The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look?

BACKGROUND: Serial computed tomography (CT) imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), contributing to improved success in splenic salvage. The practice of serial CT imaging, however, has not been embraced. The purpose of this study was to reevaluate the clinical practice of serial CT imaging within the context of an institutional protocol for the nonoperative management (NOM) of BSI.

METHOD: Consecutive patients with BSI selected for NOM were identified from our trauma registry. Patients were managed according to protocol, whereby hemodynamically stable patients with PSA on initial or follow-up CT imaging were referred for angiography. Follow-up CT was performed 24 to 48 hours after the initial CT. Data were abstracted from hospital, clinic, and radiology records, and included age, Injury Severity Score, splenic injury grade (SIG), and CT findings. The incidence and timing of PSA identification with respect to subsequent management and outcome were reviewed.

RESULTS: Of 426 BSI admissions during a 2.5-year period, 341 (80%) were selected for NOM. Mean follow-up was 39 days, with 76% followed for >or=7 days. Serial CT imaging resulted in the angiographic detection of 14 (4%) early PSAs and 11 (3%) latent PSAs. PSAs were associated with increasing SIG (p<0.001); however, 24% of PSAs were observed in SIG 1 and 2. Embolization was successful in 13 of 14 (93%) patients with early PSAs and 10 of 11 (91%) with latent PSAs. The splenic salvage rate for all patients selected for NOM during the study period was 329 of 341 (97%).

CONCLUSIONS: Adherence to a NOM protocol guided by serial CT imaging has resulted in one of the highest splenic salvage rates reported to date. Identification and embolization of latent PSA likely contributes to NOM success, given the unfavorable natural history of these lesions. Although PSA formation is correlated with increasing SIG, PSAs are not exclusive to higher-grade injury, warranting serial CT surveillance regardless of SIG.