Delayed traumatic splenic rupture

Case contributed by Assoc Prof Craig Hacking

Presentation

Motorbike accident (MBA).

Patient Data

Age: 25 years
Gender: Male

Splenic lacerations without evidence of active contrast extravasation. Hematoma surrounds the spleen and a small volume of blood tracks down to the left paracolic gutter. There is no hepatic injury.

Tear of the medial inferior aspect of the right rectus abdominis muscle with subcutaneous gas present. There is extraperitoneal blood tracking from the muscular tear inferiorly into the pelvis.

No other solid abdominal organ injury. Large and small bowel have a normal appearance.

Lumbar spine alignment is satisfactory.

Complex fracture of the sacrum with a vertical fracture line extending through the left aspect of the S2/S3 junction and tracking inferiorly through the sacral canal and involving the coccyx.

Nondisplaced fractures of the right acetabulum and both ischial bones inferiorly. There is a minor widening of the left sacroiliac joint and minor diastasis of the pubic symphysis.

There is associated hematoma within the pelvic sidewalls bilaterally that compresses the bladder, right more than left and in the presacral space. Free gas and hematoma track through the medial groins and there is the appearance of a traumatic hematocele on left.

Comminuted distal radius fracture without articular extension. No ulnar fracture. The carpal bones appear normal.

IMPRESSION

  1. Grade 3 splenic injury without active contrast extravasation.
  2. Complex fractures involving the sacrum and coccyx.
  3. Widening of the left sacroiliac joint and pubic symphysis.
  4. Nondisplaced fractures through the ischial bones bilaterally and the right acetabulum.
  5. Soft tissue hematoma in a straddle injury pattern as well as likely hematocele, and testicular injury require evaluation with ultrasound.
  6. Traumatic tear of the right rectus abdominis muscle and suspected right conjoint tendon injury
  7. Right distal radial fracture.
CT

Day 5 follow up

The extensive splenic laceration is again noted but there is a new region of contrast extravasation extending from the hilum which measures 1.5 x 2.0 x 2.3 cm. The hematoma surrounding the spleen appears slightly reduced in size. Normal appearance of the splenic artery with no evidence of aneurysm.

The abdominal aorta, IVC and portal vein opacify normally.

Small volume of free fluid within the pelvis appears stable since prior imaging. No intra-abdominal free air or collection.

The liver, pancreas, kidneys and adrenal glands opacify normally without evidence of injury.

Right rectus abdominis insertional tear and conjoint tendon appear similar to prior imaging.

Saddle injury with contrast extravasation on the arterial phase along the left penile crus and perineum appears increased since prior imaging.

Bilateral small pleural effusions and adjacent compression atelectasis.

Pelvic fractures and pubic symphysis diastasis appear stable from prior imaging.

IMPRESSION

  1. Delayed splenic rupture with contained active bleeding (pseudoaneurysm) extending from the hilum. No avulsion of the vascular pedicle. No hemoperitoneum. No splenic artery aneurysm.
  2. Saddle injury with contrast extravasation along the perineum concerning for active bleeding.
  3. Stable pelvic fractures and symphysis diastasis.
DSA (angiography)

A splenic angiogram showed slow filling of the known lower pole false aneurysm. Microcatheter angiograms showed the false aneurysm filled from only one branch, which was superselectively catheterized and embolized with microcoils. 

The final angiogram showed complete occlusion of arterial flow into the false aneurysm.

SUMMARY

Subsegmental embolization of day 5 delayed post-traumatic 1.5 cm diameter splenic pseudoaneurysm.

CT

Day 3 post splenic embolization

Embolic micro-coils are evident at the splenic hilum, just proximal to the region of the previous pseudoaneurysm. No recurrent pseudoaneurysm identified. The inferior pole of the spleen shows several lacerations, similar to the initial CT. No obvious large new splenic infarcts.

Ill-defined, mildly increased density dependently within the gallbladder likely represents biliary sludge.

The stomach is moderately distended, similar to previous.

Small bilateral pleural effusions with adjacent passive atelectasis, also similar to previous.

IMPRESSION

No residual or recurrent pseudoaneurysm identified in the region of splenic artery coiling. No evidence of splenic infarct.

CT

6 months post splenic embolization

Splenic embolization coils position is unchanged. The spleen is of uniform density with no subcapsular perisplenic collection or infarct present.

Uniform density of the liver and contrast enhancement of the portal and hepatic veins.
Remaining solid abdominal viscera are unchanged in appearance.

No complication in relation to the/screw fixation of the pubic rami/pubic body and symphysis or single screw stabilizing the left SI joint.

IMPRESSION

Expected appearance following micro-coiling of the traumatic splenic pseudoaneurysm. No evidence of splenic infarct or other delayed complication.

Case Discussion

At my institution, a repeat multiphase CT is performed day 5 post splenic injury to assess for delayed hemorrhage or pseudoaneurysm formation. This case nicely illustrates the need for imaging surveillance of such injuries after traumatic splenic injury.

The patient recovered uneventfully.

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Case information

rID: 79906
Published: 14th Jul 2020
Last edited: 4th Apr 2021
Inclusion in quiz mode: Included

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