Role of contrast-enhanced ultrasound (CEUS) in the diagnosis and management of traumatic splenic injuries

Abstract

Splenic injuries are common emergencies in the setting of abdominal trauma, as the spleen is the second most frequently injured abdominal organ after the liver. The treatment of splenic injuries underwent a severe shift from operative to non-operative due to an increased awareness of the double physiological function, both immunological and hematological, of the spleen. This, in turn, led to an increased application of splenic preservation techniques. The non-operative approach has been strengthened through radiological imaging and interventional radiology. While multidetector computed tomography is mandatory in the evaluation of hemodynamically stable patients after high-energy trauma, one ultrasound (US) can be used as a first-line technique to examine patients in cases of low-energy trauma. Unfortunately, baseline US has low sensitivity in the detection of traumatic injuries. With the introduction of contrast-enhanced ultrasound (CEUS) as a reliable alternative to baseline ultrasound for low-grade abdominal trauma, the sensitivity of the US technique in recognizing traumatic abdominal lesions has strongly increased, reaching levels of accuracy similar to those of the CT. It has also been strongly recommended for use with children, as it allows for the performance of imaging techniques with the lowest dose of radiation possible. In this review, the authors aim to present the typical appearance of traumatic splenic injuries, using enhanced CEUS capability to overcome baseline US limits, and to describe the different techniques applied according to the hemodynamic stability of the patient.

Keywords: BAT; Blunt abdominal trauma; CEUS; Contrast-enhanced ultrasound; MDCT; Multidetector computed tomography; Non-operative management; Splenic trauma; Trauma; Trauma imaging; Traumatic splenic injuries.

Fig. 1

Direct blunt abdominal trauma in a 10-year-old boy. a US depicts a subtle inhomogeneity of the middle spleen without evidence of a real injury. b CEUS shows a deep splenic lesion without perisplenic fluid

Fig. 2

a CEUS shows a double splenic lesion, at the upper and lower pole, respectively. b CE-CT on axial plane and c CE-CT on coronal plane confirm CEUS findings

Fig. 3

a US shows inhomogeneity at upper-middle splenic pole. No evidence of any parenchymal injury. b CEUS fully depicts a complete splenic laceration. c CE-CT on axial plane and d CE-CT on coronal plane confirm CEUS findings

Fig. 4

Direct blow on the left hypchondrium. a US shows a mild inhomogeneity at splenic upper pole. b CEUS clearly depicts a deep and complete laceration of the upper pole. c CE-CT on axial plane and d CE-CT on coronal plane confirm CEUS findings, along with the presence of mild perisplenic fluid

Fig. 5

a With US, the upper pole is difficult to study because of lung air interposition. b CEUS clearly depicts the deep laceration (white calipers) at the upper pole. c CE-CT on axial plane and d CE-CT on coronal plane confirm CEUS findings

Fig. 6

Direct blunt abdominal trauma in a 5-year-old girl. a US does not show any alterations. b CEUS performed with convex and c with high-frequency linear probe depicts a deep laceration at splenic lower pole

Fig. 7

a US shows a mild inhomogeneity at splenic lower pole; no evidence of traumatic injury or perisplenic fluid. b CEUS clearly depicts a huge lower pole laceration with capsular involvement and a mild perisplenic fluid. c CE-CT on axial plane and d CE-CT on coronal plane confirm splenic injury which involves the capsule with perisplenic fluid (black arrow in c)

Fig. 8

a US shows a mild inhomogeneity at the lower pole of the spleen, without evidence of traumatic injury. b CEUS depicts a little splenic lesion (white arrow) as a non-enhancing defect, sharply demarcated from the well-enhanced normal healthy tissue. c CE-CT, axial plane, d CE-CT, coronal plane confirm the traumatic lesion at the lower pole (black arrow in c) without any signs of active bleeding

Fig. 9

Same patient as in Fig. 2, CEUS follow-up at 72 h from trauma. a CEUS in arterial phase and b CEUS in portal venous phase depict a hyperechoic focus (white arrows) within the well-established traumatic injury, suggesting the diagnosis of AVF. c CE-CT on axial plane and d CE-CT on coronal plane confirm the AVF finding as a well-demarcated area of contrast enhancement within the injury zone (black arrows). The patient underwent a splenic embolization that was not successful, and a splenectomy was subsequently performed

Fig. 10

a US performed at admission shows an intraparenchymal laceration of the upper pole. b CE-CT on axial plane confirms the wide laceration of the upper pole. c CEUS performed at 1 month after non-operative management (splenic embolization) shows a hypoechoic lesion within the area of the previous injury. d MR performed after 1 month confirms the presence of the injury, appearing as an organizing hematoma because of a hyperintense edge, expression of extracellular methaemoglobin content (white arrow)