MDCT Findings of Splenic Pathology

Abstract

The delineation and characterization of splenic lesions and other abnormalities can be challenging on computed tomography. Many splenic lesions are incidentally found, imaging features tend to overlap, and without the appropriate clinical context, differentials can range from benign to malignant. Radiologists should be familiar with the wide variety of pathologies seen on computed tomography as it is often the first imaging modality a splenic lesion is seen. The purpose of this MDCT-focused review is to understand normal splenic anatomy and its variants, to illustrate and describe typical and atypical imaging patters of inflammatory, infectious, vascular, traumatic, benign, and malignant tumors of the spleen and provide clues in reaching the appropriate differential diagnosis and management.

Fig. 1

Wandering spleen. Contrast enhanced coronal CT shows the spleen in the RUQ of the abdomen below the liver. The long vascular pedicle (arrows) increases the patient’s risk of torsion.

Fig. 2

55 y/o male with history of situs inversus totalis. Contrast enhanced axial CT shows the spleen in the right upper quadrant of the abdomen. Posterior to the spleen, there are smaller, isodense and ovoid lesions (arrows) consistent with accessory spleen.

Fig. 3

47 y/o male with history of gunshot wound showing intrathoracic splenosis. A nodular opacity is projected in the posterior aspect of the chest suggestive of a pulmonary mass (short arrow) on the lateral chest radiograph; note the bullet (long arrow) from prior gunshot (a). Non-contrast (b) and venous (c) axial CT images demonstrate a homogenously enhancing left hemithoracic mass consistent with ectopic splenic tissue.

Fig. 4

55 y/o male with early satiety found to have epidermoid cyst. Double (a) and single (b) contrast upper GI study showing an extrinsic compression of the gastric fundus with no abnormality in the gastric mucosal folds. Ultrasound (c) of the left upper quadrant shows a well-defined heterogenous mass with internal echoes (arrows). Echogenic foci are representing intralesional cholesterol crystals, fat and blood. Contrast-enhanced axial CT (d) images show a large intra-splenic homogeneous fluid density mass (arrow).

Fig. 5

Type I hydatid cyst. Axial non-contrast contrast enhanced CT images show a rounded well-defined homogeneous intrasplenic cyst. Courtesy of Dr. Moguillansky

Fig. 6

Type IIC hydatid cyst. Axial contrast enhanced CT scan demonstrate a complex cystic mass in the spleen. Internal calcifications are present (arrows). This patient also shows liver involvement. Courtesy of Dr. Moguillansky

Fig. 7

Type IIB hydatid cyst. Axial post contrast CT showing a large intrasplenic hydatid cyst with multiple internal daughter cysts and mural as well as internal calcifications (arrow). Multiple cystic lesions are also seen in the liver. Courtesy of Dr. Moguillansky

Fig. 8

42 y/o male status post MVC showing post-traumatic splenic pseudocyst. Contrast enhanced axial CT image immediately after polytrauma shows multiple parenchymal lacerations and extensive hemoperitoneum (a). Subcapsular splenic hematoma is also seen (a, arrow). Contrast enhanced axial CT performed 30 days after traumatic event demonstrates a homogenous well-defined fluid containing collection compatible with pseudocyst (b, arrow).

Fig. 9

98 y/o female with history of left upper quadrant pain. Abdominal radiograph showing clustered distribution of gas (arrow) in the left upper (a). Axial (b, c) CT images show large non-delineated foci of intrasplenic gas (arrows), with minimal amount of associated fluid. The patient died immediately after the examination. Autopsy confirmed splenic abscess.

Fig. 10

43 y/o female after abdominal trauma with grade I splenic injury. Axial contrast-enhanced CT images show a linear parenchymal laceration (< 1 cm in depth) after splenic trauma (arrows). Perisplenic blood is noted (arrowheads).

Fig. 11

21 y/o male status post MVC with grade 2 splenic injury. Contrast-enhanced venous phase axial (a) CT images demonstrate large ill-defined parenchymal splenic contusion (arrow). A subcapsular hematoma is well identified on the coronal images (b) (arrow).

Fig. 12

68 y/o male with presenting after trauma with grade III splenic injury. Contrast-enhanced venous phase coronal images show large subcapsular hematomas (arrows) > 50% of the surface area consistent with a grade III splenic injury. No active extravasation is seen.

Fig. 13

33 y/o male with after trauma presenting with grade IV splenic injury. Contrast-enhanced arterial phase axial CT image show a peripheral splenic laceration with intraparenchymal and peri splenic active bleeding (yellow arrows). The active bleeding stays within the confines of the splenic capsule. The patient was taken to angiography suite, which showed persistent active bleeding (b, arrow) which was successfully embolized (c).

Fig. 14

14 y/o male without any past medical history presenting after polytrauma. Contrast-enhanced venous phase axial CT image (a) shows a complete devascularization of the spleen consistent with grade V injury.

Fig. 15

Splenic flash filling hemangioma. Axial post-contrast image of the spleen demonstrates a well-defined, rounded, hyper-vascular intraparenchymal lesion (a, arrow). Three-minute delayed image shows intralesional isoattenuation with the normal splenic parenchyma (b, arrows).

Fig. 16

Littoral cell angioma in a patient with hypersplenism. Pre-contrast (a), post-contrast early venous (b), and delayed (C) axial images of the spleen demonstrate a poorly marginated hypovascular lesion with no peripheral nodular arterial enhancement (b). PET/CT fusion image (d) shows a FDG-avid mass. Pathology confirmed: Littoral cell angioma (e, arrow).

Fig. 17

Multifocal splenic involvement in lymphoma. Axial contrast-enhanced CT images (a–b) shows an enlarged spleen with multiple well-defined hypovascular parenchymal lesions. Retrocrural, retroperitoneal and intraperitoneal adenopathy are seen (a–b, arrows).

Fig. 18

Breast cancer splenic metastases. Axial (a) and coronal (c) contrast enhanced CT images of the spleen demonstrate a complex cystic appearing lesion (arrows), not visualized on prior exam consistent with metastatic deposit.

Fig. 19

Gamna-Gandy bodies in portal hypertension. Contrast-enhanced axial CT image (a) shows multiple scattered sub-centimeter hypodense splenic lesions. Axial MRI T1 (b) and T2 (c) weighted images demonstrate multiple well-defined hypointense in T1 and T2 splenic lesions compatible with deposits of hemosiderin secondary to microfollicular hemorrhage. Gross specimen (d) confirmed Gamna-Gandy bodies (arrows).

Fig. 20

Splenic artery Aneurysms. Contrast-enhanced axial (a, b), coronal MIP (c), and volume rendered reconstruction (d) CT images showing two saccular aneurysmal dilatations in the splenic artery (arrows), the largest measuring 3 cm (b, c, d, arrows).

Fig. 21

Sarcoidosis. Contrast-enhanced axial (a–b) CT images of the spleen demonstrate solid hypovascular partially defined splenic lesions. Axial CT scan of the lungs (c) revealed a typical perilymphatic distribution of micronodules and alveolar sarcoid pattern of nodular consolidations (black arrows). Hepatic involvement is incidentally noted (a).

Fig. 22

Multiple appearances of splenic abnormalities in patients with sickle cell disease. The spleen contains a slow, tortuous microcirculation that subjects it to congestion and polymerization. First patient shows an enlarged spleen with linear calcifications likely sequela from prior infarcts (a, arrows). The second patient demonstrates small spleen with confluent calcifications (b). The third patient shows minute fully calcified spleen consistent with autosplenectomy (c, arrow).

Fig 23

Simple schematic to help differentiate splenic lesions based on certain characteristics seen on CT and history findings.