Delayed traumatic splenic pseudoaneurysms

Case contributed by Assoc Prof Craig Hacking

Presentation

Fall from 2m.

Patient Data

Age: 30 years
Gender: Female

The spleen is ruptured and there is a large volume of hemoperitoneum. Within the posterior aspect of the ruptured spleen. There are at least to small foci of arterial hyperattenuation which reduced in density on the portal venous phase in keeping with pseudoaneurysms.

The remaining solid organs of the abdomen are intact. No free gas. The stomach is distended. No signs of small or large bowel injury. No retro peritoneal hematoma.
No pelvic fracture. Hip and SI joints are normally aligned.

IMPRESSION

Grade 4 splenic injury with multiple pseudoaneurysms. Large volume of hemoperitoneum.

The patient was treated conservatively as the blood pressure remained in normal range.

Since the previous study, there is now significant increase in size of the multiple pseudoaneurysms which are now seen throughout the spleen. The spleen itself has also increased in size. There is a moderate-sized subcapsular hematoma present with a thickness of 17 mm. The volume of intra-abdominal hemorrhage has decreased mildly.

New moderate sized left-sided pleural effusion with a mild degree of collapse/consolidation in the left lung base.

The single mildly displaced left lateral ninth rib fracture is noted.

The remainder of the study is unchanged.

IMPRESSION

Significant pseudoaneurysms present throughout the spleen with increase in size of the spleen when compared with the previous study with moderate subcapsular hematoma. Moderate volume free fluid within the pelvis which has decreased slightly.

New left-sided pleural effusion.

Proximal splenic artery embolization

DSA (angiography)

Right CFA puncture with US. 5-French sheath. Aortogram and selective splenic artery angiograms demonstrate multifocal pseudoaneurysms throughout the splenic parenchyma with early filling of the splenic vein suggesting AV fistulae. Dominant supply to the pancreatic artery via the GDA.

The microcatheter was positioned within the mid splenic artery and multiple coil embolizations performed. Hemostasis confirmed on completion angiograms. Completion aortogram demonstrates collateral perfusion to the residual splenic parenchyma.

Manual hemostasis at the puncture site.

Day 7 post embolization

CT

Metallic artefact due to coil embolization of the splenic artery. The multiple previously demonstrated pseudoaneurysms within the spleen have resolved with no pseudoaneurysm or evidence of AV shunting remaining. There is a single branch artery supplying the superior pole of the spleen with heterogeneous enhancement of the splenic parenchyma. Ongoing small to moderate volume subcapsular hematoma is stable in size since the prior study measuring up to 19 mm in maximal depth. Splenic span of 10.6 cm, has reduced since the prior study (previously 12 cm).

The mesenteric/omental hematoma within the left mid anterior abdomen has also reduced in size now measuring 3.5 cm in maximal axial diameter (previously 4.6 cm. The volume of hemoperitoneum has reduced.

Normal appearance of the remainder of the visualized upper abdominal organs. The small and large bowel appear within normal limits. Small volume left pleural effusion with mild left basal atelectasis.

Left lateral ninth rib fracture.

IMPRESSION

Resolution of splenic pseudoaneurysms since the pre-embolization CTA. In addition, there is reduction in volume of the hemoperitoneum, as well as reduction in size of the left omental/mesenteric hematoma.

Case Discussion

The patient recovered well and was treated for hyposplenism.

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