Delayed presentation of a traumatic splenic artery pseudoaneurysm in an initially normal spleen: Case study and review of literature

Abstract

Background: Blunt injury of the spleen is common and with the shift towards nonoperative management in haemodynamically stable patients, the delayed development of splenic artery pseudoaneurysms are of great concern. Management traditionally involves angioembolisation with the intent to preserve splenic function; however recent studies suggest that this is not without complication.

Case presentation: We present a rare case of delayed splenic pseudoaneurysm arising 6 days post motorbike accident, with initial computerised tomography showing no evidence of splenic injury. The patient was successfully embolised and progressed well without complication. No clear cause was found for his development of splenic injury.

Conclusions: Splenic artery pseudoaneurysms are not uncommon and necessitate follow-up imaging after nonoperative management of blunt splenic trauma. Once diagnosed, embolisation versus conservative management can be considered on a case-by-case basis.

Keywords

Trauma / Spleen / Embolisation

CONFLICTS OF INTEREST DISCLOSURE

The author declares he has no conflicts of interest.

References

[1] Olthof DC, Vlies CHVD, Goslings JC. Evidence-Based Management and Controversies in Blunt Splenic Trauma. Current Trauma Reports. 2017; 3(1): 32-37. PMid: 28303214. https://doi.org/10.1007/s40719-017-0074-2

[2] Van Der Vlies CH, Hoekstra J, Ponsen KJ, et al. Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury. Cardiovascular & Interventional Radiology. 2012; 35(1): 76. PMid: 21431976. https://doi.org/10.1007/s00270-011-0132-z

[3] Frandon J, Rodière M, Arvieux C, et al. Blunt splenic injury: out-comes of proximal versus distal and combined splenic artery em-bolization. Diagnostic & Interventional Imaging. 2014; 95(9): 825-31. PMid: 24746759. https://doi.org/10.1016/j.diii.2014.03.009

[4] BAUDET R. Ruptures de la rate. Med Practique. 1907; 3.

[5] Resteghini N, Nielsen J, Hoimes ML, et al. Delayed splenic rupture presenting 70 days following blunt abdominal trauma. Clinical Imag-ing. 1900; 38(1): 73-4. PMid: 24139835. https://doi.org/10.1016/j.clinimag.2013.09.003

[6] Fernandes CM. Splenic Rupture Manifesting Two Years after Diag-nosis of Injury. Academic Emergency Medicine. 1996; 3: 946-947. PMid: 8891041. https://doi.org/10.1111/j.1553-2712.1996.tb03324.x

[7] Parithivel VS, Sajja SB, Basu A, et al. Delayed presentation of splenic injury: still a common syndrome. International Surgery. 2002; 87(2):120. PMid: 12222914.

[8] Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling: spleen and liver (1994 revision). Journal of Trauma & Acute Care Surgery. 1995; 38(3): 323-324. https://doi.org/10.1097/00005373-199503000-00001

[9] Boscak AR, Shanmuganathan K, Mirvis SE, et al. Optimizing trauma multidetector CT protocol for blunt splenic injury: need for arte-rial and portal venous phase scans. Radiology. 2013; 268(1): 79-88. PMid: 23449955. https://doi.org/10.1148/radiol.13121370

[10] Holly BP, Steenburg SD. Multidetector CT of blunt traumatic ve-nous injuries in the chest, abdomen, and pelvis. Radiographics. 2011; 31(5): 1415. PMid: 21918052. https://doi.org/10.1148/rg.315105221

[11] Sclafani SJ, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. Journal of Trauma. 1995; 39(5): 818.PMid: 7473996. https://doi.org/10.1097/00005373-199511000-00004

[12] Peitzman AB, Heil B, Rivera L, et al. Blunt Splenic Injury in Adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2000; 49: 177-189. https://doi.org/10.1097/00005373-200008000-00002

[13] Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma & Acute Care Surgery. 2012; 73(5 Suppl 4): S288. PMid: 23114483. https://doi.org/10.1097/TA.0b013e318270160d

[14] Al-Habbal Y, Christophi C, Muralidharan V. Aneurysms of the splenic artery - A review. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. 2010; 8(4): 223-231. PMid: 20569943. https://doi.org/10.1016/j.surge.2009.11.011

[15] Davis KA, Fabian TC, Croce MA, et al. Improved success in nonop-erative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. Journal of Trauma & Acute Care Surgery. 1998; 44(6): 1008-1013. https://doi.org/10.1097/00005373-199806000-00013

[16] Weinberg JA, Lockhart ME, Parmar AD, et al. Computed tomog-raphy identification of latent pseudoaneurysm after blunt splenic injury: pathology or technology? Journal of Trauma & Acute Care Surgery. 2010; 68(5): 1112-1116. PMid: 20453766. https://doi.org/10.1097/TA.0b013e3181d769fc

[17] Leeper WR, Leeper TJ, Ouellette D, et al. Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: early screening leads to a decrease in failure rate. J Trauma Acute Care Surg. 2014; 76(6): 1349-1353. PMid: 24854299. https://doi.org/10.1097/TA.0000000000000228

[18] Muroya T, Ogura H, Shimizu K, et al. Delayed formation of splenic pseudoaneurysm following nonoperative management in blunt splenic injury: Multi-institutional study in Osaka, Japan. Jour-nal of Trauma & Acute Care Surgery. 2013; 75(3): 417.PMid: 24089111. https://doi.org/10.1097/TA.0b013e31829fda77

[19] Morrison CA, Gross BW, Kauffman M, et al. Overview of Nonop-erative Blunt Splenic Injury Management with Associated Splenic Artery Pseudoaneurysm. American Surgeon. 2017; 83(6): 554. PMid: 28637555.

[20] Renzulli P, Hostettler A, Schoepfer AM, et al. Systematic review of atraumatic splenic rupture. British Journal of Surgery. 2009; 96(10): 1114-21. PMid: 19787754. https://doi.org/10.1002/bjs.6737