Introduction Computed tomography (CT) scans are very sensitive for detecting splenic injuries after trauma. Our objective was to present a case of the rare entity called ‘Delayed Splenic Rupture,’ which is the delayed manifestation of splenic injury following a trauma in which the initial CT scan showed a normal spleen. We also review the previous 13 cases and offer our recommendations.
Case Report We present a case of a 42 year old male with a motorcycle crash who presented with a normal spleen on CT scan and 5 days later was scanned again after a significant decrease in his hemoglobin revealing a large subcapsular splenic hematoma.
Conclusion A normal appearing spleen on initial imaging should not sway one from considering delayed splenic rupture as a potential delayed complication of a traumatic event.

Delayed Splenic Rupture

Prateek K Gupta, MD,¹ Janine Morris, MD,² Bala Natarajan, MD,¹ Robert Bertellotti, MD,¹ and R Armour Forse, MD, PhD¹

Departments of Surgery,¹ and Radiology,² Creighton University, Omaha, Nebraska.

Contact: Prateek K Gupta, MD E-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Citation: Gupta PK, Morris J, Natarajan B, Bertellotti R, and Forse RA. Delayed splenic rupture. J Surg Radiol. 2010 Oct 1;1(2). Download PDF Delayed Splenic Rupture 3456 Kb Received June 27, 2010. Accepted July 29, 2010. Epub August 1, 2010. Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Contents - Introduction - Case Report - Discussion - Disclosures - References

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Introduction

The diagnosis of post-traumatic splenic injuries has made enormous progress: from the implementation of physical examination and diagnostic peritoneal lavage (DPL) through the most recent development and use of computed tomography (CT). Unfortunately, there are reports in the literature discussing isolated cases of ostensibly normal spleens which were subsequently found to have delayed rupture. Many of the initial reports were based purely on clinical examination, a few upon DPL. To date, there have been 13 reported cases in which the spleen appeared normal on the initial CT scan then consequently was found to be ruptured. This is in spite of CT having a sensitivity and specificity for detection of splenic injuries as high as 96% and 100% respectively.^1,2 In this paper, we will present the case of a 42-year-old male, involved in a motorcycle accident, who presented with a normal spleen on initial CT scan. Five days later he was rescanned due to a decrease in hemoglobin. The follow-up scan revealed a large subcapsular splenic hematoma.

Case Report

A 42-year-old male was brought to the trauma bay of our institution after involvement in a motorcycle crash. Upon arrival, the patient was amnesic for the accident with a Glasgow Coma Scale (GCS) score of 14 out of 15. His hemoglobin was 13.9 g/dl with normal coagulation parameters, and he was hemodynamically stable. He reported a left-sided nephrectomy done in childhood. After obtaining the history and completing the primary and secondary surveys, he was taken for a CT scan of the abdomen and pelvis (Figure 1). The images demonstrated a mildly heterogeneous appearance of the spleen consistent with expected variation seen during early arterial phase image acquisition. No fluid surrounded the spleen. Delayed images (Figure 2) obtained ten minutes after the administration of the initial contrast bolus showed homogeneous splenic parenchyma without contrast pooling. Additional injuries identified on the initial CT scan included a solitary right kidney with laceration of the inferior pole with moderate amount of surrounding hemorrhage along with multiple blood clots in the proximal ureter and bladder. He also had fractures of right 8-12 ribs, a minimally displaced right femoral neck fracture, comminuted right femoral diaphyseal fracture, and a medial malleolus fracture.

Figure 1. Initial CT image obtained during arterial phase showing mildly heterogeneous appearance to the spleen consistent with variable contrast uptake with no surrounding hemorrhage and no findings consistent with splenic laceration (top).

Figure 2. Delayed image showing normal spleen without contrast pooling (middle).

Figure 3. Follow up CT image from 5 days after the original traumatic event showing splenic subcapsular hematoma (bottom).

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The patient was admitted to the ICU and the next day, prior to intramedullary nailing of his right femur, his hemoglobin fell to 11.5 g/dL. Post-operatively, the hemoglobin level dropped to 7.4 g/dL. This fall in hemoglobin was attributed to several factors including the renal laceration and aggressive fluid resuscitation (approximately seven liters) crystalloid/colloid; no blood products) in the operating room. Estimated blood loss in the operating room was 300 ml. During his ICU stay, his hemoglobin continued to drop and he received a total transfusion of three units of packed RBCs before stabilizing with a hemoglobin titer of 8.1 g/dL. He was then transferred to the floor on post trauma day four. The next day he experienced a syncopal episode at which time his hemoglobin was found to be 6.7 g/dL with normal coagulation parameters. He was subsequently transfused with two more units of packed RBCs and a repeat CT scan was performed.

The CT scan (Figure 3) showed interval development of a large subcapsular splenic hematoma measuring three centimeters in thickness with variable attenuation blood products. There was no active contrast extravasation or contrast pooling on delayed images. Increased free fluid was seen in the abdomen. The right renal subcapsular hematoma was stable.

Splenic embolization was considered a significant risk given that he possessed only a single kidney, had progressively worsening renal function on laboratory evaluation, and had just received a contrast bolus for the follow up CT scan. Additionally, the CT scan did not show contrast extravasation to indicate active bleeding. Consequently, the patient was taken to the operating room for a splenectomy. During surgery, the lateral capsule of the spleen was found to be lacerated. There was significant hematoma around the spleen. Approximately one liter worth of blood was present but there was no active bleeding. He was transfused with seven units of packed RBCs and two units of fresh frozen plasma in the operating room. Postoperatively, the hemoglobin was 10.4 g/dL and it remained stable throughout his postoperative hospital stay. His urine function and creatinine remained stable as well. He was discharged on post trauma day 12. 

Discussion

Delayed splenic rupture (DSR) was defined by Benjamin as rupture of spleen more than 48 hours after trauma.³ The time period is based on the “latent period of Baudet” of 48 hours which Baudet described as time from injury to rupture.⁴ The first case of delayed splenic rupture documented by CT was reported in 1981 by Toombs.⁵

Several hypotheses as to the etiology of delayed splenic rupture have been offered. It has been suggested that if the CT scan is performed too early, hemorrhages contained within the splenic parenchyma may not be visualized and subcapsular hematomas may not yet be of significant size to be detected.^6,7 In our case, the time from injury to arrival at the trauma bay was 42 minutes; an additional 37 minutes were spent in the trauma bay prior to the CT scan. The total time of approximately 80 minutes prior to scanning would seem to be ample time for the injury to produce diagnostic visual images.

The problem could also lie not only in false negative CT scans secondary to artifacts, but in imagining obtained with early generation CT scanners.⁸ At our institution, all trauma patients are imaged with a 64 slice Toshiba Aquilion CT scanner (Toshiba America Medical Systems, Inc. Tustin, California).

The use of inadequate contrast material or suboptimal timing of image acquisition may also account for failure of initial CT images to detect splenic injury. There is no uniform consensus on the ideal IV contrast, with various techniques being described in the late 20th century.^9,10,11 Gamblin et al. describe their use of Novaplus omnipaque with 120 cc administered immediately before scanning and 30 cc given as the scan is begun.¹² They also emphasize the timing of the contrast. Scanning prior to the arterial bolus peak may cause a mottled, irregular enhancement pattern of the spleen due to variations in contrast uptake between the red and white pulp. Scanning past the bolus peak may cause subtle parenchymal lesions to ‘fill-in’ with contrast and be obscured.

At our institute we administer 100 cc Isovue 370 bolus at 2 cc/sec. The region of interest (ROI) selector is placed within the descending aorta at the level of the pulmonary artery bifurcation. Contrast is injected and when the ROI selector detects a value of 180 Hounsfield Units, CT image acquisition commences. Additional CT images of the abdomen are obtained after a ten minute delay. The follow-up CT images, five days after the trauma, were obtained during the portal venous phase.

After Toombs’ article in 1981, 12 other cases of DSR had been reported; the last in 2002.⁵ Table 1 highlights these cases. The ages of the patients range from 30 to 83 years with motor vehicle crashes the mechanism of trauma in most of the cases. It is interesting to note that in two of these 13 cases, even the follow up CT scans were normal, with subcapsular splenic hematoma found in the operating room. This may have been due to the CT scan technology available at that time or for other reasons. Eight cases were managed with splenectomy, three cases were managed conservatively, and in two cases there was no report on the definitive management. The only mortality reported was by Farhat with the other patients having uneventful post-operative courses.¹³

 

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Table 1. Delayed splenic rupture with initial CT normal (NA = not available, Hgb = hemoglobin).

Multiple studies have shown that the role of repeat CT in nonoperative management (NOM) of splenic trauma is limited for clinically stable patients, both adults and children.^14-17 Indications for repeat CT scan in NOM have traditionally included hemodynamic instability and peritonitis or suspicion of blunt intestinal/mesenteric or pancreatic trauma on initial CT scan.¹⁸ Weinberg et al. recommended serial CT scans in all cases of NOM to identify latent formation of splenic artery pseudoaneurysms.¹⁹ While indications for repeat CT in splenic trauma are limited, DSR should always be considered a possibility in hemodynamically unstable patients.

CT-proven delayed splenic rupture is a rare entity. Nevertheless, it is a process associated with significant morbidity and thus, it is essential to consider it in the list of differential diagnosis for abdominal pain and dropping hemoglobin. Furthermore, a normal appearing spleen on initial imaging should not sway one from considering delayed splenic rupture as a potential delayed complication of a traumatic event.

Disclosures

The authors have no disclosures or conflicts of interest related to this manuscript.

References

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