PMC6159248_01
Axial view of the initial CT scan of thorax, acquired at 30s, showing subtle perfusion abnormalities within the spleen.
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A splenic laceration was not suspected clinically and the timing of the scan, optimized for the chest, only showed subtle splenic changes which were not identified by the original reporter (Figure 1).
Axial CT scan of abdomen/pelvis with contrast at 70s. Active haemorrhage now visible (red arrow) within the spleen indicating acute injury.
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This prompted a CT scan of abdomen/pelvis (performed at 70 s), which demonstrated a contained splenic laceration with no evidence of capsular breach (Figure 2).
Coronal view of repeat CT scan of abdomen/pelvis with contrast. Active bleeding was still seen at the spleen; however, there was now a new extravasation of contrast (red arrow), indicating splenic capsular rupture.
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A further CT scan showed splenic capsular rupture, active bleeding and large-volume intraperitoneal haemorrhage (Figure 3).
Selective splenic artery angiogram with splaying of the upper pole splenic artery branches owing to haematoma and three pseudoaneurysms (arrows).
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Angiography revealed three pseudoaneurysms, two arising from a second order upper pole branch and one from a third order equatorial branch (Figure 4).
Selective splenic artery angiogram following distal splenic artery embolisation with microcoils (deployed through a microcatheter which was then removed). The upper half of the spleen has little residual arterial filling but the lower half has been preserved.
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The decision to perform superselective embolisation was made with the intention of achieving definitive haemostasis in a patient who was likely to leave hospital at the earliest possible opportunity and not comply well with the procedural aftercare (Figure 5).
CT scan of abdomen post-embolisation therapy. Embolisation coils noted with a successful cessation of bleeding. Visible gas (red arrow) is seen in the spleen indicating infarction and necrosis. There is also a notable increase in extra-hepatic fluid (white arrow), that likely resulted from delayed presentation following the initial trauma.
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The patient's temperature and clinical features were also settling, further reassuring stabilisation of his condition (Figure 6).