Splenic laceration - AAST grade IV

Case contributed by Lemuel Marquez Narcise
Diagnosis certain


Young man involved in a surfing accident. Presented with abdominal pain and left upper quadrant tenderness in the emergency room. Decreasing hemoglobin count during admission.

Patient Data

Age: 20 years
Gender: Male

Contrast-enhanced representative axial and coronal CT images of the upper abdomen showing patchy hypodense areas in the mid to inferior segment of the spleen extending to the hilum and is surrounded by irregular contrast enhancement, which constitutes >25% devascularization.

There is note of peripheral contrast extravasation seen in the perirenal space.  Free intraperitoneal fluid collection is also seen at the perihepatic, perisplenic, hepatorenal, and splenorenal regions.

DSA study prior to Embo


Preliminary DSA studies prior to embolization, with catheter directed through the celiac axis and as well as selective angiography of the splenic artery, showing smudgy areas in the mid to inferior segment of the spleen.  This is indicative of active contrast extravasation from the lacerated segmental and trabecular vessels supplying this region.

Note contrast material filling the left renal collecting system, as a result of contrast injection from the CT exam.

DSA study after embolization


The areas with active contrast extravasation were injected with polyvinyl alcohol (PVA) embolization particles.  Post embolization DSA showing selective occlusion of the segmental branch vessels, previously noted to have smudgy appearance.  Patchy faint areas of opacification in the mid to inferior segment of the spleen indicative of the distribution of embolization particles.

Case Discussion

Injury to the spleen is usually secondary to blunt trauma.  The arterial vessels of the spleen lack anastomoses and the spleen can be divided into vascular segments, which allows for subtotal splenectomy or splenorraphy.  In this case, there is evidence of laceration extending to the hilum, and devascularization which appears to involve >25% of the spleen in keeping with AAST grade IV splenic injury. The primary goal was to stop active bleeding from the lacerated segmental and trabecular vessels.  After selective embolization, the hemoglobin count of the patient stabilized.

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