this patient ultimately required delayed splenectomy for persistent hemorrhage within 12 hours of splenic arteriography, which indicated that a splenic arterial injury identified at admission contrast-enhanced spiral CT may not have been detected at arteriography or was not apparent at the time of arteriography. In this study, splenic vascular contrast material extravasation was highly predictive of the need for transcatheter splenic embolization in patients with all CT grades of blunt splenic injury.

The appearance of posttraumatic splenic pseudoaneurysms and arteriovenous fistulas are similar at contrast-enhanced spiral CT, as identified in this study, and could be differentiated only by using splenic arteriography (Figs 3, 4). Both of these lesions appear as well-circumscribed focal areas of increased CT attenuation higher than that of the normally enhancing splenic parenchyma at contrast-enhanced spiral CT. Posttraumatic pseudoaneurysms usually result from an injury to the arterial wall. The defect in the arterial wall, although small in size, allows blood to escape into the arterial wall or the surrounding tissue. The adventitia and the perivascular tissues form the wall of the pseudoaneurysm. The rate of enlargement of the pseudoaneurysm depends not only on the integrity of the adventitial layer of the artery but also on the strength of the surrounding tissues that resist the expansion of the pseudoaneurysm (42). A splenic arterial pseudoaneurysm may be seen at admission or follow-up CT. The natural progression of splenic pseudoaneurysm is not clearly known. Although some splenic pseudoaneurysms heal by spontaneous thrombosis without intervention, investigators in recent studies (38,42) have shown that up to 67% of these lesions ultimately may rupture and therefore represent a strong predictor for the failure of nonsurgical management.

The contrast-enhanced spiral CT appearance of splenic vascular contrast material extravasation typically is seen within the splenic parenchyma, subcapsular region, or perisplenic intraperitoneal space as an irregular or linear area with high attenuation similar to or greater than that in the adjacent aorta or artery (Fig 1). These findings may help to differentiate the contrast-enhanced spiral CT appearance of splenic vascular contrast material extravasation from the well-defined round or oval focal intrasplenic areas of high attenuation that result from localized traumatic splenic vascular lesions (Fig 4).

In this study, 10 (53%) of 19 patients with posttraumatic splenic vascular lesions identified at admission contrast-enhanced spiral CT underwent transcatheter embolization or surgery. One patient had a posttraumatic splenic vascular injury that was demonstrated at only splenic arteriography and was treated with embolization. Nine patients had splenic vascular lesions at contrast-enhanced spiral CT that were confirmed at arteriography; in one patient, splenic arteriography failed to confirm a vascular lesion. This patient underwent splenectomy for delayed hemorrhage, which suggests that the splenic arteriogram likely was false-negative. The splenic arteriograms in the other nine patients with false-positive findings of contrast-enhanced spiral CT for splenic vascular lesions showed diffuse parenchymal injury without a focal vascular lesion at arteriography. These arteriographic findings did not meet the criteria for transcatheter splenic treatment that were used in this study.

A retrospective review of the false-positive contrast-enhanced spiral CT scans was performed. Findings mimicking splenic vascular lesions included islands of enhancing splenic parenchyma surrounded by low-attenuating splenic lacerations or contusions (Fig 7) and intact intrasplenic vessels traversing the center or periphery of parenchymal lacerations simulating hemorrhage surrounding a focal pseudoaneurysm. Failure to detect splenic vascular lesions with contrast-enhanced spiral CT can be related to suboptimal contrast material enhancement, particularly in obese patients with decreased tissue contrast resolution or to delayed scanning well beyond the peak of splenic parenchymal enhancement, with "washout" of extravasated contrast material by nonenhanced blood. With an understanding of these potential diagnostic pitfalls, use of an optimal volume and concentration of intravenous contrast material, performance of scanning at the peak of visceral contrast material enhancement, use of contrast material bolus timing techniques, and measurement of the attenuation of suspected vascular injuries, as compared with that of adjacent arteries, can reduce the number of false-negative contrast-enhanced spiral CT scans and improve the selection of patients for splenic arteriography. The absolute sensitivity (required rate of bleeding) for the detection of arterial bleeding with technically optimized single-section helical CT is, to the authors’ knowledge, not known. Hypothetically, multiple–detector row CT imaging systems that can perform subsecond scanning with efficient contrast material bolus tracking should improve the detection of posttraumatic splenic vascular lesions.



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  		Figure 7a. Normal splenic parenchyma mimicking posttraumatic vascular lesions in a 30-year-old patient admitted after a motorcycle accident. (a, b) Transverse contrast-enhanced spiral CT images show areas of enhancing splenic parenchyma (arrowheads) within the low-attenuating grade III splenic laceration (arrow). Splenic arteriography showed parenchymal but not vascular injury. Contrast-enhanced spiral CT findings were false-positive because objective measurements of the attenuation of suspected lesions were not compared with those within the adjacent artery.

 


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  		Figure 7b. Normal splenic parenchyma mimicking posttraumatic vascular lesions in a 30-year-old patient admitted after a motorcycle accident. (a, b) Transverse contrast-enhanced spiral CT images show areas of enhancing splenic parenchyma (arrowheads) within the low-attenuating grade III splenic laceration (arrow). Splenic arteriography showed parenchymal but not vascular injury. Contrast-enhanced spiral CT findings were false-positive because objective measurements of the attenuation of suspected lesions were not compared with those within the adjacent artery.

 
In our study, six (16%) of 37 patients with low-grade splenic injuries (grade II or less) met one or more of the two CT criteria that we proposed would predict the need for transcatheter splenic treatment. Two of the three patients with false-negative contrast-enhanced spiral CT scans for splenic vascular lesions detected with only arteriography also had low-grade splenic injuries. These results verify that even patients with low-grade splenic injuries are at risk for delayed splenic rupture. The aggressive diagnostic and therapeutic pursuit of vascular injury by using contrast-enhanced spiral CT and splenic arteriography undertaken in this study improves early diagnosis and potentially increases the number of patients with blunt splenic injuries who are treated successfully without surgery. These results are consistent with those of multiple prior studies (25–29) in which investigators have shown that a CT-based grading system of splenic injury alone cannot reliably be used to predict the success or failure of nonsurgical management of splenic injury. None of the 78 patients who underwent assessment in our study group had failed nonsurgical treatment as a result of a missed bowel, mesenteric, retroperitoneal, or solid-organ injury.

In this study, nonsurgical management ultimately was successful in 73 (94%) of the 78 patients who initially were selected for conservative management of their blunt splenic injuries. Investigators in prior studies (29–31) have proposed the absence of bleeding from the spleen at celiac arteriography as a reliable predictor of successful outcome of the nonsurgical management of splenic injury. Sclafani et al (30) reported that none of the 19 patients without evidence of contrast material extravasation at splenic arteriography had nonsurgical treatment that failed. In the current study, a total of five patients had nonsurgical treatment that failed. The findings on the celiac and selective splenic arteriograms in four patients did not meet our criteria for transcatheter splenic therapy. Two of these patients had findings at contrast-enhanced spiral CT that included contrast material extravasation (n = 1) and pseudoaneurysm (n = 1); this suggested the need for splenic arteriography or embolization. If the main splenic artery had been embolized in these two patients with CT evidence of splenic vascular injuries, the success rate of selective nonsurgical management of blunt splenic injury could potentially have increased to 96% (75 of 78 patients) in this study. The findings of contrast-enhanced spiral CT were false-negative in three patients with low-grade splenic injuries. Since splenic arteriography was performed in all patients in this prospective study, two of the three patients were found to have vascular lesions of the spleen that required transcatheter embolization.

The combined use of contrast-enhanced spiral CT and selective arteriography can optimize the chance for both early diagnosis and successful nonsurgical management of all grades of splenic injuries in patients who are hemodynamically stable and have blunt trauma.


   FOOTNOTES
 
Abbreviation: AAST = American Association for the Surgery of Trauma

Author contributions: Guarantors of integrity of entire study, K.S., S.E.M., R.B.K.; study concepts, K.S., S.E.M., T.M.S.; study design, K.S., S.E.M., T.T.; definition of intellectual content, K.S., S.E.M.; literature research, K.S., S.E.M.; clinical studies, K.S., S.E.M., R.B.K.; data acquisition and analysis, K.S., S.E.M., R.B.K.; statistical analysis, K.S., S.E.M.; manuscript preparation and editing, K.S., S.E.M.; manuscript review, K.S., S.E.M., R.B.K., T.M.S.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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