Splenic Trauma 脾外傷

Key Facts

Definition：Damage to the splenic parenchyma or splenic vessels secondary to blunt or penetrating trauma.

Spleen is most commonly injured organ following blunt trauma.Spleen injury accounts for about 40% of patients with blunt organ injury.Nonoperative management possible in about 60% of patients.Failure of nonoperative management increases with grade of injury.The only finding at CT may be perisplenic blood.

Imaging Findings

Types of injury：(1)Laceration：Linear or curved area of low attenuation relative to spleen; (2)Intrasplenic hematoma：Rounded inhomogeneous area of low attenuation; (3)Subcapsular hematoma：Crescentic low attenuation area compressing the parenchyma; (4)Fracture：Multiple crossing lacerations or fragmentation; (5)Hilar vascular injury：Devascularized splenic segment or devascularized whole spleen.CT findings：(1)In addition to the above findings,CT may show the following of which both increase the likelihood of intervention.(2)Active bleeding;(3)Expanding hematoma on a follow-up scan.

Imaging recommendations：Splenic injury is evaluated during routine CT for trauma,using an injection rate of at least 2.5 ml/s for 135-180 ml of contrast,and using a 75 s delay after beginning injection until starting the scan at the dome of the diaphragm.

Delayed scanning may be useful if there is active arterial hemorrhage.Follow-up scan may be useful if patient is suspected of having continued bleeding from expanding hematoma or rupture of the spleen.Differential diagnosis：None.

Staging or Grading Criteria

Subcapsular hematoma：(1)Grade Ⅰ：＜10% surface area; (2)Grade Ⅱ：10%-50%,＜5cm diameter; (3)Grade Ⅲ：＞50% or expanding intraparenchymal hematoma,＞5 cm or expanding.

Laceration：(1)Grade Ⅰ：＜1 cm in length; (2)Grade Ⅱ：1-3 cm; (3)GradeⅢ：＞3 cm.Devascularization：(4)Grade Ⅳ：＞25% of splenic area; (5)GradeⅤ：Total spleen.

Shattered spleen (fragmentation,multiple fractures)：Grade Ⅴ.

醫(yī)學(xué)詞匯注釋與簡要講解

splenic parenchyma 脾實質(zhì)

blunt trauma 鈍傷

penetrating trauma 穿通傷

laceration 裂傷

intrasplenic hematoma 脾內(nèi)血腫

subcapsular hematoma 包膜下血腫

fracture 脾斷裂

hilar vascular injury 脾門血管損傷

【prefix】de-解、除、去、脫

devascularized 無血供的，去血管化

decalicification 脫鈣

decompression 減壓

dome of the diaphragm 膈頂

shattered spleen 脾碎裂

Fig 1 a)Subcapsular hematoma(blood) is surrounding lateral surface of spleen (arrows) and shows higher attenuation on nonenhanced CT.On enhanced CT of arterial phase (b)and venous phase (c),a through and through laceration is present(arrow).d)Coronal CT reconstruction shows a fracture of the spleen(arrow)and ascites(arrow heads) around liver.There is fragmentation and the fracture extends to the splenic hilum.

Clinical Issues

Presentation：Acute injury may lead to hypotension and a drop in hematocrit;and delayed rupture will also present in this way.

Treatment：Surgery is required if the patient becomes hemodynamically unstable after initial stabilization.Predictors of failure of nonoperative management：(1)Onset of homodynamic instability.(2)Injury grade Ⅳor Ⅴ.(3)Large associated hemoperitoneum.(4)Active arterial extravasation seen on CT.

Complications following nonoperative management：(1)“Delayed rupture”weeks to years after initial injury; seen in ＜1% of patients if initial CT is normal.(2)Pseudoaneurysm.(3)Pseudocyst; if ＞5 cm there is 25% risk of rupture.(4)Abscess which may be delayed months or years.

手術(shù)治療的指征包括：

(1)血流動力學(xué)不穩(wěn)定；

(2)4 級 或5 級損傷；

(3)大量腹腔積血；

(4)動脈出血表現(xiàn)。

未手術(shù)者的并發(fā)癥包括：

(1)延遲脾破裂；

(2)假性動脈瘤；

(3)假性囊腫；

(4)脾膿腫。