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Blunt Splenic Trauma: Delayed-Phase CT for Differentiation of Active Hemorrhage from Contained Vascular Injury in Patients¹

¹ From the Department of Radiology, Boston University Medical Center, 88 E Newton St, 2nd Floor, Boston, MA 02215. From the 2005 RSNA Annual Meeting. Received February 27, 2006; revision requested April 27; revision received May 31; accepted June 21; final version accepted July 24. Address correspondence to S.W.A. (e-mail: Stephan.Anderson{at}bmc.org).

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 
Purpose: To retrospectively evaluate delayed-phase computed tomography (CT) in the differentiation of active splenic hemorrhage requiring emergent treatment from contained vascular injuries (pseudoaneurysms or arteriovenous fistulas) that can be treated electively or managed conservatively.

Materials and Methods: The institutional review board approved this HIPAA-compliant retrospective study; the informed consent requirement was waived. Forty-seven patients with blunt splenic injury diagnosed at CT after blunt abdominal trauma were evaluated. Abdominal and pelvic dual-phase CT was performed; images were obtained 60–70 seconds and 5 minutes after contrast material injection. Scans were reviewed in consensus by two radiologists. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale. Patients with intrasplenic hyperattenuating foci on portal venous phase images were classified as having active splenic hemorrhage (group 1) or a contained vascular injury (group 2) on the basis of delayed-phase imaging findings. Findings suggestive of active hemorrhage included areas that remained hyperattenuating or increased in size on delayed-phase images. The clinical outcome of these patients was determined by reviewing their medical records. Relationships between several factors were tested with the Fisher exact test, including (a) the presence or absence of hyperattenuating foci and management and (b) the presence of contained vascular injury or active extravasation and management.

Results: Portal venous phase CT revealed a focal high-attenuation parenchymal contrast material collection in 19 patients: nine patients were classified as group 1 and 10 were classified as group 2. All patients in group 1 underwent emergent splenectomy, and all patients in group 2 were initially treated without surgery. Significant differences in management were noted on the basis of whether hyperattenuating foci were seen on portal venous phase images (P < .001) and whether hyperattenuating foci seen at portal venous phase imaging were further characterized as active splenic hemorrhage or a contained vascular injury at delayed-phase CT (P < .001).

Conclusion: In blunt splenic injury, delayed-phase CT helps differentiate patients with active splenic hemorrhage from those with contained vascular injuries.

© RSNA, 2007

Computed tomography (CT) is widely used to evaluate patients with suspected intraabdominal injuries after blunt trauma, including splenic injuries (1–4). In hemodynamically stable patients, CT helps in the differentiation of patients with active splenic hemorrhage that may necessitate immediate intervention or special attention from patients with more localized injuries that can be managed less urgently to reduce surgical morbidity and preserve immunocompetence (4–11).

Traditionally, a single-phase intravenous contrast material–enhanced CT technique has been the imaging study of choice for evaluation of the spleen and other abdominal organs after trauma (3,4). At single-phase CT, an extrasplenic accumulation of contrast-enhanced blood is usually indicative of active splenic hemorrhage, whereas a focal accumulation of contrast-enhanced blood within the splenic parenchyma is usually indicative of a contained vascular injury (3,4). With use of similar techniques and diagnostic criteria, Shanmuganathan et al (4) achieved a success rate of 100% in the diagnosis of free splenic hemorrhage and a success rate of 83% in the diagnosis of contained vascular injuries (eg, pseudoaneurysm and arteriovenous fistulas).

At our institution, a level 1 trauma center, we routinely use a dual-phase CT technique to characterize major solid organ injuries after blunt abdominal trauma. The first set of images is obtained during the portal venous phase of enhancement, and the second set is obtained 5 minutes after the administration of intravenous contrast material (delayed-phase images). The purpose of this study was to retrospectively evaluate delayed-phase CT in the differentiation of patients with active splenic hemorrhage that necessitates emergent treatment from those with contained vascular injuries (pseudoaneurysms or fistulas) that can be treated electively or managed conservatively.

	MATERIALS AND METHODS

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Patient Group
For this retrospective study, all consecutive adult patients with blunt trauma in whom a splenic injury was diagnosed at our institution from November 16, 2003, through October 15, 2005, were identified by one of the investigators (S.W.A.). Patients were identified from the trauma registry records of our institution. During this period, 68 patients with a final diagnosis of splenic injury resulting from blunt trauma were treated at our trauma center. Twenty-one (31%) of these 68 patients were hemodynamically unstable at admission and underwent immediate exploratory laparotomy, at which point a splenic injury was identified. The remaining 47 patients (69%) underwent CT at admission and comprise our study group. There were 35 men and 12 women, with a mean age of 37 years (mean age for men, 35 years; mean age for women, 43 years) and an age range of 18–84 years (age range for men, 18–84 years; age range for women, 18–74 years). There were no significant differences between age distributions by birth sex on the basis of an independent samples t test (P = .18). The mechanism of injury was a motor vehicle collision in 36 of the 47 patients (77%), a fall from height in six (13%), an assault in three (6%), and construction work–related crush injury in two (4%). The investigations review board of our institution approved this study and waived the need for informed consent. The study complied with the Health Insurance Portability and Accountability Act.

CT Technique
All CT examinations were performed by using multidetector units. Images were obtained in a craniocaudal direction from the diaphragm to the pubic symphisis. In 16 patients (34%), images were obtained before January 1, 2004, by using a four-section CT system (MX8000; Philips Medical Systems, Andover, Mass) with 3.2-mm-thick sections and a pitch factor of 1.5. Twenty-three patients (49%) were imaged between January 1, 2004, and May 1, 2005, with 16-section CT (LightSpeed Pro; GE Medical Systems, Milwaukee, Wis). The remaining eight patients (17%) were studied after May 5, 2005, with 64-section CT (LightSpeed VCT; GE Medical Systems). The CT scans obtained with 16 detector rows and those obtained with 64 detector rows were obtained with a section thickness of 1.25 mm, a gantry rotation time of 0.5 second, a table speed of 39.37 mm per rotation, and a noise factor of 19.

None of the patients received oral contrast material according to our departmental multidetector CT protocol for patients with blunt abdominal trauma. A 100-mL dose of iohexol (320 mg of iodine per milliliter, Optiray; Mallinckrodt Imaging, Hazelwood, Mo) was administered intravenously to all patients through a cannula located in an antecubital vein at a rate of 4 mL/sec by using a power injector (Stellant CT Injection System; Medrad, Indianola, Pa). The set of images obtained in the portal venous phase was obtained 60–70 seconds after the initiation of contrast material injection. This scan delay varied with the specific scanner used: Images were obtained 60 seconds after injection for the four-section scanner, 65 seconds after injection for the 16-section scanner, and 70 seconds after injection for the 64-section scanner. The second set of images (delayed phase) was obtained 5 minutes after the initiation of contrast material injection. A tube current of 120 kVp was used for both phases. For scans obtained with the four-section scanner, 200–300 mAs was used for the portal venous phase. This parameter was fixed at 100 mAs for the delayed phase. For scans obtained with the 16- and 64-section scanners, the noise factor was set at 19 for the portal venous phase and 25 for the delayed phase.

Image Analysis
For the purpose of this study, the CT scans were loaded on a picture archiving and communication systems workstation (Aurora, software 6.5; Merge eFilm, Milwaukee, Wis) by an investigator who was not involved in image interpretation (S.W.A.), and all patient identifying information was subsequently removed. These images were then interpreted in consensus by two radiologists (B.C.L., J.A.S.) with 5 and 12 years of experience, respectively, in abdominal trauma imaging. All additional patient data, including any subsequent clinical, imaging, or surgical findings and the final diagnoses, were withheld from the reviewers at image analysis.

The radiologists were initially shown the portal venous phase CT scans and asked to classify splenic injuries according to the American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) (12) (Table 1). The radiologists were then asked to determine whether any hyperattenuating extravascular focus was present in or around the spleen. During a second session performed 14 days after the first session, the delayed-phase CT scans from all patients were shown in a different order to the same two reviewers. The reviewers were again asked to record the presence of any hyperattenuating extravascular focus in or around the spleen. Finally, in a third session performed 2 weeks after the second session, the portal venous and delayed-phase CT scans of all patients were shown in conjunction to the same two reviewers. The radiologists were asked initially to subjectively determine, by using all images available, whether any hyperattenuating extravascular foci were present.

Clinical Follow-up
An investigator who was not involved in the interpretation of CT scans (S.W.A.) reviewed the surgical and angiographic reports, as well as the patients' clinical charts to determine clinical outcome. The specific data recorded by reviewing patient records were the need for laparotomy and splenectomy or splenorrhaphy, splenic artery angiography, and splenic artery embolization. Emergent splenectomy was defined as splenectomy undertaken within 24 hours of the patient's admission to our trauma center. The types of management (conservative vs surgical or embolization) were compared with the injury scale grade as determined with CT. The patients' treatment and outcomes were also compared with the presence or absence of hyperattenuating foci at CT. Finally, patient treatment and outcome were compared with the type of hyperattenuating foci as classified by the radiologists by using the methods and criteria described earlier (ie, active bleeding or contained vascular injury).

Statistical Analysis
With use of the Fisher exact test (R statistical system, version 2.0.1; R Foundation for Statistical Computing, Vienna, Austria), the relationship between the following parameters was tested: injury grade and management, injury grade and presence or absence of hyperattenuating foci, presence or absence of hyperattenuating foci and management, and presence of contained vascular injury or active extravasation and management. P values of less than .05 were considered to indicate a statistically significant difference.

	RESULTS

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Image Analysis
Splenic injuries were classified as grade 1 in six of the 47 patients (13%), grade 2 in 21 patients (45%), grade 3 in 10 patients (21%), grade 4 in nine patients (19%), and grade 5 in one patient (2%). A hyperattenuating focus was seen in 19 of the 47 patients (40%) at portal venous phase CT. Of these 19 patients, nine (47%) were found to meet the imaging criteria of active splenic hemorrhage at delayed-phase CT (Fig 1). The mean increase in size of the average of the axial dimensions of the largest hyperattenuating focus for these nine patients was 10 mm (range, 3.5–20.5 mm). The mean attenuation difference between the hyperattenuating foci in these nine patients was 44 HU (range, 6–110 HU) for portal venous phase images and 36 HU (range, 20–70 HU) for delayed-phase images. Ten of the 19 patients (53%) had washout of the hypervascular focus to within 10 HU of that of the aorta at delayed-phase CT and, thus, met the criteria of a contained vascular injury (Fig 2). The mean attenuation difference between portal venous phase and delayed-phase images was 4 HU (range, 3–7 HU). In six of these 10 patients, the foci decreased in size between portal venous and delayed-phase CT by a mean of 2.3 mm (range, 2–4 mm). In the remaining four patients, the hyperattenuating foci remained unchanged in size.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: Contrast-enhanced CT scans in a 37-year-old man involved in a motor vehicle collision. (a) Transverse portal venous phase image demonstrates a hyperattenuating focus (arrow) adjacent to the spleen. (b) Transverse image obtained 5 minutes after contrast material administration (delayed phase) shows persistence of the hyperattenuating region (arrow) seen on the initial scan. This finding is consistent with active splenic hemorrhage.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: Contrast-enhanced CT scans in a 37-year-old man involved in a motor vehicle collision. (a) Transverse portal venous phase image demonstrates a hyperattenuating focus (arrow) adjacent to the spleen. (b) Transverse image obtained 5 minutes after contrast material administration (delayed phase) shows persistence of the hyperattenuating region (arrow) seen on the initial scan. This finding is consistent with active splenic hemorrhage.

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Contrast-enhanced CT scans in an 18-year-old woman involved in a motor vehicle collision. (a) Transverse portal venous phase image shows a hyperattenuating focus (arrow) in the spleen. (b) Transverse image obtained 5 minutes after contrast material administration (delayed phase) shows that the hyperattenuating focus noted on the early scan has washed out. This finding is consistent with a vascular abnormality, such as a pseudoaneurysm or an arteriovenous fistula.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Contrast-enhanced CT scans in an 18-year-old woman involved in a motor vehicle collision. (a) Transverse portal venous phase image shows a hyperattenuating focus (arrow) in the spleen. (b) Transverse image obtained 5 minutes after contrast material administration (delayed phase) shows that the hyperattenuating focus noted on the early scan has washed out. This finding is consistent with a vascular abnormality, such as a pseudoaneurysm or an arteriovenous fistula.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Contrast-enhanced CT scan in a 22-year-old woman involved in a motor vehicle collision. Transverse portal venous phase image demonstrates a hyperattenuation focus (arrow) (which is one of many foci) that was washed out at delayed imaging. Nonsurgical treatment failed, and the patient underwent emergent splenorrhaphy.

Six of the 47 patients (13%) underwent splenic artery embolization. Five patients had hyperattenuating foci at CT, and one did not. The latter was a patient with a grade 4 splenic injury and perisplenic hemorrhage. Because of the patient's hemodynamic stability and injury confined to the spleen, it was decided to attempt transcatheter embolization rather than splenectomy. This patient recovered after the embolization procedure, and no further intervention was required. Splenic artery embolization failed in one of the five patients with hyperattenuating lesions at CT. As described previously, the procedure failed as primary therapy failed in one patient with a grade 3 injury and contained vascular injury due to incomplete embolization. This patient became hemodynamically unstable the day after the embolization procedure, and emergent splenectomy was necessary. Of the remaining four patients with hyperattenuating foci who underwent splenic artery embolization, two had a pseudoaneurysm and one had an arteriovenous fistula confirmed at angiography. These three patients were treated with splenic artery embolization and recovered, with no complications at a mean follow-up of 241 days.

Twenty-seven of the 47 patients (57%) were treated conservatively (nonsurgical management): Four patients had focal hyperattenuating lesions, and 22 did not. The four patients with focal hyperattenuating lesions were hemodynamically stable and had one small (<3 mm) contained vascular injury. The 22 patients with no hyperattenuating foci were also hemodynamically stable. These 27 patients remained stable and did not require therapeutic interventions during the follow-up period (mean, 310 days).

Analysis with the Fisher exact test revealed a significant difference in the type of management on the basis of the presence or absence of hyperattenuating foci (P < .001). Patients with hyperattenuating foci were much more likely to need laparotomy or splenic artery embolization than were patients without hyperattenuating foci. Among the patients with hyperattenuating foci, a significant difference in the type of management was also shown on the basis of whether the hyperattenuating foci represented active splenic hemorrhage or contained injury based on dual-phase CT findings (P < .001). Patients with active splenic hemorrhage were much more likely than patients with contained injuries to undergo splenectomy.

	DISCUSSION

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Although intravenous contrast-enhanced CT has been shown to be accurate in the evaluation of splenic injuries resulting from blunt trauma (13–15), CT-based grading systems are unreliable for guiding clinical management decisions (13–15). CT is limited in the differentiation of higher grades of splenic injury (16). CT findings of active splenic hemorrhage and vascular abnormality, including pseudoaneurysm and arteriovenous fistulas, have been described (4,17). These findings are crucial because they affect the success rates of the various management options available (3,6,7,18). The clinical implications of these findings, however, remain controversial (18).

Although the splenic injury grade (American Association for the Surgery of Trauma criteria) continues to be used for communicating findings to trauma surgeons, the presence of hyperattenuating foci and their further characterization as active extravasation or contained injury often takes precedence when discussing management options. The results of our study demonstrate that the presence or absence of hyperattenutating foci within the spleen incurred in blunt trauma is independent of the splenic injury grade (American Association for the Surgery of Trauma criteria). The presence or absence of hyperattenuating foci on portal venous phase images does affect management at our institution, and this finding has also previously been noted to affect management success rates (3,6,7,18). Our results reveal significant differences in management on the basis of further characterization of hyperattenuating foci seen on portal venous phase images at dual-phase CT. Therefore, a more complete grading scale of splenic injury may include characterization of vascular injuries into active splenic hemorrhage or contained injury by using dual-phase CT. As noted, evidence of active hemorrhage is more likely to prompt the trauma surgeon to perform exploratory laparotomy, often with splenectomy. The management of contained vascular injuries remains somewhat controversial.

As was the case in our study, CT findings suspicious for contained vascular injuries are not always confirmed with angiography. In one study (4), CT findings of a vascular abnormality were confirmed during conventional angiography in only 47% of patients. Explanations for these false-positive results have been proposed and include potentially misleading CT findings. For instance, small areas of normally perfused splenic parenchyma surrounded by hypoattenuating hematoma or devascularized tissue may mimic hyperattenuating foci. A second explanation for the discrepancy between CT findings and angiographic results is that contained vascular injuries may thrombose in the interval between CT and angiography. A final consideration for the discrepancy between CT findings and those at conventional angiography include false-negative results at angiography. As CT technology improves, it seems likely that the false-negative angiography rates may increase as increasingly subtle abnormalities are detected at CT (19).

As noted earlier, all patients with CT findings consistent with active splenic hemorhage underwent surgical treatment. Recently, angiography and transcatheter arterial embolization have been applied to patients with increasingly severe splenic injuries such as grade 4 and 5 injuries (4,20,21). In addition, angiography and embolization may be attempted in patients who may have previously been considered too unstable on the basis of episodes of hypotension (20,21). In our institution's trauma center, similar trends of increasing the application of angiography and embolization to splenic injury have also been noted recently. Surgery, however, remains an integral part of the management of blunt splenic injury, depending on imaging and clinical findings.

The limitations of our study include the sole use of CT for differentiating contained vascular abnormalities from active splenic hemorrhage. Given the retrospective nature of this study, some of our patients did not undergo conventional angiography, which is the current reference standard for differentiating between vascular abnormality and active hemorrhage. This limits our comparison of the differing clinical outcomes of the two patient groups. A further limitation of this study is that, given its retrospective nature, clinical factors that have a substantial effect on management decisions are not controlled. This includes clinical parameters such as blood pressure and factors including total blood volume lost, which may or may not be related to the presence or absence of hyperattenuating foci involved in splenic injuries. Finally, given the current weight that CT findings carry in determining clinical management, it is difficult to separate CT findings from subsequent clinical outcomes. With no possibility of conducting a study in which surgeons are blinded to CT findings given the weight placed on imaging findings, it now remains difficult to separate this influence from clinical decisions. Earlier studies, such as that by Federle et al (11), in which the CT findings may not have initially been recognized or their importance fully understood during preliminary reading, retained an increased ability to study the clinical outcomes of imaging findings without directly affecting management decisions.

In conclusion, delayed CT of blunt splenic trauma may be used to differentiate active splenic hemorrhage from contained vascular injury. The characterization of splenic injuries with dual-phase CT may be used in clinical management decisions.

	ADVANCES IN KNOWLEDGE

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 

• The presence or absence of hyperattenuating foci seen on portal venous phase images at CT of blunt splenic trauma is independent of splenic injury grade.
  
• Significant differences in management are noted on the basis of whether hyperattenuating foci are seen at portal venous phase imaging in patients with blunt splenic trauma (P < .001).
  
• Significant differences in management are noted on the basis of whether hyperattenuating foci seen at portal venous phase imaging of splenic injury are further characterized as active splenic hemorrhage or contained vascular injury at delayed-phase CT (P < .001).
  

	FOOTNOTES

 
Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, S.W.A., B.C.L., E.F.H.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, S.W.A., J.C.V., B.C.L., E.F.H.; clinical studies, S.W.A., J.C.V., B.C.L., J.A.S.; statistical analysis, S.W.A., J.C.V., E.F.H.; and manuscript editing, S.W.A., J.C.V., B.C.L., E.F.H., J.A.S.

	References

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2431060376v1 243/1/88    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Anderson, S. W. Articles by Soto, J. A. Search for Related Content PubMed PubMed Citation Articles by Anderson, S. W. Articles by Soto, J. A.