PMC9205459_01
(a-h) Plain computed tomography (CT) scan and enhancement of the upper abdomen CT before intervention shows that the density of liver parenchyma is significantly reduced, and the shadow of intrahepatic vessels shows relative density on plain CT scan. The spleen is enlarged, and there is a mixed density shadow in the spleen with a size of about 10.0 x 8.8 x 12.5 cm. The plain CT value is about 11-67 HU, the boundary is unclear, and the enhanced CT shows partly obvious progressive lesion enhancement. Patchy and slightly high-density shadows were observed around the spleen, liver, and abdominal space, and the CT value is about 44-71 HU. The clinical impression is neoplastic lesions with rupture and hemorrhage, which may be vascular tumors. Intraperitoneal accumulation of blood and fluid. Severe fatty liver. (a,b) PLAIN CT scans; (c,d) Arterial phase of CT; (e,f) Portal veinphase of CT; (g,h) Delayphase of CT. (i-l) Digital subtraction angiography (DSA) and interventional embolization of the spleen. DSA showed splenic artery rupture and bleeding, abdominal fluid accumulation.
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F1
Severe fatty liver is shown in Figures 1a-h. Angiography revealed that the main splenic artery was clearly displayed, the branches in the spleen were not clearly displayed, the branches of the splenic artery in the lower part of the spleen were ruptured, the contrast medium was exuded, and the ruptured splenic artery branches were blocked after embolization with microspheres and medical glue.The peripheral defect of the spleen was approximately 40%, and the overall operation was smooth (Figures 1i-l).
(a-p) Computed tomography (CT) scan 9 days after splenic artery embolization: the spleen is enlarged, with strip-like and spot-like dense shadows and gas accumulation in the operation area; a mass mixed density shadow is seen, and the internal high density mass was about 8.0 x 7.3 x 7.8 cm. The CT value of the plain scan is about 11-67 HU. The enhanced scan part shows progressive enhancement. The edge is surrounded by low-density shadows, the wall is slightly enhanced, the boundary with the adjacent spleen is unclear, and this extends to the paracolic space. The rest of the spleen parenchymal part of the enhancement is reduced, showing irregular flakes or wedges. Patchy and cord-like high-density shadows are seen in the remaining adjacent abdominal fat spaces, with poorly defined boundaries, and the left renal anterior fascia is thickened. No obvious space-occupying lesions are found in the pancreas. The density of liver parenchyma is significantly reduced. The clinical impression is a change after splenic artery embolization, which is better than before, and severe fatty liver. (i-p) Changes after splenectomy, patchy and cord-like dense shadows are seen in the operation area, and the adjacent abdominal fat space, with poorly defined borders, and scattered patchy low-density shadow. The larger size mass was approximately 5.3 x 5.6 cm, with part of it encapsulated. Part of the edge of the enhanced scan shows mild enhancement, and the anterior fascia of the left kidney is thickened. (a,b,i,j) CT plain scans; (c,d,k,l) Arterial phase of CT; (e,f,m,n) Portal vein phase of CT; (g,h,o,p) Delay phase of CT.
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F2
Patchy and cord-like high-density shadows were observed in the remaining adjacent abdominal fat spaces, with poorly defined boundaries, and the left renal anterior fascia was thickened (Figures 2a-p). Severe fatty liver is shown in Figures 2a-g.
Pathological biopsy of the splenectomy specimen shows large hemorrhage and necrosis under microscope, and abnormally proliferated vascular tissue around the hemorrhage area [hematoxylin & eosin staining; (a) x100; (b), x200; (k), x40; (l), x200]. Vascular tissue (elastic fiber staining +), blood vessel wall tissue (elastic fiber staining +), and local hyperplasia of myofibroblastic cells are shown [(h), x20; (i), x40; (j) x200]. Immunohistochemistry showed actin [SM +, (c) x200], Ki67 [10% +, (d) x200), ALKp80 [-, (e) x200], melanA [-, (f) x200], HMB45 [-, (g) x200]. The above findings are consistent with a splenic hemangioma with ruptured hemorrhage and necrosis.
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F3
Combined with imaging, immunohistochemistry, and special staining, the diagnosis of SH with ruptured hemorrhage and necrosis was confirmed (Figure 3).