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757

Pictorial

CT Appearance Nonoperatively

of Splenic

Injuries

Essay

Managed

Huy M. Do1 and John J. Cronan

This essay on

CT

scans

illustrates

the appearance

obtained

during

the

of the traumatized

course

spleen

of conservative

1A and 2A). The CT findings

treat-

than

ment. Although the CT appearance of acute rupture of the spleen has been adequately described, little has been reported about the appearance of the spleen as it heals after trauma. Examples of CT studies of splenic injuries illustrate the various changes in appearance over time in the traumatized spleen that is treated nonoperatively.

those

splenic splenic

of subcapsular

peritoneal

tions

may

Splenic They

cavity occur

infarcts

the

apices

develop

solve within

and Methods

cases

were

selected

for

this

essay.

Patients

injuries were treated with surgery were excluded

in whom

CT features

matomas, rarely,

intrasplenic splenic

Received 1

Both

requests

margin

as irregular

August authors:

splenic

after

of

fluid collections the

spleen.

low-density

2, 1990; accepted Department

Intrasplenic

areas

within

after revision

of Diagnostic

and,

hematomas

(Figs.

October

1991 0361 -803X/91/1

and

weeks

perisplenic

splenic

hilum

areas (Fig.

4A).

as a result

of trauma.

hematoma

usually

re-

or intrasplenic

he-

[2]. Subcapsular

gradually

decrease

and become

May 2, 1991.

Imaging,

Rhode

Island

Hospital

and Brown

University

to J. J. Cronan.

AJR 157:757-760,

the

hematomas.

unenhancing

Splenic hematomas may become infected and form abscesses. Fifteen percent of splenic abscesses are associated with trauma (Fig. 3) [5]. CT is helpful in the early detection of splenic abscess, demonstrating a well-defined, low-density

appear or indent

the spleen

toward

devascularization fluid

2-4

subcapsular

in

lacera-

resolution of the hematomas. In some patients, the final sequela may be a chronic splenic pseudocyst containing serous fluid [5].

he-

lacerations,

hematomas that flatten

without

pointing

inhomogeneous and free fluid

less than that of the normal spleen [4]. Sharply defined margins develop in the hematomas as they diminish. This maturation of the hematomas is the result of lysis of clotted blood and resorption of fluid, protein, and necrotic debris (Figs. 1 and 2). Several months may be required for complete

from this study.

are subcapsular

[1 ]. Subcapsular

low-density

lateral

appear

trauma

hematomas,

infarcts

as lenticular, the

of splenic

or

as wedge-shaped,

more

indistinct

2A, and 3A). Splenic

1 A,

values of splenic hematomas

splenic

Results Initial

with

vary

include

matoma evolves during a period of weeks to months. Within 1 -2 days of bleeding, CT attenuation values of splenic hematomas may be equal to or greater than that of the splenic parenchyma [3]. During the next few weeks, CT attenuation

We reviewed the medical records and abdominal CT scans of 12 patients 5-32 years old (mean, 1 8 years) with splenic injuries who had CT studies of the abdomen obtained at presentation with injury and at follow-up examinations between 1 985 and 1 989. Representative

(Figs.

appear

Intraperitoneal

Materials

lacerations They

margins, low-density fracture lines, parenchyma, perisplenic hematoma,

the

with

of splenic

hematomas.

574-0757

© American

Roentgen

Ray Society

Program

in Medicine,

Providence,

Al 02902.

Address

reprint

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758

DO

AND

Fig. 1.-10-year-old boy injured in a motor vehicle accident. A, CT scan shows splenic laceration and large, low-density intrasplenic B, After 9 days, hematoma is organized, with well-defined border.

CRONAN

hematoma

AJA:157, October

(arrow)

in posterior

portion

1991

of spleen.

C, 5 months after initial injury, spleen appears normal without evidence of residual hematoma.

Fig. 2.-Splenic A, Initially, B, 1 week C, Splenic

laceration in a 5-year-old girl injured in a motor vehicle accident. CT scan shows both lenticutar subcapsular hematoma and poorly defined intrasplenic hematoma (arrows). later, communicating hematomas (arrow) are more organized and now occupy midportion of spleen. fracture (arrow) is still evident I month later, but spleen appears well healed with virtual resorption of hematomas.

focal

area

within

within

the

abscess

cavity.

infarcts

resolve

Splenic

the spleen.

(Fig. 4). The time needed

Gas

may

or may

over a period for resolution

seen on CT varies, depending

not be seen

of several

of splenic

months

lacerations

on the size and depth

tear. Small peripheral lacerations may take resolve, whereas deeper tears may require pear [2].

several months

of the

weeks to to disap-

Discussion CT has proved to be a sensitive technique in establishing the presence and extent of acute injuries to the spleen [1 , 6]. In our experience, CT has also been beneficial in documenting the healing process of the spleen. The pattern and duration of healing depend on the nature and severity of the initial injury, with parenchymal injuries taking longer to

AJA:157,

October

CT

1991

OF

SPLENIC

759

INJURIES

Fig. 3.-16-year-old boy injured in bicycling accident. Patient was discharged after 1 week of nonoperative treatment, but returned 6 weeks

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later with recurrent fever and pain in left upper abdomen. A, Initial CT scan shows lacerations (straight arrow) throughout midspleen and subcapsular hematoma (curved arrow) posteriorly. B, I week later, subcapsular hematoma is

better defined. C, CT scan 6 weeks later shows well-defined, low-attenuation

cutaneous

fluid collection

aspiration

confirmed

posteriorly.

Per-

this to be a post-

traumatic abscess. After placement of sump catheter (straight arrow), cavity size is markedly reduced. There is also some left pleural reaction (curved arrow). D, Follow-up CT scan obtained 1 month after

drainage shows unenhancing residual pseudocyst (arrow). Color Doppler sonography and dynamic CT showed rysm. The patient

that it was not a pseudoaneuwas asymptomatic.

Fig. 4.-Traumatized spleen in a 10-year-old boy who fell on his left side. A, Initial CT scan shows a large, low-attenuation, wedge-shaped infarct affecting anterior half of spleen (arrow). B and C, CT studies obtained after 2 (B) and 5 (C) months show significant liquefaction and marked reduction in size of infarct

(arrows).

DO AND

760

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return to normal than perisplenic or intraabdominal fluid collections do [2]. Successful outcome of conservative management of patients with splenic trauma is defined as the resolution of abnormalities found on initial CT scans, along with relief of

any signs and symptoms intervention abdominal

that might

indicate

these abnormalities can be assessed by serial CT scans. Deterioration in a patient’s clinical status may signal that conservative management is unsuccessful. Follow-up CT patients

may reveal

worsening

of the initial CT

The changes in the CT findings in patients treated conservatively should not be misconstrued as changes indicating the need for intervention. Although delayed rupture is an important feature of splenic trauma that should be recognized promptly, the value of CT scans repeated at regular intervals

after splenic trauma

remains

unproved

[6]. Nevertheless,

various manifestations taken for nonhealing

vention

of splenic healing or new hemorrhage

in these cases is not indicated

ening of the initial clinical status [4].

injuries

classification

and

correlation

with

prognosis

5. Faer MJ, Lynch AD, Lichtenstein JE, Madewell the AFIP. Radiology 1980;134:371-376

6. Jeffrey RB. CT diagnosis the future. Radiology

834

JJ,

REVIEWS

eds.

of Neuroimaging.

Kirkwood

and

treatment.

Radiology

JR

JE, Feigin

DS. APC from

of blunt hepatic and splenic injuries: a look to

1989:1 71 :17-18

Essentials

784

in the patient’s

1989;171 :33-39

866

768 776

unless there is wors-

1 . Federle MP, Griffiths B, Minagi H, Jeffrey RB. Splenic trauma: evaluation with CT. Radiology 1987; 1 62 :69-71 2. Lupien C. Sauerbrei EF. Healing in the traumatized spleen: sonographic investigation. Radiology 1984;1 51 :181-185 3. Jeffrey RB, Laing FC, Federle MP, Goodman PC. Computed tomography of splenic trauma. Radiology 1981;141 :729-732 4. Mirvis SE, Whitley NO, Gens DR. Blunt splenic trauma in adults: CT-based

842 850

702

should not be misof the spleen. Inter-

and deterioration

Imaging of the Lumbar Spine. Griffiths HJ Diagnosis of Diseases of the Chest, 3rd ed., vol. IV. Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP Management of Cardiothoracic Trauma: Turney SZ, Rodriguez A, Cowley RA, eds. Atlas of Oral Diagnostic Imaging. Higashi T, Shiba JKC, Ikuta H Morphologic and Fuctional MR of the Kidneys and Adrenal Glands. Krestin GP Imaging of the Pelvis: MRI with Correlations to CT and Ultrasound. FishmanJavitt MC, Stein HL, Lovecchio JL, eds. Comparative Cardiac Imaging: Function, Flow, Anatomy, and Quantitation. Brundage BH, ed. Practical MRI Atlas of Neonatal Brain Development. Barkovich AJ, Truwit CI Manual of Clinical Magnetic Resonance Imaging, 2nd ed. Heiken JP, Brown

692

1991

REFERENCES

the

LIST OF BOOK 684

AJA:157, October

the need for

(e.g., orthostatic hypotension, falling hematocrit, distension, or left shoulder pain). The evolution of

scans in these findings [4].

CRONAN