Spleen: Trauma, Vascular, andInterventional Radiology 98Suvranu Ganguli

Introduction

The spleen is a highly vascular organ, appropriate

for its active roles in immunosurveillance and hema-

topoiesis. Knowledge of the normal splenic vascular

anatomy is important for understanding the imaging

characteristics of the spleen and its vascular pathology,

including splenomegaly, splenic infarcts, splenic vein

thrombosis, and splenic artery aneurysms. Imaging

of the spleen plays a central role in evaluating the

trauma patient, as the spleen is the solid organ most

frequently injured in blunt abdominal trauma. Identi-

fying and grading splenic injury, including identifying

and characterizing hematomas, lacerations, and vascu-

lar injuries carries utmost clinical importance for

management. Vascular and nonvascular interventions

related to the spleen also play an important role in varied

clinical situations, including trauma, hypersplenism,

biopsy of unknown splenic lesions, and percutaneous

drainage of splenic abscesses.

Vascular Anatomy

The spleen is predominately supplied by the splenic

artery, which also supplies portions of the stomach and

pancreas. The splenic artery extends off the celiac axis

from the aorta, and courses toward the left side of the

upper abdomen, superior and anterior to the splenic

vein, along the superior edge of the pancreas.

The splenic artery most commonly divides into supe-

rior and inferior terminal branches at the splenic hilum,

and each branch further divides into four to six seg-

mental intrasplenic branches. The superior terminal

branches are usually longer than the inferior terminal

branches, and provide the major splenic arterial sup-

ply. A superior polar artery usually arises from the

distal splenic artery near the hilum, but it may originate

from the superior terminal artery. The inferior polar

artery usually gives rise to the left gastroepiploic

artery, but this artery may also arise from the

distal splenic or inferior terminal artery. The left

gastroepiploic artery then continues within the greater

omentum along the great curvature of the stomach to

anastamose with branches of the right gastroepiploic

artery (Stallard et al. 1994).

Numerous short gastric branches arise from the

terminal splenic or left gastroepiploic artery to supply

the gastric cardia and fundus. The splenic artery has

many branches that supply the pancreatic body and

tail. The first large branch is the dorsal pancreatic

artery, and the second large branch is the greater pan-

creatic artery (or arteria pancreatica magna), which

arises from the middle segment of the splenic artery.

Accessory spleens are usually also supplied from

splenic artery (Mortele et al. 2004).

The spleen is intrinsically perfused by two different

systems. A minority (<10%) of the blood slowly per-

fuses the spleen through an open circuit flowing from

the capillaries into the cords of Billroth and entering

into the venous sinusoids through the discontinuities of

the endothelial membrane. The open circuit allows

prolonged contact of the circulating cells and particles

with the macrophages and the other cellular compo-

nents of the cords. The majority of the blood flows

S. Ganguli

Massachusetts General Hospital/Harvard Medical School,

Boston, MA, USA

B. Hamm, P. R. Ros (eds.), Abdominal Imaging, DOI 10.1007/978-3-642-13327-5_133,# Springer-Verlag Berlin Heidelberg 2013

1523

rapidly and directly from the capillaries into the

venous sinuses (closed circuit) without filtering

through the red pulp.

The splenic vein is formed by the union of four

to five venous branches which drain the spleen and

converge at the splenic hilum. The splenic vein passes

from left to right along the superior margin of the

pancreas below the artery, and ends behind the neck

of the pancreas by uniting with the superior mesenteric

vein to form the main portal vein. A superior polar vein

from the upper pole of the spleen may join the splenic

vein more proximally. The splenic vein also receives

short gastric veins, the left gastroepiploic vein, pancre-

atic veins, and the inferior mesenteric vein.

Vascular Pathology

The terminal and intrasplenic segmental splenic arter-

ies are end-arteries, which predisposes the splenic

parenchyma to infarction when they are occluded.

There are many causes of splenic arterial occlusion

and splenic infarction, including cardiac emboli from

endocarditis, atrial fibrillation, and left-ventricular

thrombus; hematological malignancies such as

myleofibrosis, leukemia, and lymphoma; and

vasculitis and pancreatitis (De Schepper and Hoeffel

2000; Balcar et al. 1984; Jaroch et al. 1986).

The typical appearance of acute splenic infarction

is a sharply marginated peripheral wedge-shaped

lesion that demonstrates hypoattenuation on CT and

decreased echogenicity on ultrasound. Contrast-

enhanced CT markedly improves visualization of

splenic infarcts (Fig. 98.1). On MR imaging, splenic

infarcts typically appear as wedge-shaped areas of

abnormal signal intensity. The signal intensity on MR

depends on the evolution of the splenic infarct and the

amount of hemorrhagic necrosis and/or degradation

of blood products within the infarct. Infarcts lack

enhancement after gadolinium administration.

Splenic infarcts can also present with atypical

appearances including as multiple nodules with ill-

defined margins or diffuse low attenuation (Fig. 98.2)

(Balcar et al. 1984). These can be indistinguishable from

other splenic lesions, such as abscesses, hematomas, and

neoplasms. Percutaneous needle aspiration may be

required to distinguish these entities. Over time, infarcts

may disappear completely, or gradually change the size,

configuration, and imaging appearance of the spleen.

They generally appear as small, wedge-shaped areas of

increased echogenicity or hypoattenuation due to scar

formation and fibrosis.

Fig. 98.1 Paradoxical splenic

embolization. A 48-year-old

man who presented with left

lower extremity swelling and

left upper quadrant pain.

Contrast-enhanced CT shows

multiple peripheral

wedge-shaped areas of

hypoattenuation (arrows)consistent with splenic

infarcts. On further work-up,

the patient was diagnosed with

left lower extremity deep vein

thrombosis and a patent

foramen ovale, the source and

cause for his splenic infarcts

1524 S. Ganguli

Splenic vein thrombosis is often secondary to pan-

creatitis, pancreatic carcinoma, hypercoagulable

states, or after splenectomy (Petit et al. 1994). Splenic

vein thrombosis may result in the development of three

different collateral pathways: venous drainage via

short gastric veins into the right and left gastric veins

and then into the portal vein; collateral circulation

through the left and right gastroepiploic veins and

superior mesenteric veins; and retroperitoneal venous

collateral drainage via the left renal vein and inferior

vena cava (De Schepper and Hoeffel 2000; Vujic

1989). Like some patients with portal hypertension,

many patients with splenic vein thrombosis will have

esophageal varices due to inadequate decompression

through the short gastric veins. These varices can pro-

mote significant gastrointestinal hemorrhage.

Contrast-enhanced CT or MRI and Doppler ultra-

sound can all reliably make the diagnosis of splenic

vein thrombosis. In acute thrombosis, the splenic vein

is dilated and noncompressible, with lack of flow on

color Doppler ultrasound. Contrast-enhanced CT or

MRI shows a dilated, low attenuation thrombosed

splenic vein on CT or T2 hyperintense vein on MRI,

with lack of contrast enhancement (Fig. 98.3).

Adjacent enhancement of the vasa vasorum of the

venous wall is seen. Associated splenomegaly and

enlarged gastric varices which supplant the venous

drainage of the spleen can also be identified on

contrast-enhanced CT or MRI.

Splenic artery aneurysms are the most common

abdominal visceral artery aneurysm, representing up to

60%of all visceral artery aneurysms (Trastek et al. 1982).

Most aneurysms are small (<2 cm in diameter), saccular,

and located at a bifurcation in a middle or distal segment

of the splenic artery. Splenic artery aneurysms are

multiple in 20% of cases. Splenic artery aneurysms

are more common in women and are associated with

pregnancy, likely secondary to hormonal and hemody-

namic effects on the arterial wall during pregnancy.

Splenic artery aneurysms are also associated with portal

hypertension and cirrhosis. Other uncommon causes

of splenic artery aneurysms include fibromuscular

dysplasia, infection, and congenital anomalies (Madoff

et al. 2005).

a b c

Fig. 98.2 A 2-year-old child who underwent resection of

a retroperitoneal neuroblastoma resulting in complete splenic

infarction. The splenic infarcts initially appeared as hypoechoic

nodules (arrows) within a heterogeneously echoic spleen on

ultrasound (a). 2 weeks later, the entire spleen appeared

hypoattenuating on CT (b) consistent with complete infarction.

Ultrasound (c) examination now revealed a shrunken, heteroge-

neously echoic spleen. The hypoechoic nodules were no longer

visualized

Fig. 98.3 Contrast-enhanced CT scan of a patient with acute

pancreatitis and acute splenic vein thrombosis. The splenic vein

(arrowheads) is dilated with low attenuation, consistent with

thrombosis. Associated splenic infarct (arrow) is partially

visualized

Spleen: Trauma, Vascular, and Interventional Radiology 1525

Most splenic artery aneurysms are detected inciden-

tally during diagnostic imaging performed for other

indications, often when rim calcifications within the

wall of the aneurysm are identified on abdominal plain

films (Fig. 98.4). Splenic artery aneurysms appear as

hypoechoic masses in the left upper quadrant, demon-

strating turbulent or pulsatile flow on color Doppler

ultrasound. However, calcification and/or intraluminal

thrombus may limit ultrasound evaluation. Contrast-

enhanced CT andMR show a rounded or saccular mass

contiguous with the splenic artery (Fig. 98.5) which

displays marked and early arterial enhancement, with

attenuation or signal intensity values which mimic the

aorta on the portal venous phase. Selective splenic

angiography is sometimes required to confirm the

diagnosis or serve as a road map for further

intervention.

Indications for treatment of splenic artery aneu-

rysms include symptoms (epigastric pain, left upper

quadrant pain, back pain), female sex and childbearing

age, presence of portal hypertension, planned liver

transplantation, or diameter of more than 2.5 cm. Rup-

ture of splenic artery aneurysms is rare, but associated

with a high mortality rate. Historically, the treatment

for splenic artery aneurysm has been surgical ligation

of the splenic artery, ligation of the aneurysm, or

aneurysmectomy with or without splenectomy,

depending on the location of the aneurysm. Splenic

artery aneurysms are now treated with interventional

techniques such as transcatheter embolization

(Fig. 98.5), placement of a covered stent-graft to

exclude the aneurysm, or percutaneous injection of

coils and/or thrombin. Transcatheter embolization is

associated with significantly lower morbidity and mor-

tality than are surgical procedures (Madoff et al. 2005;

McDermott et al. 1994).

Trauma

The spleen is the solid organ most frequently injured in

blunt abdominal trauma. Assessment of splenic injury

represents one of the most common and challenging

problems in diagnostic imaging of the spleen. Injury to

the spleen may be secondary to direct compression,

avulsion of the vascular attachments from sudden

deceleration forces, or laceration by fractured adjacent

skeletal structures. Splenic trauma can result in

hypovolemia, blood loss, and local or referred symp-

toms from hemoperitoneum. Blood loss secondary to

splenic trauma can subsequently lead to tachycardia,

hypotension, and shock. Hemoperitoneum can lead to

rebound tenderness, diffuse abdominal rigidity,

abdominal distention, and decreased bowel sounds.

Management, including the need to perform diagnostic

imaging studies, should be dictated by the patient’s

clinical status (Emery 1997).

Conventional radiography has a relatively low yield

for splenic trauma. However, medial displacement of

the stomach, elevation of the left hemidiaphragm,

downward displacement of the splenic flexure of the

colon, or overlying rib fractures may suggest potential

splenic injury. Ultrasound and CT have replaced con-

ventional radiographs in the evaluation of patients with

blunt or penetrating trauma (Velmahos et al. 2003).

Ultrasonography of the injured spleen, with either

laceration or hematoma, reveals areas of both

increased and decreased echogenicity. Initial hemato-

mas are generally hyperechoic, but gradually progress

to lower echogenicity and finally anechogenicity as

Fig. 98.4 Mural rim calcification (arrow) of a 4 cm splenic

artery aneurysm is incidentally detected on an AP lumbar film

performed for back pain

1526 S. Ganguli

there is degradation of blood products. Subcapsular

hematomas or perisplenic fluid collections present as

anechoic to hypoechoic areas surrounding the spleen.

The benefits of ultrasound are reduced cost when com-

pared to CT as well as portability and absence of

ionizing radiation. However, small hematomas or lac-

erations can be missed on ultrasound, and accurate

grading of splenic injury requires CT (Benya and

Bulas 1996).

CT provides detailed resolution of the entire abdo-

men including the retroperitoneum in the evaluation of

trauma patients. By shortening examination times and

improving bolus contrast enhancement, multidetector

CT has become a major advancement in the evaluation

of trauma patients. The reported sensitivity of CT in

the detection of splenic injury ranges from 96% to

100% (Shuman 1997). CT has become the modality

of choice for grading splenic injury (Table 98.1). Grad-

ing of splenic injury can be used as a guideline for

patient management; however, clinical judgment

should still supersede CT findings when deciding

between operative or nonoperative management.

Subcapsular hematomas present as crescentic

regions of hypoattenuation that flatten or indent the

splenic margin. Intrasplenic hematomas are identified

as rounded areas within the spleen of mixed

attenuation, depending on the age of the lesion. Lacer-

ations are identified as linear, hypoattenuating areas

within the spleen parenchyma, often associated with

perisplenic fluid (Fig. 98.6). Extravasation of contrast

material from active hemorrhage or traumatic

pseudoaneurysms may be identified (Fig. 98.7).

Nonenhancing areas of the spleen are indicative of

vascular injury or thrombosis. With time, splenic

hematomas and lacerations become hypodense to the

adjacent splenic tissue. Hematomas may become

sharply delineated as their size decreases. Areas of

devascularized splenic tissue typically show

a b

c d

Fig. 98.5 3 cm splenic artery

aneurysm (arrow) identifiedon axial (a) and coronal (b)contrast-enhanced CT as

a saccular mass contiguous

with the splenic artery.

Selective digital subtraction

catheter angiography of the

splenic artery (c) confirms the

splenic artery aneurysm

(arrow), which was

subsequently coil embolized.

Follow-up CT (d) shows a coilmass (arrow) now filling the

previous location of the

splenic artery aneurysm

Table 98.1 Splenic CT injury grading scale

Grade I Laceration(s) <1 cm deep

Subcapsular Hematoma <1 cm in diameter

Grade II Laceration(s) 1–3 cm deep

Subcapsular or central hematoma 1–3 cm in

diameter

Grade III Laceration(s) 3–10 cm deep

Subcapsular or central hematoma 3–10 cm in

diameter

Grade IV Laceration(s) >10 cm deep

Subcapsular hematoma >10 cm in diameter

Grade V Splenic tissue maceration or devascularization

Spleen: Trauma, Vascular, and Interventional Radiology 1527

reperfusion on follow-up examinations. Following

injury, the shape of the spleen may return to normal,

or contour deformity may persist. Rarely, a traumatic

pseudocyst or calcification may form at the site of

splenic injury.

In patients who have had splenic trauma and or

rupture, splenosis may develop. Splenosis is defined

as the autotransplantation of splenic tissue resulting

from the spillage of cells from the pulp of the spleen

after splenic injury or splenectomy. Splenic implants

are generally numerous, and can be located anywhere

in the peritoneal cavity. Splenic implants located in the

peritoneal cavity may be confused with renal neo-

plasms, abdominal lymphomas, and endometriosis. If

splenic rupture is associated with a diaphragmatic tear,

the implants may seed the pleural cavity or pericar-

dium, which causes intrathoracic splenosis. 99mTc

sulfur colloid scintigraphy can help confirm the diag-

nosis with correlative areas of increased activity.

Functional imaging of the spleen may also be obtained

with denaturated blood cell scintigraphy, which is con-

sidered more sensitive than 99mTc sulfur colloid scin-

tigraphy and allows imaging of the splenic tissue

independent of imaging of the liver.

Interventional Radiology

Although surgery is usually performed in patients who

have traumatic injuries to the spleen and unstable

hemodynamics, patients with stable hemodynamics

may be treated with nonsurgical management, includ-

ing splenic arterial embolization. Indications for

splenic arterial embolization vary by practice, but

evidence of arterial injury on CT scans is considered

an indication for endovascular treatment (Madoff et al.

2005). The decision to use a particular embolic agent

depends on the ability to access the target and the

nature of the injury. When accessible, arteriovenous

fistulas and traumatic pseudoaneurysms are treated

with microcoils, with or without particles or gelatin

sponge to augment the thrombotic effect. Emboliza-

tion is optimally performed in the small arterial branch

that supplies the segment where the extravasation,

pseudoaneurysm, or vascular injury is identified, to

preserve perfusion to the remaining splenic paren-

chyma. The degree of splenic infarction and possible

associated pain and infectious complications are

decreased with superselective embolization (Killeen

et al. 2001).

Patients with diffuse injury or at high risk for sec-

ondary rupture of the spleen should undergo emboli-

zation with coils in a more proximal segment of the

splenic artery, to reduce the pressure in the entire

splenic parenchyma and to facilitate splenic healing

(Fig. 98.7) (Link et al. 1989). The placement of coils in

a middle segment of the splenic artery allows reconsti-

tution of the blood supply through collateral vessels,

principally via the short gastric and gastroepiploic

arteries. This embolization method is also useful as

a preoperative technique for reducing intraoperative

blood loss in patients undergoing open or laparoscopic

splenectomy. During treatment, visualization of the

pancreatic arteries is essential to reduce the risk of

their unintended embolization.

Surgical removal or transcatheter embolization

of splenic parenchyma may be performed for the man-

agement of hypersplenism. Hypersplenism is a

a b

Fig. 98.6 Contrast-enhanced CT images (a, b) of a 40-year-oldmale in a motor vehicle collision shows linear, hypoattenuating

area within the spleen parenchyma (arrow) consistent with

a lacerations. This is associated with hemoperitoneum, seen as

high-attenuation fluid (arrowheads) surrounding the spleen and

liver. This patient required splenectomy

1528 S. Ganguli

pathologic condition characterized by the spleen

preventing the normal circulation of corpuscular ele-

ments of the blood, by either sequestering them or

destroying them. Hypersplenism may be seen in many

disorders, including cirrhosis with portal hypertension;

hematologic abnormalities such as idiopathic thrombo-

cytopenic purpura, thalassemia major, and hereditary

spherocytosis; and diffuse splenic infiltration from pri-

mary malignancies such as leukemia and lymphoma

(Madoff et al. 2005; Athale et al. 2000). Total

splenectomy may be an effective treatment for

hypersplenism, but it impairs the body’s ability to pro-

duce antibodies against encapsulated microorganisms

and predisposes patients to sepsis. Splenic arterial

embolization and intentional infarction of splenic tissue

is an alternative treatment that can reduce the spleen’s

consumptive activity. Hematologic responses correlate

with the amount of infarcted splenic tissue. Infarction of

60–70% of the splenic mass is advocated to control

sequestration and destruction of the blood elements

a

b c

d e

Fig. 98.7 Contrast-enhanced

axial (a) and coronal (b) CTimages of a 36-year-old

female after motor vehicle

collision shows linear and

wedge-shaped areas of

hypoattenuation within the

spleen parenchyma (arrow)consistent with lacerations.

Active contrast extravasation

(arrowhead) from active

hemorrhage into the

peritoneum was also

identified. This patient

proceeded to angiography

given relatively stable

hemodynamics, where

nonselective digital

subtraction aortography

(c) confirms active contrast

extravasation (arrow) from the

midpole of the spleen.

Selective splenic

arteriography (d) also shows

a large midpole laceration as

an area of devascularization

(arrow) and active contrast

extravasation (arrow). Thispatient underwent gelfoam

embolization of the midpole

splenic arterial branch from

which the active contrast

extravasation was identified.

Selective splenic

arteriography after treatment

(e) also shows proximal

splenic artery coil

embolization (arrowheads), toreduce the pressure in the

entire splenic parenchyma and

to facilitate splenic healing.

Pancreatic branches extending

off the splenic artery were

avoided to prevent pancreatic

necrosis, with embolization

occurring distal to these

branches

Spleen: Trauma, Vascular, and Interventional Radiology 1529

(e.g., red blood cells, platelets), maintenance of the

spleen’s immunologic function, and preservation of

antegrade flow in the splenic vein (Kumpe et al. 1985).

Percutaneous biopsy of the spleen can be used for

diagnostic purposes (McInnes et al. 2011), although

there is increased risk of post-biopsy hemorrhagic

complications compared to other solid organs because

of the vascularized nature of the spleen (Fig. 98.8).

Indications for biopsy include evaluating a single or

multiple lesions in the spleen without a known primary

Fig. 98.8 Contrast-enhanced

CT image of the spleen shows

multiple hypoattenuating

lesions (dashed arrow)throughout the spleen.

Percutaneous biopsy (arrow)was performed using

ultrasound guidance for

diagnosis. Pathology revealed

littoral cell angioma of the

spleen. Diffusion weighted

images of the spleen show

numerous hyperintense lesions

(dashed arrow), consistentwith restricted diffusion

a

b

c

Fig. 98.9 Axial (a) and coronal (b) contrast-enhanced CT scan

of a 72-year-old female with pancreatic cancer who developed

a large intrasplenic abscess (arrowheads). There was extensionof the abscess collection into the perisplenic space and the

posterior chest wall (arrow). The patient underwent CT-guided

drainage (c) in a right lateral decubitus position with pigtail

drainage catheter (arrow) inserted from an anterolateral

approach. A separate pigtail drainage catheter was also placed

into the perisplenic collection

1530 S. Ganguli

tumor, evaluating a lesion in the spleen for metastatic

disease in a patient with a known primary tumor,

characterizing infection via a splenic lesion biopsy in

an immunocompromised patient or in leishmaniasis

(O’Malley et al. 1999). Steps to minimize the risk of

hemorrhage after biopsy include identifying and

correcting any underlying coagulopathy, avoiding

biopsy of hilar lesions, using 20 or 22 gauge needles,

embolizing the needle tract with gelfoam, and having

a cytopathologist present to minimize the number of

required passes. Percutaneous drainage of splenic

abscesses can also be performed safely and success-

fully (Fig. 98.9). The same precautions as for percuta-

neous biopsy should be performed to minimize

hemorrhagic complications. An anterolateral or pos-

terolateral approach is usually taken, with care to limit

injury to the diaphragm and lung.

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