University of Pisa
Department of Translational Research and New Technologies in Medicine and Surgery
Diagnostic and Interventional Radiology
Director: Prof. Carlo Bartolozzi
Postgraduate Thesis
Correlation between Multi Detector Computed Tomography findings and management of blunt splenic injuries in multytrauma patients
Supervisor Candidate
Prof. Carlo Bartolozzi Francesco Ruschi
A mamma
Can’t we give ourselves one more chance? Why can’t we give love that one more chance? Why can’t we give love?
Cause love’s such an old fashioned word, and love dares you to care for the people on the edge of the night, and love dares you to change our way of caring about ourselves
This is our last dance This is our last dance This is ourselves Under Pressure
Index
• Abstract
• Introduction
• Overview: Splenic Trauma
o Epidemiology, Pathophysiology and Clinical Observation
o Radiological Diagnosis
o Clinical Management
• Materials and Methods
• Results
• Discussion
• Conclusion
• Bibliography
Abstract
OBJECTIVE: to correlate in terms of sensitivity, specificity, positive/negative predictive values and
diagnostic accuracy the Multi Detector Computed Tomography (MDCT) findings, ranked according to the Baltimore Grading System, with the management of blunt splenic injuries in multytrauma patients.
MATERIALS AND METHODS: thirty-six trauma patients (25 male, 11 female), mean age 40 years, were
admitted to the Emergency Department in Pisa and underwent a contrast-enhanced MDCT (CEMDCT) with diagnosis of blunt splenic injury (study group). MDCT scans were obtained by using a 64 slices CT. MDCT results were collected retrospectively and then ranked according to the Baltimore Grading System criteria.
RESULTS: the MDCT findings were categorized as true positive, true negative, false positive or false
negative to determine the sensitivity, specificity, positive and negative predictive value and accuracy of MDCT in suggesting the management of patients. The MDCT findings based on the Baltimore Grade had an overall sensitivity of 92.30%, specificity of 91.30%, positive predictive value of 85.71%, negative predictive value of 95.45% and diagnostic accuracy of 91.66%. Of all the hemodynamically stable patients at admission to the Emergency Radiology (thirty-three of thirty-six patients), thirty patients (91%) had a successful nonoperative management (NOM). Only in three patients (9%) NOM failed, leading to splenectomy, because of respectively post-embolization splenic abscess, post- embolization splenic rupture, and inability to catheterize the splenic artery.
CONCLUSION: the Baltimore Grading System of Blunt Splenic Injuries shows high sensitivity, specificity,
negative predictive value and diagnostic accuracy in predicting the management of patients. In agreement with the literature data, our experience confirms that NOM of blunt splenic injuries is the standard of care in patients who are hemodynamically stable at admission to the Emergency Radiology.
Introduction
The management of patients admitted to an Emergency Department with a blunt
abdominal injury is a very common task for the trauma physician and the
emergency radiologist. The ability to obtain high resolution images during optimal
contrast enhancement at high speed is the reason why Multi Detector Computed
Tomography (MDCT) is the primary imaging modality of choice in evaluating
hemodynamically stable multytrauma patients during the secondary survey
[1,2,3]. During the primary survey in the shock room only a chest, cervical and
pelvis X-Ray associated with a FAST (Focused Assessed Sonography of Trauma)
sonography are allowed, according to the ATLS (Advanced Trauma Life Support)
criteria [94].
The spleen is the most commonly injured solid abdominal organ following a blunt
trauma. In the last few years the management of blunt splenic injuries both in
adults and children has shifted towards a conservative approach because of the
and because of the risks of post-operative complications. In this context MDCT has
played a significant role to allow the conservative management of blunt splenic
trauma in clinically stable patients [5,6].
For this goal the CT grading of splenic injury proposed by Mirvis et al [7,32] is
fundamental to predict outcome of nonoperative management (NOM), as it is
incorporated the presence of vascular injuries (active bleeding, arteriovenous
fistulas and pseudoaneurysms) with the parenchymal lesions (lacerations,
contusions and hematomas) and so it predicts better the outcomes of
nonoperative management. The classical surgical grading system (AAST system)
was previously proposed and studied, but, it did not show enough reliability in
predicting outcome of NOM as it excluded the vascular splenic lesions revealed by
the MDCT.
The purpose of this work is to correlate the MDCT findings with the management
of patients in terms of sensitivity, specificity, positive/negative predictive values
Coma Scale, however, 40% of patients with significant hemoperitoneum have
Overview: Splenic Trauma
Epidemiology, Pathophysiology and Clinical Observation
The mortality rate of blunt trauma reaches 10% [10]. Injuries result from traffic
accidents (50-75% of cases), accidental falls and precipitation accidents at work.
The abdominal organs are involved in 31% of multytrauma patients; the spleen
and the liver are the most affected organs (16% and 13% of cases respectively).
The incidence is higher in males (M / F: 3/2) with a peak between 14 and 30 years
old.
The most common presenting features of blunt intra-abdominal injury are
abdominal pain, tenderness, guarding and distention. In the spleen injuries there
is often a pain referred to left shoulder (Kehr’s sign) as well as the association with
fractures of the lowest left ribs (from IX to XII). Other symptoms such as shortness
of breath or chest pain may also be associated with significant abdominal injuries.
no peritoneal signs [8,9,11].
According to the ATLS protocol, blunt multytrauma patients should have plain Splenectomy has been the routine choice for treatment of traumatic spleen
injuries in the past. The incentive to change this management is attributed to
the growing awareness of the role of spleen in immunocompetence and of risks
of postoperative complications. Conscious of this protective role of the spleen,
Wanborough began the nonoperative management (NOM) at Sick Children's
Hospital in Toronto. Despite an initial skepticism about the feasibility and safety
of conservative treatment in adult patients, thanks to the encouraging results
obtained in the paediatric filed, this approach is today the treatment of choice
when the patient is hemodynamically stable without other associated injuries
requiring laparotomy. While the efficacy and safety of nonoperative treatment
of splenic injuries of low degree (Grade I and II AAST) is well documented, more
caution is request in more complex lesions. It is therefore necessary to give
these patients a period of close monitoring in an appropriate structure, having
quick access to diagnostic imaging, angiography and to the operating room [4].
radiographs of the cervical spine, chest and pelvis as part of their evaluation in
hemorrhage, and these are the reasons why MDCT scanning may be necessary the shock room. Whenever hemodynamic stability allows, the need for further
imaging is based on the mechanism of injury and findings during the primary
evaluation [11, 94].
A Focused Assessment with Sonography in Trauma (FAST) examination must be
performed in the shock room during the primary survey without hampering the
resuscitation maneuvers. The FAST examination is finalized to exclude
hemoperitoneum, hemotorax or hemopericardium as causes of hemodynamic
instability. The current FAST protocol consists of four acoustic windows
(pericardial, perihepatic, perisplenic, and pelvic – the four P’s) with the patient
supine. FAST can be performed simultaneously with resuscitation efforts during
the initial trauma management and only takes about 2 minutes to be performed
[67]. Reported sensitivities and negative predictive values for ultrasound in
detecting the hemoperitoneum are 78-99% and 93- 99%, respectively. But the
reliance of hemoperitoneum as the sole indicator of abdominal visceral injury
to further delineate the blunt injuries in stable patients. The consensus remains
organ injury grading and ongoing bleeding. In addition it can play a critical role that although a positive FAST is a strong predictor of injury, a negative FAST does
not rule out significant intra-abdominal injury or bleeding [11,13].
MDCT can accurately diagnose the four principal types of splenic injury including
hematomas, lacerations, active hemorrhage, pseudoaneurysms and
arteriovenous fistulas. It provides high quality isotropic images and multiplanar
reconstructions (MPR). These images can be used to detect the relationship
between the parenchymal lesions and vascular structures.
MDCT in trauma is the most valuable and most widely used tool in the initial
evaluation of the hemodynamically stable patient with blunt abdominal trauma.
The presence of the CT scanner in the emergency department, within seconds of
the trauma bay, may enable the speedy evaluation of critically injured patients.
MDCT can provide highly reliable information about the presence and size of
hemoperitoneum, the vascular injuries, the extent of many solid organ lesions,
in selecting the therapeutic modality in patients with solid organ injuries. This
[23,28,50,87].
includes, for example, the determination of whether the trauma physician should
resort to operative treatment versus angiographic embolization or only bed and
observation strategy for selected injuries [15,16,17,18,23,24,28].
MDCT offers the possibility of multiphase image acquisition after contrast agent
injection. While the mandate to minimize radiation dose requires restraint in
application of multiphase CT, dual-phase protocols have demonstrated utility in
trauma imaging. A dual-phase CT protocol including both arterial and portal
venous phase imaging provides better overall diagnostic performance for
evaluation of blunt splenic injury than either phase alone; the portal venous phase
is superior for demonstration of parenchymal injuries and active bleeding, while
the arterial phase is more sensitive for vascular lesions. Diagnosis of splenic
vascular injuries is important because these lesions are associated with higher risk
of failure of NOM [31,46,86]. Conversely, absence of contrast material
capsule and the enhancing splenic parenchyma. The subcapsular hematomas Figure 1: Diagnostic performance (in terms of sensitivity, specificity, diagnostic accuracy, positive predictive value
PPV, negative predictive value NPV) of arterial, portal-venous and dual-phase MDCT exams for splenic injuries
(pseudoaneurysm, active bleeding, nonvascular injury, perisplenic hematoma) [17]
The splenic hematomas (Figure 2) may be intraparenchymal or subcapsular. On
unenhanced MDCT the subcapsular hematoma is hyperdense relative to normal
splenic parenchyma. On contrast enhanced CT the subcapsular hematoma are
often compress the underlying splenic parenchyma and this finding helps to
parenchyma, where a laceration is recognizable (arrowhead).
differentiate them from small amounts of blood or fluid in the perisplenic space.
An uncomplicated subcapsular hematoma typically resolves within 4 to 6 weeks.
Its attenuation value usually decreases with the age of the lesion. On contrast
enhanced CT, the intraparenchymal hematomas appear as irregular high or low
attenuation areas within the parenchyma.
Figure 2: 42 y.o. male involved in a motor vehicle collision. The axial CT image obtained in the portal venous
The acute splenic lacerations (Figure 3) have sharp or jagged margins and
arrows), in keeping with a splenic laceration.
appear as linear or branching low attenuation areas on contrast enhanced CT.
With time the margins of splenic lacerations and hematomas become less well
defined and the lesions decreases in size until the area becomes isodense with
normal splenic parenchyma. Enlargement or extension of the lesion on
follow-up CT should raise the possibility of injury progression warranting close clinical
follow-up, further follow-up CT or arteriography. Complete healing by CT
appearance may take weeks to months depending usually on the initial size of
the injury.
Figure 3: 26 y.o. male admitted to the Emergency Department following a fall. The axial (left) and sagittal
On contrast enhanced MDCT active hemorrhage (Figure 4) in the spleen is seen
as an irregular or linear area of contrast extravasation. The active splenic
hemorrhage may be seen within the splenic parenchyma, subcapsular space or
intraperitoneal. The ongoing hemorrhage is represented by an increase of the
amount of contrast material extravasation on images obtained in the identical
anatomic region during the arterial, venous and delayed phases. The significant
difference between the attenuation value of extravasated contrast material (on
average 130 HU) and hematoma (on average 50 HU) is helpful in differentiating
active bleeding from clotted blood.
during the splenic angiography [11, 13,15,16,17,18,23,24,28].
vascular splenic peduncle is not damaged as seen in (c), that is why this is not a grade V injury). In the arterial
phase in (a) a large splenic laceration is visible (red arrow), surrounded by hemoperitoneum (also seen in (d), red
arrow). In the image (b) obtained in the late phase an area of high density within the perisplenic hematoma is
recognizable, which consists with active bleeding.
The ability to scan during peak contrast enhancement in the early arterial and
during the portal venous with MDCT is crucial to differentiate active bleeding from
post-traumatic splenic pseudoaneurysms or arteriovenous fistulas (Figure 5).
Usually post-traumatic vascular injuries are similar in attenuation value to active
hemorrhage in the arterial phase but wash out in the excretory phase becoming
minimally hyperdense or isodense compared to normal splenic parenchyma. A
significant correlation of MDCT findings of active splenic hemorrhage and need for
angiographic or surgical intervention has led to an aggressive diagnostic and
therapeutic pursuit of splenic vascular injury with MDCT and splenic angiography.
The appearance of post-traumatic splenic pseudoaneurysms and arteriovenous
may be the only CT finding of blunt splenic trauma and occur without any Figure 5: 65 y.o. female involved in a car accident. Axial CT images in the arterial (a) and portal venous phase
(b)show presence of post-traumatic pseudoaneurysms (red arrows) seen as well-circumscribed focal areas of
increased attenuation. There is a large quantity of perisplenic hematoma surrounding a complete splenic
laceration, as seen in the MPR images in (c) and (d), resulting in a grade IV/IVa grade of injury. The diagnostic
angiography in (e) confirms multiple pseudoaneurysms; post-embolization image in (f) shows complete
obliteration of the pseudoaneurysms.
On contrast enhanced MDCT post-traumatic splenic infarcts (Figure 6) appear as
well-demarcated segmental wedge shape low attenuation areas with the base of
adjacent free fluid. Splenic infarcts may also be seen in association with splenic
lacerations and segmental infarcts in the kidney. Injury to the intima of splenic
artery branches from sudden deceleration at the time of impact can lead to
thrombosis and infarction of the splenic parenchyma from lack of perfusion distal
to the intimal injury. The majority of these lesions usually heal without need for
surgical or angiographic intervention. Delayed complications of post- traumatic
splenic infarction include splenic abscess (Figure 7) formation and delayed rupture
Figure 6: Post-traumatic splenic infarct in a 39-year-old female involved in a motor vehicle collision. (A) Axial MDCT
image shows a well-demarcated wedge-shaped region of decreased enhancement (arrow), consistent with the
appearance of a posttraumatic splenic infarct. Follow-up MDCT images obtained at (B) 3 days, (C) 1 month, and
(D) 4 months show evolution over time with a reduction in size of the infarcted area and loss of splenic parenchyma
findings that may be suggestive of traumatic splenic injury may lead to less Figure 7: splenic abscess in a 35 y.o. male involved in a motor vehicle collision, 5 days after treatment of multiple
arteriovenous fistula with proximal embolization. CT examination performed because of fever, abdominal pain
and leukocytosis demonstrated the presence of a large splenic abscess with multiple air bubbles in the context
(red arrows). At laparotomy splenectomy was performed and the splenic abscess was confirmed.
The splenic clefts (Figure 8) are an important anatomical variant to recognize, as
they may be mistaken for splenic lacerations. Arising from the grooves that
originally separated the fetal splenic lobules during development, splenic clefts
may occasionally be as deep as 2–3 cm, and thus could be misinterpreted for a
grade II Association for the Surgery of Trauma (AAST) splenic injury. Recognizing
diagnostic confusion when presented with this finding [78].
(AAST) Organ Injury Scaling Committee was formally organized in 1987 to devise
Figure 8: Splenic cleft. Axial MDCT image demonstrates a linear low-attenuation area with rounded margins
representing a large splenic cleft (arrow). Large amount of hemoperitoneum (arrowheads) is seen secondary to
active bleeding from a mesenteric injury (not shown). The splenic cleft was confirmed at laparotomy [16].
Many systems have been proposed to grade splenic injury following trauma. The
splenic injury grades may be based on the extent of injury seen at laparotomy, CT
or autopsy. The purpose of a grading system is to standardize reporting, plan
appropriate management, and enable comparisons between institutions and
injury severity scores that could facilitate clinical investigation and outcomes
research [81]. The organ injury scale is a classification scheme based on the
anatomic disruption caused by injury to an individual organ. The complexity of the
injury increases with the grade [81]. The organ injury scale for the spleen was
revised in 1994 [82], in part as a result of the more widespread use of CT in the
setting of blunt abdominal trauma and as a result of increased understanding of
the relatively benign course of certain low-grade injuries. However, active
bleeding and vascular injuries were not incorporated in the revised system.
The American Association for the Surgery of Trauma (AAST) score is based on an
anatomic depiction of splenic disruption including the length and number of
lacerations, the surface area involved, and the extent of subcapsular or
injuries predicts the need for arterial embolization or surgical management Figure 9: AAST Splenic Injury Scale (1994 Revision) [7]
CT-based grading systems, derived from the AAST scale, are based on the extent
of anatomic disruption of the spleen, but without taking into consideration the
importance of some CT findings like active splenic bleeding, pseudoaneurysms or
post-traumatic arteriovenous fistulas. Recent radiological and surgical literature
suggests that these three CT findings have a high association with failed
nonoperative management (NOM) [18,20,31].
Marmery and colleagues [7,32] have developed a new grading system
(‘‘Baltimore’’ grading system), which is based on experience from multiple
[31,33,48]. In this new system, such previously low-grade splenic injuries are
upgraded to grade 4a or 4b and these patients are candidates for splenic
arteriography or splenic surgery. The quantity of blood in the peritoneal cavity is
not taken into consideration in assigning grades with this modified system
[2,7,31,33,48,80]. The aim of the proposed grading system is to identify cases in
which observation alone is likely to fail.
This ‘‘Baltimore’’ CT grading system seems to be better than the AAST system
for predicting which patients are the most likely candidates for embolization or
splenic surgery [13].
Figure 11: Comparison between the AAST and the Baltimore splenic injury grading systems [13]
Clinical Management
During the past two decades, major changes in the management of splenic injuries
have occurred. Traditionally, operative management (OM) was the standard for
patients with splenic injury. Once the spleen has been mobilized, a decision must
be made regarding splenectomy or splenic salvage procedures (mesh
splenorrhaphy, partial resection, adhesive and/or coagulation techniques). Due
overwhelming postsplenectomy sepsis, a trend from splenectomy toward
splenic conservation has emerged [47]. Presently, nonoperative management
(NOM) of splenic injury is the most common management strategy in
hemodynamically stable patients. NOM can be divided as observation or
angiography and embolization. Improved imaging techniques and advances in
interventional radiology have helped to differentiate patients who can be
observed versus those who need embolization [13,20,38].
Some prospective and retrospective studies have demonstrated that aggressive
pursuit of splenic pseudoaneurysms detected on contrast enhanced CT with
splenic angiography and embolization resulted in an improvement in the success
rate of nonoperative management of blunt splenic injuries from 87% to 94%
Figure 12: Meta-analysis of the most recent and important studies regarding the efficacy of splenic embolization
Both proximal splenic artery embolization (PSAE) and selective distal splenic
artery embolization have been applied and are described in the literature [20,50].
PSAE involves occluding the proximal splenic artery, the technique of selective
distal embolization involves embolizing only the injured blood vessels. This often
involves smaller branches of the splenic artery. Proximal embolization is mostly
used when there is diffuse bleeding of the spleen, when there are multiple focal
bleeding vessels in the spleen, when there is time-pressure as a result of the
hemodynamic situation of the patient, or when tortuosity of the splenic artery
prevents selective distal embolization. Selective distal embolization is usually
reserved for patients who have one or only a few focal bleeding vessels in the
spleen and in whom the anatomy and hemodynamic situation allow employment
per millimeter with a flow rate of at least 3 mL/sec, with selection of 100-120 kV
Materials and methods
From January 2014 to March 2015, thirty-six multytrauma patients (25 males, 11
females), aged 8-83 years old (mean age 40.7 years), were admitted to the
Emergency Department of Pisa (a Level I Trauma Center) with a blunt abdominal
trauma, and were studied by MDCT with a diagnosis of splenic injury (study group).
The MDCT examinations were executed with a 64 slices GE Lightspeed VCT (GE
Healthcare, Milwaukee, USA) before and after the intravenous administration of
contrast material and saline solution (mechanical power injector: Medrad,
Pittsburgh, USA). The type, volume and flow rate of contrast and radiation dose
parameters were dependent on the patient’s physical body characteristics and the
type of venous access. With “standard patients”, mean age and weight without
any particular problem in obtaining a peripheral venous access, it was used
vascular injuries. Coils were usually the embolic agents of choice.
and mAs automatic modulation. In case of paediatric patients we performed only
an enhanced phase avoiding the nonenhanced scan. The CT protocol was tailored
on the basis of the age of the children and the body mass. In the adult patients our
standard protocol consisted of a nonenhanced CT (NECT) and a contrast enhanced
CT (CECT) with a dual-phase acquisition in the arterial and portal-venous phase. A
delayed phase (after eight minutes on average) was acquired only in those cases
with the suspicion of a urinary tract injury. Oral contrast was never used. The scans
were obtained from the level of the dome of diaphragm to the symphysis pubis
using a slice thickness of 2.5mm.
Splenic arterial catheterization was performed using the common femoral artery
access, placing a 5-6 French introducer sheath. Diagnostic series of the splenic
artery were obtained, and for selective catheterization of splenic artery branches
coaxial micro-catheters and micro-guidewires were used. Techniques and
materials used for embolization depended on anatomical considerations, the
immediate splenectomy (Table 1).
Results
Thirty-three (92%) patients were hemodynamically stable at admission to the
Emergency Radiology. Of these, twenty-two (67%) patients were successfully
observed (successful NOM); seven (21%) patients underwent distal embolization
because of a vascular injury and then observed (successful NOM); two (6%)
patients underwent embolization and in the following days splenectomy because
of splenic abscess in one case and splenic rupture in the other one (NOM failure);
one (3%) patient with a suspect pseudoaneurysm at MDCT underwent
angiography (which was negative for the presence of vascular injury) and then was
observed successfully (NOM successful); one (3%) patient with multiple
pseudoaneurysms at MDCT underwent angiography but not embolization (due to
inability to catheterize the splenic artery because of a tight stenosis), and then
underwent splenectomy. Three (8%) patients developed hemodynamic instability
Table 1: Summary of 36 patients with clinical outcome
MDCT results (by different radiologists) were collected retrospectively and then
ranked according to the Baltimore Grading System criteria (Table 2).
BALTIMORE GRADE PERCENTAGE
I 9 (25%)
II 10 (28%)
III 3 (8%)
IVa 8 (22%)
IVb 6 (17%)
Indications for transcatheter splenic embolization included evidence of
intraparenchymal/subcapsular/intraperitoneal bleeding, post-traumatic
pseudoaneurysm or arteriovenous fistula.
On the basis of the MDCT findings the patients were categorized as true positive,
true negative, false positive or false negative to determine the sensitivity,
specificity, positive and negative predictive value and accuracy of MDCT in
suggesting the correct management.
True positive was defined as MDCT or MDCT + angiography showing evidence of
splenic vascular contrast material extravasation or splenic vascular lesions, and
followed by embolization or embolization + surgery or immediate surgery.
True negative was defined as MDCT showing no evidence of splenic vascular
contrast material extravasation or splenic vascular lesions, with consequent
successful nonsurgical management.
False positive was defined as MDCT showing evidence of splenic vascular contrast
extravasation or splenic vascular lesions, not confirmed at angiography, with
consequent successful nonsurgical management.
contrast material extravasation or splenic vascular lesions, with consequent
NOM failure and required surgery or embolization + surgery. False negative was
also defined as MDCT showing no evidence of splenic vascular contrast material
extravasation or splenic vascular lesions, findings not confirmed at angiography
which observed vascular lesions, with consequent NOM failure and required
embolization or surgery or embolization + surgery (Table 3).
CATEGORY MDCT ANGIOGRAPHY CLINICAL MANAGEMENT
POSITIVE POSITIVE EMBOLIZATION/EMBOLIZATION+SURGERY
TRUE POSITIVE (TP)
POSITIVE / IMMEDIATE SURGERY
TRUE NEGATIVE (TN)
NEGATIVE / SUCCESSFUL NOM
FALSE POSITIVE (FP)
POSITIVE NEGATIVE SUCCESSFUL NOM
NEGATIVE / NOM FAILURE (SURGERY/EMBOLIZATION+SURGERY)
FALSE NEGATIVE (FN)
NEGATIVE POSITIVE NOM FAILURE
(EMBOLIZATION/SURGERY/EMBOLIZATION+SURGERY)
The correlation of the contrast-enhanced MDCT criteria basing on the Baltimore
Grading System, the arteriographic findings and the clinical outcome were
categorized as true positive (12 patients), true negative (21 patients), false positive
(two patients), or false negative (one patient). The MDCT findings had an overall
sensitivity of 92.30%, specificity of 91.30%, positive predictive value (PPV) of
85.71%, negative predictive value (NPV) of 95.45% and diagnostic accuracy of
91.66% in predicting the correct management of patients (Table 4).
BALTIMORE GRADING SYSTEM RESULTS
SENSITIVITY 92.30% SPECIFICITY 91.30%
PREVALENCE 36.11%
POSITIVE PREDICTIVE VALUE (PPV) 85.71% NEGATIVE PREDICTIVE VALUE (NPV) 95.45%
DIAGNOSTIC ACCURACY 91.66%
Of all the hemodynamically stable patients at admission to the Emergency
Radiology (thirty-three patients), thirty patients (91%) had a successful nonoperative management (NOM):
• twenty-two patients (67%): simple NOM
• seven patients (21%): embolization + NOM
• one patient (3%): diagnostic angiography negative for vascular lesions Only in three patients (9%) nonoperative management failed:
• two patients (6%): embolization + NOM with consequent splenic abscess and splenic rupture respectively (splenectomy)
Discussion
The spleen is the most commonly injured solid abdominal organ. Bleeding from
splenic trauma can be fatal and unstable patients are usually taken immediately
to surgery. On the other hand, for the clinically stable patient with splenic injury
nonoperative management is reported to be the most appropriated, given the
lifelong increased risk of sepsis in asplenic patients, and due to the postoperative
complications [1,2,3,5,6,13,20,38].
MDCT is the primary imaging modality of choice in evaluating hemodynamically
stable multytrauma patients during the secondary survey of the ATLS protocol
[94]. The CT-based Baltimore grading system [7,32] of blunt splenic lesions takes
into consideration the importance of traumatic splenic vascular lesions (active
bleeding, pseudoaneurysms and post-traumatic arteriovenous fistulas) and it
gives a good prediction of management of multytrauma patients [13].
In our study, nonoperative management was attempted in thirty-three of thirty-
these thirty-three patients (6%) underwent embolization and consequent NOM,
but in the following days they developed hemodynamic instability requiring
urgent splenectomy because of a splenic abscess in one case, and a splenic rupture
in the other one. In one of the thirty-three stable patients (3%) it was impossible
to catheterize the splenic artery because of a significant proximal stenosis, and
splenectomy was necessary because of the presence of a vascular lesion at the
preliminary MDCT.
The remaining 91% of stable patients (thirty of thirty-three) were successfully
observed. Twenty-two (67%) of these thirty-three were simply monitorated and
on the following days discharged home; seven (21%) underwent embolization and
then observation; one (3%) underwent angiography because of the evidence of
a vascular lesion at the MDCT, but angiography revealed nothing (MDCT false
positive).
Three of the thirty-six patients (9%) underwent splenectomy immediately at
et al [7,18].
Table 5: Summary of 36 patients with splenic injury with management
The MDCT findings ranked according to the Baltimore Splenic Injury Grading
System showed sensitivity of 92.30%, specificity of 91.30%, positive predictive
value (PPV) of 85.71%, negative predictive value (NPV) of 95.45% and diagnostic
accuracy of 91.66% in predicting the correct management of patients; these
Shanmuganathan et al. [2,7,16,18,26,32] demonstrated that splenic vascular
patient observation. These results are similar to those reported by injuries correlate substantially with Baltimore Splenic Injury Grade. According to
their prospective study, MDCT shows an overall sensitivity of 81%, specificity of
84%, and accuracy of 83% in demonstrating vascular injury.
In our study the high NPV (95.45%) suggests that when the MDCT examination is
negative for the presence of vascular injuries, simple NOM (bed and observation)
is successful in most cases. Furthermore the high sensitivity (92.30%) and
specificity (91.30%) of the MDCT suggests that, respectively, it is highly probable
for a vascular blunt splenic lesion, when present, to be detected at MDCT and, it
is highly probable that the absence of a vascular lesion can be confirmed at MDCT.
According to our results we can also conclude that NOM is the treatment of choice
for stable patients with blunt splenic injury, as in our study group it was performed
in 91% of cases. Embolization has a central role in the spread of the NOM as the
treatment of choice for hemodynamic stable patients, as in 21% of cases it made
Shanmuganathan et al [2]; in particular these authors suggest that centers
attempting nonoperative management should be well aware of the potential for
its failure. Facilities to closely monitor vital signs and immediate availability of
surgeons and operating rooms in case of NOM failure are necessary.
Marmery et al [46] suggest this algorithm for blunt splenic injuries (Figure 13): bed
and observation for low-grade injuries (grades I, II, III) and embolization for all
high-grade injuries (grades IVa, IVb). They conclude that this policy has helped
them to achieve a success rate of 96% in patients selected for nonoperative
management and an overall splenic salvage rate of 85% in patients with
MDCT-diagnosed splenic vascular injury. This results are consistent with our ones, as in
our study we achieved a success rate of nonoperative management of 91% (thirty
Conclusion
In conclusion, according to our findings, we can state that MDCT findings based on
the Baltimore Grading System of Blunt Splenic Injuries show an overall high
sensitivity, specificity, negative predictive value (NPV) and diagnostic accuracy in
predicting the correct management of patients.
In agreement with the literature data, our experience confirms that NOM of blunt
splenic injuries is the standard of care in patients who are hemodynamically stable
2001;51:272-8.
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Acknowledgements
Un ringraziamento speciale va a Michele Tonerini per il prezioso aiuto e
supporto per la stesura di questa tesi, nondimeno per essere amico e infinita
fonte di ispirazione professionale.
Grazie ad Alessandro Paolicchi, per avermi fatto capire già durante i miei primi
passi professionali cosa vuol dire essere Radiologo a 360 gradi; grazie inoltre
per esserci sempre stato, anche nei momenti di buio pesto in cui tutto sembra
crollarti addosso. E so che sempre ci sarà. Grazie di cuore!
Grazie al Dottor Napoli, per i suoi insegnamenti e per le “massime lavorative”
che mi porterò dietro per tutto il mio futuro percorso professionale.
Grazie inoltre a tutti i medici, specializzandi, tecnici, infermieri, operatori
sanitari e personale amministrativo che mi hanno sopportato e che hanno
