active hemorrhage and vascular injuries in splenic trauma

Original research n

EmErgEncy radiology

Radiology: Volume 270: Number 1—January 2014 n radiology.rsna.org 99

active hemorrhage and Vascular injuries in splenic Trauma: Utility of the Arterial Phase in Multidetector CT1

Jennifer W. Uyeda, MDChristina A. LeBedis, MDDavid R. Penn, MDJorge A. Soto, MDStephan W. Anderson, MD

Purpose: To determine whether the addition of arterial phase com-puted tomography (CT) to the standard combination of portal venous and delayed phase imaging increases sen-sitivity in the diagnosis of active hemorrhage and/or con-tained vascular injuries in patients with splenic trauma.

Materials and Methods:

The institutional review board approved this HIPAA-compliant retrospective study; the requirement to obtain informed consent was waived. The study included all pa-tients aged 15 years and older who sustained a splenic injury from blunt or penetrating trauma and who under-went CT in the arterial and portal venous phases of image acquisition during a 74-month period (September 2005 to November 2011). CT scans were reviewed by three ra-diologists, and a consensus interpretation was made to classify the splenic injuries according to the American As-sociation for the Surgery of Trauma splenic injury scale. One radiologist independently recorded the presence of contained vascular injuries or active hemorrhage and the phase or phases at which these lesions were seen. Clinical outcome was assessed by reviewing medical records. The relationship between imaging findings and clinical man-agement was assessed with the Fisher exact test.

Results: One hundred forty-seven patients met the inclusion cri-teria; 32 patients (22%) had active hemorrhage and 22 (15%) had several contained vascular injuries. In 13 of the 22 patients with contained injuries, the vascular lesion was visualized only at the arterial phase of image acquisi-tion; the other nine contained vascular injuries were seen at all phases. Surgery or embolization was performed in 11 of the 22 patients with contained vascular injury.

Conclusion: The arterial phase of image acquisition improves detec-tion of traumatic contained splenic vascular injuries and should be considered to optimize detection of splenic in-juries in trauma with CT.

q RSNA, 2013

1 From the Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118. Received June 5, 2012; revision re-quested July 25; revision received April 10, 2013; accepted April 30; final version accepted July 19. Address corre-spondence to J.W.U. (e-mail: [email protected]).

q RSNA, 2013

Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.

100 radiology.rsna.org n Radiology: Volume 270: Number 1—January 2014

EMERGENCY RADIOLOGY: Splenic Trauma: Utility of Arterial Phase in Multidetector CT Uyeda et al

years]; 48 female patients aged 15–95 years [mean age, 47 years]) fulfilled the criteria for inclusion (splenic injury iden-tified at both arterial and portal venous phases in patients aged 15 years). During the 74-month period, 35 patients with splenic injuries were excluded from the study; four patients were younger than 15 years, 13 patients did not have a splenic injury at repeat evaluation of the images, 17 patients had splenic injuries that were not imaged during the arterial phase, and one patient was transferred to an outside hospital. Of the 147 pa-tients, 130 had delayed images in ad-dition to the arterial and portal venous phase images. The mechanisms of injury for the 147 patients were as follows: mo-tor vehicle collision, 65 patients (44%); fall, 33 (22%); pedestrian struck by car, 15 (10%); motorcycle collision, 12 (8%); gunshot wounds, eight (5%); assault with blunt force trauma, six (4%); stab wounds, five (3%); and crush injury, three (2%). Patients who underwent splenectomy, exploratory laparotomy, or catheter-directed angiography with em-bolization before CT were also excluded from this study.

CT TechniqueAll CT examinations were performed with a 64–detector row CT scanner (Light-Speed VCT; GE Medical Systems, Milwaukee, Wis), and all images were obtained in a craniocaudal direction from the thoracic inlet through the greater trochanters. The following pa-rameters were used: reconstruction

of portal venous and delayed phase im-aging increases sensitivity in the diag-nosis of active hemorrhage and/or con-tained vascular injuries in patients with splenic trauma.

Materials and Methods

The institutional review board approved this retrospective study. The study complied with the Health Insurance Portability and Accountability Act; the requirement for informed patient con-sent was waived.

Patient PopulationFor this retrospective study, the picture archiving and communication system was queried to identify 147 consec-utive patients (age 15 years) who sustained splenic injury from blunt or penetrating trauma during a 74-month period (September 2005 to November 2011) and were seen at our urban level I trauma center. Three investigators (J.A.S., S.W.A., C.A.L., with 17, 6, and 3 years of experience in trauma im-aging, respectively), who were blinded to the patients’ clinical data and clini-cal outcomes, reviewed all images and identified those patients whose splenic injuries were imaged at both the arte-rial phase (included in the lower aspect of the CT acquisition of the chest) and the standard portal venous and delayed phases. One investigator (S.W.A.) then independently recorded the presence of contained vascular injuries or active hemorrhage and the phase or phases at which these lesions were seen.

A total of 147 patients aged 15–95 years (mean age, 41 years; 99 male pa-tients aged 17–84 years [mean age, 39

The advent of multidetector com-puted tomography (CT) has proved invaluable in the rapid evaluation

of intraabdominal injuries in patients who sustain multiple trauma (1–9). Multidetector CT has high accuracy for detecting hollow- and solid-organ injury in the trauma setting, including the eval-uation for traumatic splenic injuries (1–3,8–10). The detection of active splenic hemorrhage and contained vascular in-juries is crucial for identifying the need for subsequent direct intervention (eg, surgery or transcatheter embolization) versus conservative, nonsurgical treat-ment (1–3,6,7,9,11–15).

Multiphasic multidetector CT pro-tocols enable imaging of the chest, ab-domen, pelvis, and, when necessary, extremities with use of a single intra-venous bolus of contrast material. Tra-ditionally, the CT assessment of trau-matic intraabdominal injuries, including splenic injuries, has relied on portal ve-nous phase imaging, with the addition of delayed phase imaging as necessary (3,11,13,14,16,17). Recently, arterial phase imaging of the abdomen and pel-vis has been proposed for better depic-tion of vascular injuries of the solid ab-dominal organs (14,18). The additional arterial phase acquisition increases ra-diation exposure, a consideration that must be weighed against the clinical utility of potentially improving the iden-tification and characterization of trau-matic injuries in the abdomen. Thus, the benefits of arterial phase imaging of the abdomen and pelvis in the trauma setting warrants further investigation. The purpose of this study was to retro-spectively determine whether the addi-tion of arterial phase computed tomog-raphy (CT) to the standard combination

Implications for Patient Care

n The use of arterial phase imaging as part of multiphasic whole-body trauma CT markedly in-creases the sensitivity of CT in the detection of contained vascu-lar injuries in splenic trauma.

n The arterial phase of CT image acquisition should be considered to optimize the detection of trau-matic splenic injuries.

Advance in Knowledge

n More than half of the contained vascular injuries (13 of 22 [59%]) were visualized only at the arterial phase of CT, demon-strating that sensitivity and accu-racy are improved with the addi-tion of the arterial phase of image acquisition as part of mul-tiphasic whole-body trauma CT.

Published online before print10.1148/radiol.13121242 Content code:

Radiology 2014; 270:99–106

Abbreviation:AAST = American Association for the Surgery of Trauma

Author contributions:Guarantors of integrity of entire study, J.W.U., S.W.A.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, J.W.U., J.A.S.; clinical studies, J.W.U., C.A.L., J.A.S., S.W.A.; statistical analysis, J.W.U., S.W.A.; and manuscript editing, J.W.U., C.A.L., J.A.S., S.W.A.

Conflicts of interest are listed at the end of this article.



interventional reports, in a blinded manner to determine the surgical and angiographic outcomes as well as the clinical course during hospitalization. The specific data collected included the need for laparotomy, splenorrha-phy or splenectomy, angiography, and splenic artery embolization. Emergent splenectomy was defined as surgical re-moval of the spleen within 24 hours of presentation.

Statistical AnalysisThe Fisher exact test (R: A Language and Environment for Statistical Computing; R Foundation for Statistical Computing, Vienna, Austria) was used to analyze the relationships between (a) AAST splenic injury scale and subsequent clinical management, (b) AAST splenic injury scale and the presence of active hemor-rhage or contained vascular injury, (c) presence of active hemorrhage or con-tained vascular injury and subsequent clinical management, and (d) phases of image acquisition at which the active hemorrhage or contained vascular injury was identified and subsequent clinical management. P , .05 was considered indicative of a statistically significant difference. In patients found to have a contained vascular injury, the AAST splenic injury grade was incorporated

splenic injury scale (1994 revision) (Table 1) (19). All information, includ-ing clinical outcome, surgical findings, and final diagnosis, was withheld from the reviewers at the time of image inter-pretation. All available images, including 1.25- and 3.75-mm axial data sets and multiplanar coronal and sagittal recon-structions, were reviewed as necessary.

One radiologist (S.W.A.) indepen-dently recorded the presence of splenic vascular injuries, including active hem-orrhage and contained vascular in-juries (eg, arterial pseudoaneurysms and arteriovenous fistulas). Linear or irregular foci of extravascular contrast material–enhanced blood located in or adjacent to the splenic parenchyma that increased in size at portal venous and delayed phases (when available) were defined as active hemorrhage. Con-tained vascular injuries were defined as circumscribed areas of extravascular contrast-enhanced blood, equal or sim-ilar in attenuation to the aorta or an adjacent major artery at all phases of image acquisition.

Clinical OutcomesTwo investigators (J.W.U. and D.R.P., both radiology residents) reviewed the patients’ electronic medical re-cords, specifically the surgical and

thickness, 1.25 and 3.75 mm; 120 kVp; noise index, 23 (automatic dose modula-tion); pitch, 1:0.984; and gantry rotation time, 0.5 second. In all cases, multipla-nar reformations in coronal and sagittal planes were provided (2.5 3 2.5 mm).

All patients received a bolus of 100 mL of intravenous contrast material (Optiray; Mallinckrodt Imaging, Hazel-wood, Mo [350 mg iodine per millili-ter]) at a rate of 4–5 mL/sec with use of a power injector via an 18- or 20-gauge cannula in an antecubital vein. In addi-tion, a 30-mL saline chasing bolus was used immediately after administration of the intravenous contrast material. All patients with penetrating trauma received oral and rectal contrast ma-terial, in addition to the intravenous agent, per our departmental protocol. Oral contrast material was not adminis-tered to patients with blunt trauma, per departmental protocol.

CT of the chest, from the thoracic inlet through the caudal extent of the diaphragm, was performed by using a 30-second delay after the initiation of intravenous contrast material injection. Subsequently, images of the abdomen and pelvis from the superior aspect of the diaphragm through the greater tro-chanters were acquired with a 70-sec-ond delay. In addition, a 5-minute de-layed acquisition of the abdomen and pelvis was obtained at the discretion of the radiologist who performed the pre-liminary evaluation of the thoracic and portal venous phase abdominal images at the scanner console. Delayed phase images, when obtained, were acquired by using a higher noise factor value (noise factor, 27), thereby decreasing radiation exposure, allowing for reduced tube current–time product values, and resulting in an increase in image noise; delayed phase images were used to def-initely characterize lesions.

Image AnalysisThree experienced abdominal radiolo-gists (J.A.S., S.W.A., and C.A.L.) retro-spectively reviewed all images in a blind-ed manner. A consensus interpretation was made to classify the splenic injuries according to the American Associa-tion for the Surgery of Trauma (AAST)

Table 1

AAST Splenic Injury Grading Scale

AAST Grade and Type of Injury Description

I Hematoma Subcapsular, ,10% of surface area Laceration Capsular tear, ,1 cm of parenchymal depthII Hematoma Subcapsular, 10%–50% of surface area; intraparenchymal, ,5 cm in diameter Laceration 1–3 cm in parenchymal depthIII Hematoma Subcapsular, .50% of surface area; ruptured subcapsular or parenchymal hematoma;

intraparenchymal hematoma, .5 cm in diameter Laceration .3 cm parenchymal depth or involving trabecular vesselsIV Laceration Laceration involves segmental or hilar vessels producing major devascularization

(.25% of spleen)V Laceration Completely shattered spleen Vascular Hilar vascular injury that devascularized spleen



visualized only at the arterial phase and were not seen at the portal venous or de-layed phases (Figs 1, 2). In the remaining nine patients (41%), however, the in-juries were seen at both the arterial and portal venous or delayed phases (Fig 3). Without the arterial phase, most of the contained vascular injuries (13 of 22 cases [59%]) would not have been detected; however, use of the arterial

treated conservatively; the remaining 11 patients (50%) underwent surgery or splenic artery embolization. Re-sults of the Fisher exact test showed a significant difference (P , .0001) in comparing rates of surgery and/or em-bolization in patients with and patients without contained vascular injuries.

In 13 of the 22 patients with contained vascular injuries (59%), the lesions were

into a multiple logistic regression model as a function of the patient’s sex, pres-ence of solid organ injury, presence of pelvic injury (ie, fracture, active extrava-sation), and whether the contained vas-cular injury was detected at the arterial phase only or at the arterial and portal venous phases. The presence of solid organ and pelvic injuries were included as variables because these could affect whether the patient underwent surgery and/or embolization versus conservative treatment. Although the AAST grading scale for splenic injuries consists of five distinct grades, the grades have been classified into two categories for statis-tical analysis: low (grades I and II) and high (grade III–IV).

Results

Injury GradeOf the 147 patients who fulfilled inclu-sion criteria, one patient had a con-tained vascular injury but did not ful-fill criteria for classification according to the AAST grading scale because no hematoma or laceration was found. Ac-cording to the AAST scale, the splenic injuries were classified as grade I in 20 of the 146 patients (14%), grade II in 30 (21%), grade III in 68 (46%), grade IV in 25 (17%), and grade V in three (2%) (Tables 1, 2). The frequency of success-ful conservative management decreased with increasing severity of splenic injury such that, for example, 18 of the 20 pa-tients with grade I splenic injuries (90%) were successfully treated conservatively compared with none of the patients with grade V splenic injuries (Table 2). Re-sults of the Fisher exact test revealed a significant difference in the management of splenic injuries on the basis of injury grade (P , .0001) in comparing man-agement (surgery and/or embolization vs conservative management) of low-grade (grades I and II) and high-grade (grade III–V) injuries.

Visualization of Contained Vascular Injuries and Clinical OutcomesContained vascular injuries were found in 22 of the 146 patients (15%). Of these 22 patients, 11 were

Table 2

Patient Treatment according to Grade of Splenic Injury

TreatmentGrade I (n = 20)

Grade II (n = 30)

Grade III (n = 68)

Grade IV (n = 25)

Grade V (n = 3)

Conservative 18 29 45 4 0Surgical 1 1 20 16 2Embolization 1 0 3 5 1

Note.—Data are numbers of patients.

Figure 1

Figure 1: Contrast-enhanced CT scans in 39-year-old man who fell 30 feet. A, B, Transverse images in arterial phase demonstrate three small hyperattenuating foci (arrows) in spleen. C, D, Transverse images in portal venous phase show that these lesions have washed out. Findings are consistent with contained vas-cular injury (eg, pseudoaneurysm or arteriovenous fistula) and were seen only at arterial phase. This patient underwent emergency splenectomy.



Twenty-five of the 32 cases of ac-tive hemorrhage (78%) were seen at the arterial, portal venous, or delayed phases. In the remaining seven cases, the extravasated contrast material was visualized at the portal venous and delayed phases only. Of the 25 patients in whom active hemorrhage was seen at the arterial, portal ve-nous, or delayed phases, 22 (88%) underwent surgery or embolization and the remaining three were suc-cessfully treated conservatively. Of the seven patients in whom the ac-tive hemorrhage was seen only at the portal venous and delayed phases, five were treated with surgery or embo-lization and the remaining two were treated conservatively. There was no significant difference in treatment (surgery and/or embolization vs con-servative management) between pa-tients in whom the active hemorrhage was seen at the arterial, portal ve-nous, and delayed phases and those in whom hemorrhage was seen only at the portal venous and delayed phases (P = .296).

Of the patients with active hem-orrhage, the overwhelming majority (29 of 32 patients [91%]) sustained high-grade splenic injuries (grade III–V) (Table 4). The prevalence of active hemorrhage increased progressively with increasing grade of injury (Table 2). The Fisher exact test showed a statistically significant difference in the prevalence of active hemorrhage when we compared low-grade (grade I and II) and high-grade (grade III–V) splenic injuries (P = .0006).

Discussion

In this study, contained vascular in-juries, including pseudoaneurysms or arteriovenous fistulas, were seen in 22 of the 147 patients (15%). More than half of these injuries were iden-tified only at the arterial phase of im-age acquisition. The identification of contained vascular injuries is essential because these injuries have an unfa-vorable outcome with conservative management, with an increased inci-dence of overt bleeding necessitating

damage), three underwent emboliza-tion, and four were treated conserva-tively. There were no significant differ-ences in management (surgery and/or embolization vs conservative manage-ment) between the patients with con-tained vascular injuries seen only at the arterial phase compared with the pa-tients with contained vascular injuries seen at the arterial and portal venous or delayed phases (P = .99). On the ba-sis of a multiple variable logistic regres-sion model, no significant difference was seen (P = .28) in surgery and/or embolization versus conservative man-agement as a function of patient age, sex, AAST splenic injury grade, pres-ence of solid organ injury, presence of pelvic injury, or whether the contained vascular injuries were detected at the arterial phase only or at the arterial and portal venous phases.

The prevalence of contained vascu-lar injuries increased progressively with increasing grade of injury. A single case of contained vascular injury was seen in a grade I splenic injury, and two cases were detected in grade II splenic in-juries. Twelve of the 68 patients with a grade III injury (18%), four of the 25 with a grade IV injury (16%), and two of the three with a grade V injury had contained vascular injuries (Table 4). Results of the Fisher exact test demon-strated a significant difference between the prevalence of contained vascular in-juries in low-grade (grades I and II) and high-grade (grade III–V) splenic injuries (P = .046).

Visualization of Active Hemorrhage and Clinical OutcomesActive hemorrhage was seen in 32 of the 146 patients (22%) (Table 3, Fig 4). Of the 32 patients with active hem-orrhage, five (16%) were successfully treated conservatively, whereas 27 (84%) underwent surgery or splenic artery embolization. Results of the Fisher exact test showed a significant difference in management (surgery and/or embolization vs conservative management) between the patients with active hemorrhage and those with-out evidence of active hemorrhage at CT (P , .0001).

phase provides greater sensitivity for the detection of contained vascular in-juries. Use of the McNemar test with continuity correction on the aug-mented data in the 22 patients with contained vascular injuries showed that there was a significant improve-ment (P = .008) in the detection of contained vascular injuries with the additional arterial phase. Of the 13 contained vascular injuries seen only at the arterial phase, seven were man-aged conservatively. However, of the remaining six patients, one under-went embolization and five underwent urgent splenectomy; one of these five patients died of extensive traumatic injuries (Table 3). Of the nine patients with contained vascular injuries seen at the arterial, portal venous, and delayed phases, two patients under-went splenectomy (one of whom died secondary to extensive neurologic

Figure 2

Figure 2: Contrast-enhanced axial CT scans in 95-year-old woman who fell down a flight of stairs. A, Transverse image in arterial phase shows hyper-attenuating focus (arrow) in spleen. B, Transverse image in portal venous phase shows that focus seen at arterial phase (arrow) is much less conspicuous and not clearly visualized. Findings are consistent with contained vascular injury (eg, pseudoaneurysm or arteriovenous fistula). Patient underwent conser-vative treatment.



be tolerated (23). The second major consideration is whether detection of these additional contained vascular injuries provides meaningful benefit to the patient. In this study, although the sample size limits generalization, 46% of patients with contained vascular injuries identified only during the ar-terial phase of image acquisition (six

additional radiation exposure must be weighed as a potential risk. Given the inherent high contrast-to-noise ratio in arterial phase imaging, lower exposure settings compared with standard portal venous phase imag-ing with reduced tube current–time product values may be appropriate because a higher level of noise may

blood transfusions, splenectomy with associated lifelong risk of infection, and delayed diagnosis and treatment, potentially leading to increased mor-tality (11,15,17,20,21). The obser-vation that most cases of contained vascular injury were visualized only at the arterial phase of image acquisition supports recent work by Bosack et al (22) demonstrating the improved sen-sitivity and accuracy gained with the addition of an arterial phase of image acquisition for detecting contained vascular injuries in trauma. Because most cases of contained vascular in-juries were visible only at the arterial phase of image acquisition, the use of arterial phase imaging of the ab-domen in blunt or penetrating trauma should be strongly considered.

However, certain factors must be weighed when considering imple-mentation of arterial phase imaging of the abdomen in trauma. First, the

Figure 3

Table 3

Patient Treatment with Respect to CT Findings at Various Imaging Phases

Variable No. of InjuriesNo. of Patients Undergoing Surgery and/or Embolization

No. of Patients Receiving Nonsurgical Treatment

Active hemorrhage 32 27 5 Arterial, PV, delayed phases 25 22 3 PV and delayed phases 7 5 2Contained vascular injury 22 11 11 Arterial phase only 13 6 7 Arterial and PV phases 9 5 4

Note.—PV = portal venous.

Figure 3: Contrast-enhanced CT scans in 49-year-old man who fell 10 feet. (A–C) Transverse images in, A, arterial, B, portal venous, and, C, delayed phases and, D, reformatted coronal image in arterial phase show indistinct area of hyperattenuating foci (arrows in A, B, D) in spleen visualized at arterial and portal venous phases; this area washes out at delayed phase. E, Patient un-derwent angiography, and contained vascular injuries (arrows) were embolized.



venous or delayed phases of image ac-quisition. Thus, on the basis of this study, the use of an arterial phase of image acquisition did not yield signif-icant clinical utility in the imaging of active hemorrhage in splenic trauma.

Limitations of this study include the sole use of CT for the assess-ment of splenic injuries and diagno-sis of vascular injuries without rou-tine confirmation with conventional angiography. Second, because of the retrospective nature of this study, the trauma surgeons were not blind-ed to the CT findings at the time of the patient treatment decision; thus, causality between the CT findings and ultimate clinical management is not definitively established. Third, the use of standard timing delays for image acquisition after the administration of intravenous contrast material, as per our technique, imparts an inher-ent variability in the actual phase of contrast. For instance, differences in hemodynamic measures between pa-tients may have resulted in slight dif-ferences in the phase of image acqui-sition with use of a standard delay for the timing of all phases of image ac-quisition. Finally, the relatively small number of splenic vascular injuries, particularly contained vascular in-juries, limits the conclusions that may be drawn from this work.

In conclusion, this study demon-strates that the use of arterial phase imaging markedly increases the sen-sitivity of CT in the detection of con-tained vascular injuries in splenic trauma. However, the effect of these gains in sensitivity on clinical man-agement and patient outcomes re-mains uncertain and must be weighed against risks to the patient popula-tion, including additional radiation exposure. Nevertheless, the use of arterial phase imaging in abdominal trauma should be strongly considered and deserves further inquiry.

Disclosures of Conflicts of Interest: J.W.U. No relevant conflicts of interest to disclose. C.A.L. No relevant conflicts of interest to dis-close. D.R.P. No relevant conflicts of interest to disclose. J.A.S. No relevant conflicts of in-terest to disclose. S.W.A. No relevant conflicts of interest to disclose.

of 13 patients) underwent surgical intervention. However, the causality between the presence of a contained vascular injury seen only at the arte-rial phase and surgical interventions remains unclear given the retrospec-tive nature of this study.

In the case of active hemorrhage, most cases (25 of 32 patients [78%]) were seen at all phases of image ac-quisition. As expected, significant dif-ferences in treatment were identified between patients with and patients

Table 4

CT Findings and Grade of Splenic Injury

CT FindingsGrade I (n = 20)

Grade II (n = 30)

Grade III (n = 68)

Grade IV (n = 25)

Grade V (n = 3)

Active hemorrhage 2 1 13 14 2Contained vascular injury 1 2 12 4 2

Note.—Data are numbers of patients.

Figure 4

Figure 4: Contrast-enhanced axial CT scans in 34-year-old man involved in motorcycle accident. Transverse images in, A, arterial, B, portal venous, and, C, delayed phases show hyperattenuating contrast material (arrow) that persists and progressively enlarges at subsequent delayed imaging. Findings were consistent with active extravasation. Patient underwent splenectomy.

without active hemorrhage at CT, sup-porting the results of previous work (1,2,7,9,13,24,25). However, no sig-nificant differences in treatment were seen between patients whose active hemorrhage was visible at all phases of image acquisition and those whose hemorrhage was seen only at the portal venous and delayed phases. In both groups, most patients underwent surgery or embolization. Finally, in contradistinction to the case of con-tained vascular injuries, the use of an arterial phase of image acquisition is not projected to increase the sensitiv-ity of CT in the diagnosis of these in-juries because, in all cases, the active hemorrhage is identified at the portal



References 1. Shanmuganathan K, Mirvis SE, Sover ER.

Value of contrast-enhanced CT in detecting active hemorrhage in patients with blunt ab-dominal or pelvic trauma. AJR Am J Roent-genol 1993;161(1):65–69.

2. Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical man-agement of blunt splenic injury: use of CT criteria to select patients for splenic arteri-ography and potential endovascular therapy. Radiology 2000;217(1):75–82.

3. Willmann JK, Roos JE, Platz A, et al. Multidetector CT: detection of active hem-orrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol 2002;179(2): 437–444.

4. Novelline RA, Rhea JT, Rao PM, Stuk JL. Helical CT in emergency radiology. Radiol-ogy 1999;213(2):321–339.

5. Yao DC, Jeffrey RB Jr, Mirvis SE, et al. Using contrast-enhanced helical CT to vi-sualize arterial extravasation after blunt abdominal trauma: incidence and organ distribution. AJR Am J Roentgenol 2002; 178(1):17–20.

6. Yoon W, Jeong YY, Kim JK, et al. CT in blunt liver trauma. RadioGraphics 2005; 25(1):87–104.

7. Hagiwara A, Yukioka T, Ohta S, Nitatori T, Matsuda H, Shimazaki S. Nonsurgical man-agement of patients with blunt splenic in-jury: efficacy of transcatheter arterial embo-lization. AJR Am J Roentgenol 1996;167(1): 159–166.

8. Thompson BE, Munera F, Cohn SM, et al. Novel computed tomography scan scoring system predicts the need for intervention after splenic injury. J Trauma 2006;60(5): 1083–1086.

9. Smith HE, Biffl WL, Majercik SD, Jednacz J, Lambiase R, Cioffi WG. Splenic artery em-

bolization: have we gone too far? J Trauma 2006;61(3):541–544; discussion 545–546.

10. Becker CD, Spring P, Glättli A, Schweizer W. Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery? AJR Am J Roentgenol 1994;162(2): 343–347.

11. Bessoud B, Denys A, Calmes JM, et al. Non-operative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization? AJR Am J Roentgenol 2006;186(3):779–785.

12. Haan JM, Biffl W, Knudson MM, et al. Splenic embolization revisited: a multicen-ter review. J Trauma 2004;56(3):542–547.

13. Anderson SW, Varghese JC, Lucey BC, Burke PA, Hirsch EF, Soto JA. Blunt splenic trauma: delayed-phase CT for differentiation of active hemorrhage from contained vascu-lar injury in patients. Radiology 2007;243(1): 88–95.

14. Hamilton JD, Kumaravel M, Censullo ML, Cohen AM, Kievlan DS, West OC. Multi-detector CT evaluation of active extravasa-tion in blunt abdominal and pelvic trauma patients. RadioGraphics 2008;28(6):1603–1616.

15. Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative manage-ment of blunt splenic injuries: emboliza-tion of splenic artery pseudoaneurysms. J Trauma 1998;44(6):1008–1013; discussion 1013–1015.

16. Stuhlfaut JW, Anderson SW, Soto JA. Blunt abdominal trauma: current imaging tech-niques and CT findings in patients with solid organ, bowel, and mesenteric injury. Semin Ultrasound CT MR 2007;28(2):115–129.

17. Marmery H, Shanmuganathan K, Alexan-der MT, Mirvis SE. Optimization of selec-tion for nonoperative management of blunt splenic injury: comparison of MDCT grad-

ing systems. AJR Am J Roentgenol 2007; 189(6):1421–1427.

18. Taourel P, Vernhet H, Suau A, Granier C, Lopez FM, Aufort S. Vascular emergencies in liver trauma. Eur J Radiol 2007;64(1): 73–82.

19. Moore EE, Cogbill TH, Jurkovich GH, et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995;38(3):323–324.

20. Shapiro MJ, Krausz C, Durham RM, Mazus-ki JE. Overuse of splenic scoring and com-puted tomographic scans. J Trauma 1999; 47(4):651–658.

21. Cocanour CS, Moore FA, Ware DN, Mar-vin RG, Clark JM, Duke JH. Delayed com-plications of nonoperative management of blunt adult splenic trauma. Arch Surg 1998; 133(6):619–624; discussion 624–625.

22. Boscak AR, Shanmuganathan K, Mirvis SE, et al. Optimizing trauma MDCT protocol for blunt splenic injury: need for arterial and portal venous phase scans [abstract]. In: Radiological Society of North America Sci-entific Assembly and Annual Meeting Pro-gram. Oak Brook, Ill: Radiological Society of North America, 2011; 60.

23. Uyeda JW, Anderson SW, Sakai O, Soto JA. CT angiography in trauma. Radiol Clin North Am 2010;48(2):423–438, ix–x.

24. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Sur-gery of Trauma. J Trauma 2000;49(2):177–187; discussion 187–189.

25. Federle MP, Courcoulas AP, Powell M, Fer-ris JV, Peitzman AB. Blunt splenic injury in adults: clinical and CT criteria for manage-ment, with emphasis on active extravasa-tion. Radiology 1998;206(1):137–142.

active hemorrhage and vascular injuries in splenic trauma

Documents