Splenic Trauma: Evaluation With Contrast-Specific Sonography and a Second-Generation Contrast Medium

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1 Article Splenic Trauma: Evaluation With Contrast-Specific Sonography and a Second-Generation Contrast Medium Preliminary Experience Orlando Catalano, MD, Roberto Lobianco, MD, Fabio Sandomenico, MD, Alfredo Siani, MD Abbreviations CT, computed tomography Received November 20, 2002, from the Department of Radiology, S. Maria delle Grazie Hospital, Pozzuoli, Italy. Revision requested December 24, Revised manuscript accepted for publication January 14, Address correspondence and reprint requests to Orlando Catalano, MD, via Crispi 92, I Naples, Italy. Objective. To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. Methods. From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrastenhanced harmonic sonography and contrast-enhanced helical computed tomography. Results. Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrastenhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrastenhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. Conclusions. Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness. Key words: computed tomography; sonography, contrast media; sonography, harmonic imaging; sonography, technology; spleen, trauma by the American Institute of Ultrasound in Medicine J Ultrasound Med 22: , /03/$3.50

2 Contrast-Specific Sonography of Splenic Trauma Contrast-enhanced computed tomography (CT) is unanimously considered the diagnostic standard in the evaluation of stable patients with blunt abdominal trauma, and its accuracy is unsurpassed by other imaging modalities. 1 3 Nevertheless, recently there has been growing interest in the literature about the use of sonography as a screening tool. In the examination termed focused abdominal sonography for trauma, a devoted protocol is used, which is carried out during patient resuscitation or during subsequent radiology department assessment. 4 8 Regions scanned include the right upper quadrant (with attention to the subphrenic space and to the Morison pouch), the left upper quadrant (left subphrenic space and splenorenal space), the pelvis (median space), and the paracolic gutters. Sonography is a quickly performed, rapidly interpreted, noninvasive, inexpensive, and portable (or even handheld) tool. Emergency physicians, trauma surgeons, and radiologists can detect very small amounts of hemoperitoneum near the site of bleeding and within the dependent peritoneal spaces. 9 Unstable patients with free fluid shown on sonography can undergo surgery without any further imaging. 3 The amount of hemoperitoneum is among the factors predicting successful observation of blunt splenic injury, 10,11 and a sonographic hemoperitoneum score has been shown to predict the need for surgery (83% sensitivity) better than initial blood pressure and a base deficit. 10 The pattern of fluid accumulation within the various spaces correlates with the site of injury. 8 The efficacy of sonography is not influenced by the patient trauma score. 12 With the use of screening sonography, a 43% reduction in per-patient expenditure has been reported, 13 resulting from an 8-fold reduction in the use of diagnostic peritoneal lavage and a 2-fold reduction in the use of CT. Although some reports have advocated rapid but careful solid organ exploration, 7,12,14 17 trauma sonography is mainly intended for detecting peritoneal fluid as a noninvasive and quick replacement of peritoneal lavage. 3 Hence, focused sonography may miss parenchymal injuries, especially when no free fluid is present, with potential catastrophic consequences. In our institution, sonography is currently used as the screening procedure to evaluate patients with blunt trauma. No focused technique is used, and a complete abdominopelvic survey is always carried out. Moreover, in January 2002, we started using a more sophisticated protocol, in selected cases, including a harmonic sonographic technique with a second-generation contrast medium. In this article, we report our initial experience and results from the use of contrastenhanced sonography in patients with trauma, and we give special reference to splenic trauma. Materials and Methods Patients From January to May 2002, 128 consecutive patients were evaluated in our department to rule out abdominal trauma or for suspected abdominal injury. Among these, there were 5 severely injured patients who were directly submitted to CT without any sonographic imaging. Three patients were judged too unstable hemodynamically and were promptly sent to the operating room after unenhanced sonography yielded positive findings. The remaining 120 subjects formed the population enrolled in our study: 74 male and 46 female; age range, 3 to 79 years (mean, 28 years). This group underwent screening sonography, eventually followed by both contrast-enhanced sonography and contrast-enhanced CT. Indications for further examinations were baseline sonographic findings positive for blunt splenic injury (n = 12), baseline sonographic findings positive for peritoneal fluid (not dealing with ovulation) without evidence of organ injury (n = 4), interpretative doubts (indeterminate results) or technical limitations (mainly due to obesity) of baseline sonography (n = 7), and high clinical or laboratory suspicion (unexplained fall in red blood cell count and hemoglobin level) of blunt trauma despite negative basal sonographic findings (n = 2). Hence, there were 25 nonconsecutive patients among the 120 total patients studied with baseline sonography who also underwent contrast-enhanced sonography and CT. The decision to add these other imaging modality studies was mainly made by the radiologist performing the initial sonography, although often in agreement with the trauma team. A staff radiologist, experienced with trauma imaging, was present 24 h/d, 7 d/wk, and access to the study was always possible. Contrastenhanced sonography was performed in all 468 J Ultrasound Med 22: , 2003

3 Catalano et al patients immediately after baseline sonography. Computed tomography was executed in all subjects within 20 minutes of contrast-enhanced sonography. Imaging Techniques Baseline sonographic studies were performed personally by experienced radiologists using a Technos MP unit (Esaote Biomedica, Genoa, Italy) and curved phased array transducers, with frequencies ranging from 2.5 to 5 MHz. In all cases, complete surveys of abdominal parenchyma and abdominopelvic spaces were obtained. Routinely, no transcatheter filling of the bladder was attempted before the examination, although this has been advocated to displace bowel loops and to better assess the pelvic space. 7,14 In 40 slim patients, a high-frequency probe ( MHz) was also used because of its greater discriminatory power in showing splenic lacerations or small amounts of free fluid around the splenic lower pole. 18 Tissue harmonic imaging (unenhanced), although recently shown to improve visualization of organ injuries, 19 was not used in this preliminary study. Contrast-enhanced sonographic studies were carried out with a contrast-devoted unit (EsaTune; Esaote Biomedica) that had contrastspecific, continuous-mode software (CnTI [contrast-tuned imaging]). A low-pressure setting (derated pressure, kpa; and mechanical index, ) was used. A sulfur hexafluoride based microbubble contrast medium (SonoVue; Bracco SpA, Milan, Italy) was injected intravenously in 1 to 2 seconds via a 20-gauge needle; a volume of 4.8 ml was administered, followed by a 5-mL saline flush. Immediately after contrast medium injection, the left upper quadrant was continuously scanned sonographically for 3 to 4 minutes until the enhancement effect began to decrease. Computed tomographic studies were interpreted by radiologists with at least 7 years of experience with emergency helical CT. All CT examinations were performed with a singledetector scanner with a 0.75-second revolution time (Somatom Plus 4 Expert; Siemens AG, Erlangen, Germany). The contrast-enhanced study was carried out with 5-mm collimation, a 7.5-mm/s table speed, 120 kv (peak), 180 ma, and a 5-mm reconstruction interval. A nonionic contrast medium (iomeprol, 350 mgi/ml [Iomeron; Bracco]) was administered via a 20- gauge needle and a power injector (Angiomat 6000; Liebel-Flarsheim, Cincinnati, OH). A volume of 130 to 140 ml was given at 2.5 to 3 ml/s. Acquisition delay ranged from 50 to 60 seconds. In 17 patients, a second helical acquisition of the upper abdomen, with the same parameters, was carried out at about 100 seconds from contrast medium injection; in 8, only targeted additional scans at the level of interest were obtained. Data Analysis The studies were reviewed by 2 radiologists (O.C. and R.L.) who reached a consensus; a third reviewer (F.S.) decided in cases of disagreement (6 instances in 5 patients). Unenhanced sonographic studies were analyzed on the basis of review of recorded videocassettes, whereas contrast-enhanced studies were analyzed on the basis of review of sonography unit stored video clips. Computed tomographic studies were reviewed on hard copies and were considered the diagnostic standards. Various parameters were considered: evidence of peritoneal fluid (if not limited to the pouch of Douglas in women of reproductive age), evidence of perisplenic clots (defined as echoic areas on basal and contrast-enhanced sonography and as hyperdense areas on CT), evidence of hypoperfused splenic areas (infarcts, defined as hypoechoic, well-defined areas with the base to the capsule on basal and contrast-enhanced sonography and as hypodense, well-defined areas with the base to the capsule on contrastenhanced CT), and evidence of splenic injury (defined as parenchymal contusion, parenchymal laceration, parenchymal hematomas, subcapsular hematoma, or a combination thereof). A contusion was considered an area showing subtle and inhomogeneous echogenicity without a mass effect or parenchymal vessel displacement; a laceration was considered a clear hypoechoic band, linear or branched, eventually reaching the organ surface; and a hematoma was considered a poorly defined, inhomogeneous collection within the splenic parenchyma or below its capsule. The detection rate of parenchymal injuries was the only finding considered for assessing the sensitivity of each tool. We also subjectively analyzed the extent of these splenic injuries (on basal and contrast-enhanced sonography, classified as comparable with CT or as underestimated or overestimated) and their conspicuity (on J Ultrasound Med 22: ,

4 Contrast-Specific Sonography of Splenic Trauma basal sonography, contrast-enhanced sonography, and CT, defined as the lesion-to-parenchyma contrast and graded subjectively from 0 [absent] to 3 [high]). We also reviewed the images for findings undetectable on basal sonography: evidence of a hypoperfused spleen (defined as less-thanexpected enhancement involving all or most of the organ on contrast-enhanced sonography and CT), evidence of contrast medium pooling (defined as small, persistent parenchymal areas of vessel-like hyperechogenicity on contrastenhanced sonography and as small, persistent parenchymal areas of vessel-like hyperattenuation on contrast-enhanced CT), and evidence of contrast medium extravasation (defined as extrasplenic vessel-like intermittent hyperechoic jets on contrast-enhanced sonography and as extrasplenic hyperdense areas on CT). Results In all 25 cases submitted for contrast-enhanced sonography, technically adequate examinations were accomplished. Contrast-enhanced sonography always added limited time to basal imaging. In this series, a baseline abdominopelvic sonographic exploration took about 4 minutes; preparing and injecting (via already-present venous access) the contrast medium solution took about 20 seconds; and completing the contrast-enhanced study took 2 to 4 minutes. Normally, the spleen showed inhomogeneous enhancement during the first 10 to 20 seconds; this finding was similar to the well-known zebra pattern recognizable on early-phase CT scans. Then the splenic parenchyma showed an increase in echogenicity, which was homogeneous (except for the presence of small hyperechoic vessels close to the hilum) and lasted for at least 3 minutes. Among the 25 patients studied by all the techniques, 6 had no evidence of splenic trauma on initial and follow-up evaluations and were considered to have negative findings. One patient had spleen shock without any parenchymal lesion, and 18 patients had traumatic splenic injury (19 positive). The sonographic and CT findings in our cases with positive results are summarized in Table 1. Spleen shock appeared as a small organ with evidence of splenic artery opacification but without relevant parenchymal enhancement (clearly lower than expected and clearly lower than usual in comparison with the left kidney). Hemoperitoneum was identified on all 3 imaging modalities in 74% of the 19 cases with positive findings. The presence of perisplenic fluid was identified slightly better on baseline than on contrast-enhanced sonography, although in all cases it was undetected on contrast-specific sonography. Perisplenic sentinel clots were recognized in 58% of the 19 cases on CT and in 42% on baseline and enhanced sonography. Again, the finding was minimally more evident on baseline than on contrast-enhanced sonography, without any effective difference in sensitivity. Splenic infarctions were found in 11% of the 19 cases on contrast-enhanced sonography and CT, whereas in none of these cases were they shown on unenhanced sonography. Direct signs of splenic injury (contusion, laceration, parenchymal hematoma, and subcapsular hematoma) were found in 63% of the cases on unenhanced sonography, in 89% on contrastenhanced sonography, and in 95% on contrastenhanced CT (Figs. 1 and 2). The only patient without CT signs of injury had hypoperfused spleen shock (see below); no lesion was found at follow-up, and the findings in this case were negative for splenic injuries on contrast-enhanced sonography. The other patient with negative contrast-enhanced sonographic findings, the only one to be properly considered as having a false-negative result, had 2 small lacerated and contusive areas on CT and a tiny perisplenic effusion (detected on both basal and enhanced sonography); the patient was treated conservatively and recovered without complications (Fig. 3). Five other patients had false-negative baseline sonographic findings. The extent of the 12 splenic injuries on basal sonography was comparable with that on CT in 5, underestimated in 6, and overestimated in 1. The extent of 17 splenic injuries on contrastenhanced sonography was comparable with that on CT in 13 and underestimated in 4 (Table 2). The conspicuity of the splenic injuries was considerably greater on contrast-enhanced sonography and CT than on basal sonography (Table 3). A maximal conspicuity score (grade 3) was given for 7 of the 17 patients with findings positive for splenic injury on contrast-enhanced sonography and for 8 of the 18 patients with findings positive for splenic injury on CT; no patient received this score for basal sonography. 470 J Ultrasound Med 22: , 2003

5 Catalano et al Table 1. Findings From Unenhanced Sonography, Contrast-Enhanced Sonography, and CT in 19 Patients With Traumatic Splenic Changes Unenhanced Contrast-Enhanced Contrast-Enhanced Finding Sonography Sonography CT Peritoneal fluid 14 (74) 14 (74) 14 (74) Perisplenic clots 8 (42) 8 (42) 11 (58) Nonperfused splenic areas 0 (0) 2 (11) 2 (11) Splenic parenchymal injuries 12 (63) 17 (89) 18 (95) Hypoperfused spleen ND 2 (11) 2 (11) Intrasplenic contrast medium pooling ND 4 (21) 4 (21) Contrast extravasation ND 1 (5) 2 (11) Numbers in parentheses are percentages and refer to the total of 19 patients with positive findings (18 with splenic injuries and 1 with spleen shock). ND indicates not detectable. Spleen hypoperfusion was found in 2 patients on both contrast-enhanced sonography and contrast-enhanced CT. In the first patient, large hemoperitoneum and parenchymal traumatic inhomogeneity were evident, and the decreased enhancement was thought to be secondary to pedicle trauma (surgically confirmed). In the second patient, in the absence of splenic pedicle injury and contrast extravasation, the hypoperfusion was considered a sign of hypovolemic shock 20,21 ; no splenic injury was found at followup studies in this patient. Intrasplenic contrast medium pooling was found in 21% of the cases on both contrastenhanced sonography and CT (Fig. 4). Contrast extravasation was recognized in 11% of the patients on CT. In 1 of these 2 patients, contrast-enhanced sonography showed the intrasplenic contrast medium pooling but failed to show the extrasplenic leakage. Discussion By using a low applied peak pressure (low mechanical index), contrast-specific harmonic techniques such as contrast-tuned imaging produce images based on nondestructive, nonlinear acoustic effects of ultrasound interaction with microbubble contrast media. 22 The high harmonic emission capabilities of stabilized microbubbles containing gases other than air (so-called second-generation contrast media) allow imaging with gray scale display of contrast enhancement and continuous (real-time) exploration of the organ of interest during circulation and recirculation of these contrast agents. 22 The spleen is a very good organ to study with these blood pool contrast agents: it has a superficial location; it has dense vascularization (without major intraparenchymal vessels or any other internal structure); it normally has a small volume (which can be scanned several times in any of its parts); and it shows persistent enhancement (3 5 minutes, more than enough time for exploring any portion of this small organ). Tissue harmonic imaging has already been shown 19 to improve solid organ injury detection, and some experimental studies 23,24 have also shown the capabilities of tissue-specific, contrast-enhanced sonography in detecting abdominal bleeding sites in animals. Nevertheless, to the best of our knowledge, the use of contrast-enhanced harmonic imaging has not been reported in clinical practice in trauma cases. The second-generation agent SonoVue can be prepared in a few seconds and administered immediately. In our series, the time for baseline plus enhanced sonography was a maximum of 8 minutes; this is approximately equal to the room time for contrast-enhanced abdominal CT in our institution. In our series, sonographic contrast medium injection allowed a notable increase in the lesion-to-parenchyma conspicuity, with injuries becoming clearly evident in comparison with the undamaged hyperechoic parenchyma. Very subtle parenchymal changes on baseline sonography became evident after contrast medium administration. Moreover, in our cases, the proper size of parenchymal injuries was better defined on contrast-enhanced sonography, showing a greater J Ultrasound Med 22: ,

6 Contrast-Specific Sonography of Splenic Trauma Figure 1. Splenic lacerated contusion without hemoperitoneum. A, Unenhanced oblique sonogram at the level of the splenic lower pole showing subtle hypoechoic foci (arrows). B, Contrast-enhanced oblique sonogram at the level of the splenic lower pole clearly showing a hypoechoic parenchymal area (arrows). C, Computed tomographic scan showing a lacerated contusive area within the spleen (arrow; note the similarity to the image in B). A Figure 2. Splenic laceration with hemoperitoneum. A, Contrastenhanced oblique sonogram clearly showing free peritoneal fluid around the splenic lower pole (arrows). B, Contrastenhanced oblique sonogram at the level of the spleen showing a large hypoechoic, inhomogeneous area starting from the splenic deep pole and pointing to the hilum (arrows). C, Poorquality CT scan with evident beam-hardening artifacts (patient upper limbs lateral to the body) barely showing a lacerated contusive area within the posterior aspect of the spleen (arrows). A B B C C 472 J Ultrasound Med 22: , 2003

7 Catalano et al correlation with CT findings than basal sonography. The latter tool had a tendency to underestimate the lesion extent. Finally, contrast-enhanced sonography allowed recognition of findings not accessible on baseline sonography and previously thought exclusive of CT (and angiography). These included parenchymal contrast medium pooling, contrast medium extravasation, and decreased splenic parenchyma enhancement (partial or near total) due to infarctions, pedicle avulsion, or hypoperfusion (hypovolemic shock). 20,21 Particularly, the CT evidence of contrast extravasation (10% 18% of trauma cases) 25,26 has been addressed as a very important element in decision making (significant relationship to the grade of splenic injury and a high predictor of conservative treatment failure) The new possibility of recognizing this feature by using sonography is a very interesting aspect. Real-time, contrast-coded software inevitably involves a certain loss in spatial resolution and image quality. This probably explains why in our series perisplenic fluid and clots were slightly more recognizable during non contrast-enhanced scanning. Figure 3. Very small splenic lacerations with minimal hemoperitoneum. A, Unenhanced oblique sonogram of the posterior aspect showing a minimal amount of anechoic peritoneal fluid filling a posterior surface incisure of the spleen (arrow). B, Contrast-enhanced oblique sonogram at the same level confirming the subtle peritoneal effusion (arrow) but failing to show any parenchymal change. C, Computed tomographic scan at a level slightly cephalad to the splenic hilum showing 2 very small areas of parenchymal injury (arrows) and combined left pleural effusion. D, Computed tomographic scan at a level slightly caudad to the splenic hilum showing a minimal amount of fluid posterior to the spleen (arrow). A B C D J Ultrasound Med 22: ,

8 Contrast-Specific Sonography of Splenic Trauma Table 2. Extent of Splenic Injuries on Unenhanced and Contrast-Enhanced Sonography Compared With CT Imaging Technique Underestimated Comparable With CT Overestimated Total Unenhanced sonography 6 (50) 6 (42) 1 (8) 12 Contrast-enhanced sonography 4 (24) 13 (76) 0 17 Numbers in parentheses are percentages and refer to the total patients with findings positive for splenic injury. One patient with spleen shock who had no direct injury was excluded. Computed tomography is the accepted criterion standard for imaging of patients with blunt abdominal trauma and polytrauma 1 3 ; it has a great panoramic field and can show both intraperitoneal and extraperitoneal structures that are difficult to examine by sonography. Nevertheless, in our country, sonography is routinely used as a screening modality to exclude cases with negative findings. Computed tomography is performed only in selected patients who have sonographic findings that are positive or indeterminate for abdominal injuries or for whom high clinical suspicion exists despite negative sonographic findings. This approach allows the reduction of the costs, radiation exposure, and need for iodized contrast media administration connected with CT use. Contrast-enhanced CT is not used as a screening method in our country: a rate of 96% for CT studies with truenegative findings, as reported in a recent multiinstitutional survey, 29 is a percentage that in our country would not be accepted. The use of screening sonography for blunt abdominal trauma has had encouraging results in recent years. In a study by Lingawi and Buckley 6 94% sensitivity and 100% negative predictive value were found, although a 1.7% falsepositive rate and a 2.5% indeterminate result rate were also reported. Dolich and coworkers 30 had 86% sensitivity for sonography with a 1.7% falsenegative rate (33% of these cases required Table 3. Conspicuity of Splenic Injuries on Unenhanced and Contrast-Enhanced Sonography When Compared With CT Conspicuity Score Imaging Technique Total Unenhanced sonography Contrast-enhanced sonography Contrast-enhanced CT Total refers to the patients with findings positive for splenic injury. One patient with spleen shock who had no direct injury was excluded. exploratory laparotomy). McKenney et al 15 calculated 86% sensitivity and 99% specificity when sonography was used as the primary screening technique for blunt abdominal trauma. In the experience of Bode and colleagues, 12 screening sonography correctly identified all patients requiring emergency laparotomy, with 88% sensitivity and 99% specificity; only 0.4% of the patients in that series who were discharged home after negative sonographic findings and 12-hour observation were mistakenly discharged. Yoshii et al 16 reported 90% sensitivity for detecting splenic injuries. The variable results of sonography in these articles were due to several factors, including the examination technique and extent of sonography, the operator experience, and the reference tool used (patient s course, diagnostic peritoneal lavage, or CT and laparotomy). 7 One of the main limitations of focused sonography is the relatively poor sensitivity in the detection of parenchymal injuries and the tendency to understage these injuries despite great accuracy in identifying even minimal amounts of free peritoneal fluid. Rothlin and colleagues 17 reported 41% sensitivity for detecting parenchymal lesions. Richards et al 31 only detected 19% of the splenic lesions in their series. In contrast, Yoshii and coworkers 16 obtained greater than 90% sensitivity for identifying organ injuries. The risk of missing traumatic visceral injuries without combined free fluid has been highlighted. 4,14,29,31 Richards et al 31 detected free fluid in only 67% of their patients with blunt splenic injury studied by sonography. In a series from Chiu and coworkers, 4 29% of all patients with confirmed blunt abdominal injuries had no associated hemoperitoneum, and 4 of 15 patients with negative focused sonographic findings, all with splenic injuries, needed surgery. Shanmuganathan and colleagues 29 reported that, in their CT series, 34% of the confirmed trauma cases had no evidence of peritoneal fluid 474 J Ultrasound Med 22: , 2003

9 Catalano et al (probable false-negative focused sonographic findings): 17% of the patients with hemoperitoneum-negative findings ultimately required surgery, and 40% to 50% of the patients with hemoperitoneum-negative findings had hepatic or splenic injuries of a high grade. Some authors 6,8 claimed that in their series the percentages of trauma cases without evidence of free fluid were lower than reported. In 1 series, 32 only 12% of the splenic injuries occurred with minimal or no peritoneal fluid combined. Sirlin et al 8 found no peritoneal effusion in only 12% of patients with isolated splenic injuries. Moreover, some authors 6,32 have argued that in the absence of hemoperitoneum, parenchymal injuries are usually minor, and it is unlikely that the patient will require surgical intervention when stable during the first hours of observation after sonography with negative findings. Nevertheless, it is clear that focused sonography is mainly intended to rule out blunt trauma and not to show specific injuries. In our preliminary experience, contrast-specific sonography proved more sensitive than unenhanced sonography in showing splenic injury, with greater conspicuity of the lesions recognized and greater correlation with CT. In only 1 case did contrast-enhanced sonography miss parenchymal injuries that were shown on CT; these subtle lesions had limited practical relevance, and the patient was easily treated conservatively. Real-time contrast-coded sonography allows accurate study of the whole spleen parenchyma during contrast enhancement, repeated scanning of all parenchymal areas, and eventual review of video clips after the patient leaves. However, the resolution of current contrast-specific software needs to improve. Relevant findings not detectable with baseline sonography can be identified with the use of a contrast-enhanced technique. The contrast medium pooling within the spleen can be clearly seen and distinguished from the vessels branching from the hilum. The extrasplenic leakage can be readily differentiated from blood clots. In our series, there was a patient in whom CT showed perisplenic contrast extravasation that was missed on contrast-enhanced sonography (probably because of concurrent clots), but in that patient, sonography clearly showed the intrasplenic contrast medium pooling. We never administered a supplementary dose of a sonographic contrast agent, but these media are optimally tolerated; in cases of interpretative doubt, the injection can be easily and immediately repeated. Administering a second volume of an iodized contrast agent for CT is not recommended, especially in patients at risk of hypovolemic shock. 21 Finally, contrast-enhanced sonography could be proposed for serial imaging of conservatively treated splenic traumas. This issue was not considered in our series, in which contrast- Figure 4. Splenic laceration with active bleeding. A, Contrast-enhanced oblique sonogram showing a large, deep area of splenic laceration with internal hyperechogenicity due to contrast medium pooling (curved arrow) and perisplenic fluid with slightly hyperechoic clots internally (small arrows). B, Computed tomographic scan showing changes very similar to the sonographic findings in A, with splenic laceration, contrast medium pooling (arrow), perisplenic fluid, perisplenic clots, and fluid in the Morison pouch. A B J Ultrasound Med 22: ,

10 Contrast-Specific Sonography of Splenic Trauma enhanced sonography was only used in the initial evaluation. In institutions where sonography is used for follow-up of patients with trauma, 33 the adjunct of contrast enhancement may represent a useful application of this modality. Some limitations of this initial report should be discussed. First, the number of cases studied by all tools was statistically limited: performing contrast-enhanced sonography and CT in all 120 patients would have had a greater impact and would have removed the selection bias of performing these second-level studies only in suspected cases. Moreover, the use of contrastenhanced sonography in a larger population with a lower probability of splenic trauma or a greater presence of high-grade injury probably would have led to less dramatic differences between baseline and enhanced sonography. Additionally, in this series, the operator performing contrast-enhanced sonography was never blinded to the results of baseline examinations; the contrast-enhanced sonography was performed immediately after the unenhanced sonography by the same radiologist, and in the revision of the series, it was always analyzed after the baseline sonography. Finally, CT was considered the standard for assessing the sensitivity of each tool for all findings and also for evaluating the accuracy in showing the extent of parenchymal lesions. Although CT is considered highly sensitive and specific in defining the presence and size of splenic lesions, 1 3 we cannot theoretically exclude the possibility that CT could yield false-positive or -negative findings in some of our patients and could incorrectly show the extent of some splenic lesions in others. In conclusion, our preliminary data show that contrast-enhanced harmonic sonography is a promising tool in the evaluation of blunt splenic trauma. It is more accurate and informative than standard sonography and correlates better with CT. If confirmed in a larger series with a less biased population and if proved extendable to other abdominal organs, the possibilities of contrast enhancement will allow reduction of the intrinsic limitations of sonography and consequently will increase its role as a screening modality. References 1. Delgado Millan MA, Deballon PO. Computed tomography, angiography, and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma. World J Surg 2001; 25: Mirvis SE. Role of CT in diagnosis and management of spleen injury. Appl Radiol 2000; 29: Poletti P-A, Wintermark M, Schnyder P, Becker CD. Traumatic injuries: role of imaging in the management of polytrauma victim (conservative expectation). Eur Radiol 2002; 12: Chiu WC, Cushing BM, Rodriguez A, et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma 1997; 42: Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma 1996; 40: Lingawi SS, Buckley AR. Focused abdominal US in patients with trauma. Radiology 2000; 217: McGahan JP, Wang L, Richards JR. Focused abdominal US for trauma. Radiographics 2001; 21:S191 S Sirlin CB, Casola G, Brown MA, Patel N, Bendavid EJ, Hoyt DB. Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury. J Ultrasound Med 2001; 20: Paajnen H, Lahti P, Nordback I. Sensitivity of transabdominal ultrasonography in detection of intraperitoneal fluid in humans. Eur Radiol 1999; 9: McKenney KL, McKenney MG, Cohn SM, et al. Hemoperitoneum score helps determine need for therapeutic laparotomy. J Trauma 2001; 50: 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. J Trauma 2002; 49: Bode PJ, Edwards MJR, Kruit MC, et al. Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. AJR Am J Roentgenol 1999; 172: McKenney MG, McKenney KL, Hong JJ, et al. Evaluating blunt abdominal trauma with sonography: a cost analysis. Am Surg 2001; 67: J Ultrasound Med 22: , 2003

11 Catalano et al 14. Brown MA, Casola G, Sirlin CB, Patel NY, Hoyt DB. Blunt abdominal trauma: screening US in 2693 patients. Radiology 2001; 218: McKenney KL, Nunez DB, McKenney MG, et al. Sonography as the primary screening technique for blunt abdominal trauma: experience with 899 patients. AJR Am J Roentgenol 1998; 170: Yoshii H, Sato M, Yamamoto S, et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998; 45: Rothlin MA, Naef R, Amgwerd M, Candidas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993; 34: Stengel D, Bauwens K, Sehouli J, Nantke J, Ekkernkamp A. Discriminatory power of 3.5 MHz convex and 7.5 MHz linear ultrasound probes for the imaging of traumatic splenic lesions: a feasibility study. J Trauma 2001; 51: Blaivas M, DeBehnke D, Sierzenski PR, Phelan MB. Tissue harmonic imaging improves organ visualization in trauma ultrasound when compared to standard ultrasound mode. Acad Emerg Med 2002; 9: Berland LL, VanDyke JA. Decreased splenic enhancement on CT in traumatized hypotensive patients. Radiology 1985; 156: Rotondo A, Angelelli G, Catalano O, et al. Abdominal computed tomographic findings in adults with hypovolemic shock. Emerg Radiol 1997; 4: Lencioni R, Cioni D, Bartolozzi C. Tissue harmonic and contrast-specific imaging: back to gray scale in ultrasound. Eur Radiol 2002; 12: Goldberg BB, Merton DA, Liu J-B, Forsberg F. Evaluation of bleeding sites with a tissue-specific sonographic contrast agent: preliminary experiences in an animal model. J Ultrasound Med 1998; 17: Schurr MJ, Fabian TC, Gavant M, et al. Management of blunt splenic trauma: computed tomography contrast blush predicts failure of nonoperative management. J Trauma 1995; 39: Federle MP, Courcoulas AP, Powell M, Ferris J, Peitzman AB. Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation. Radiology 1998; 206: Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology 2000; 217: Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999; 212: Dolich MO, McKenney MG, Varela JE, Compton RP, McKenney KL, Cohn SM ultrasounds for blunt abdominal trauma. J Trauma 2001; 50: Richards JR, McGahan JP, Jones CD, Zhan S, Gerscovich EO. Ultrasound detection of blunt splenic injury. Injury 2001; 32: Ochsner MG, Knudson MM, Pachter HL, et al. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis. J Trauma 2000; 49: Emery KH, Babcock DS, Borgman AS, Garcia VF. Splenic injury diagnosed with CT: US follow-up and healing rate in children and adolescents. Radiology 1999; 212: Liu J-B, Merton DA, Goldberg BB, Eawool NM, Shi WT, Forsberg F. Contrast-enhanced two- and threedimensional sonography for evaluation of intraabdominal hemorrhage. J Ultrasound Med 2000; 21: Yao DC, Jeffrey RB, Mirvis SE, et al. Using contrastenhanced helical CT to visualize arterial extravasation after blunt abdominal trauma. AJR Am J Roentgenol 2002; 178: J Ultrasound Med 22: ,

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