Case s -  Active splenic bleeding and pseudoaneurysm

There is massive hemoperitoneum around the liver, spleen, and stomach.  There is diffuse splenic heterogenously with focal areas of contusion and regions suspicious for active bleeding (1 and 2).  The anterior edge of the spleen is interrupted and irregular.  The liver, pancreas, duodenum, and adrenal glands appear normal.

There are two regions suspicious for active bleeding.  The first region in the mid spleen shows high density contrast (as bright as the contrast in the arteries) in the middle of the hematoma which dissolves into the hematoma on the delayed images.

This second region anteriorly shows extravascular contrast surrounded by hematoma.  There is normally no vessel along the periphery of the spleen so the contrast is extravascular.  However, several features are not consistent with active extravasation. On delayed images the contrast does not clearly dissipate into the hematoma.  Enancement in this region continues to mirror the intravascular contents. Additionally, the collection has a very smooth contour and an ovoid shape.   The smooth contours, lack of dissipation, and persistent enhancement similar to the arteries suggests that this is instead a pseudoaneurysm. Pseudoaneurysms are not usually surrounded by hematoma, but can be.  You differentiate active extravasation from  pseudoaneurysm by the presence of hematoma, the contours of the collection, and the delayed images.  Active extravasation is associated with a hematoma, irregular contour, and dissipation on delayed images.  Pseudoaneurysm is associated with lack of hematoma, smooth contours, and lack of dissipation. This collection may be either, I cannot tell.  However pseudoaneuryms rupture and both diagnoses require consideration of angiography.

This patient was hemodynamically unstable.  He went to he operating room and had bleeding from the splenic hilum.  He had a splenectomy and lost 2.5L of blood during the procedure.

Take home point:

• Pseudoaneurysm vs active extravasation.  A pseudoaneurysm is a smoothly marginated extraluminal contrast collection that is usually not surrounded by hematoma.  It but follows the enhancement of the vessels on all phases.  Both active bleeding and pseudoaneurysms necessitate the consideration of angiography.