Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience

Spontaneously Ruptured Hepatocellular Carcinoma: Computed Tomography-Based Assessment

Spontaneously ruptured hepatocellular carcinoma (SRHCC) is an uncommon and life-threatening complication in patients with hepatocellular carcinoma (HCC). It is usually associated with chronic liver disease and has a poor prognosis with a high mortality rate during the acute phase. SRHCC can cause a severe and urgent condition of acute abdomen disease and requires a correct diagnosis to achieve adequate treatment. Clinical presentation is related to the presence of hemoperitoneum, and abdominal pain is the most common symptom (66–100% of cases). Although the treatment approach is not unique, trans-arterial (chemo)embolization (TAE/TACE) followed by staged hepatectomy has shown better results in long-term survival. A multi-phase contrast-enhanced CT (CECT) scan is a pivotal technique in the diagnosis of SRHCC due to its diagnostic accuracy and optimal temporal resolution. The correct interpretation of the main CT findings in SRHCC, such as active contrast extravasation and the sentinel clot sign, is fundamental for a prompt and correct diagnosis. Furthermore, CT also plays a role as a post-operative control procedure, especially in patients treated with TAE/TACE. Therefore, a multi-phase CECT scan should be the diagnostic tool of choice in SRHCC since it suggests an immediate need for treatment with a consequent improvement in prognosis.

Is it time to re-think FAST? A systematic review and meta-analysis of Contrast-Enhanced Ultrasound (CEUS) and conventional ultrasound for initial assessment of abdominal trauma

BACKGROUND

The Focused Assessment with Sonography for Trauma (FAST) examination using conventional ultrasound has limited utility for detecting solid organ injury. Therefore, this systematic review and meta-analysis compares the performance of contrast-enhanced ultrasound (CEUS) to conventional ultrasound when used as the initial assessment for abdominal trauma prior to computed tomography (CT) imaging.

METHODS

A systematic literature search of major databases was conducted of human studies investigating the diagnostic accuracy of conventional ultrasound and CEUS occurring prior to CT imaging for abdominal trauma. The study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The quality of studies was evaluated using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool. Paired pooled sensitivity and specificity between conventional ultrasound and CEUS were compared using data extracted from the eligible studies. Diagnostic odds ratio, number needed to diagnose values, and likelihood ratios were also determined.

RESULTS

Ten studies were included. More than half of the included studies demonstrated low risk of bias. Using McNemar's test to assess for paired binary observations, we found that CEUS had statistically higher sensitivity (0.933 vs. 0.559; two-tailed, P < 0.001) and specificity (0.995 vs. 0.979; two-tailed, P < 0.001) than conventional ultrasound in the setting of abdominal trauma, respectively. When divided into particular findings of clinical interest, CEUS had statistically higher sensitivity than conventional ultrasound in screening for active bleeding and injuries to all abdominal solid organs. CEUS also had superior diagnostic odds ratios, number needed to diagnose values, and likelihood ratios than conventional ultrasound.

CONCLUSION

The diagnostic value of CEUS was higher than that of conventional ultrasound for differentiating traumatic abdominal injuries when used as the initial assessment in the emergency department.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Contrast-enhanced ultrasound in pediatric blunt abdominal trauma: a systematic review

PURPOSE

Intra-abdominal injury is a major cause of morbidity in children. Computed tomography (CT) is the reference standard for the evaluation of hemodynamically stable abdominal trauma. CT has an increased risk of long-term radiation induced malignancies and a possible risk associated with the use of iodinated contrast media. Contrast-enhanced ultrasound (CEUS) might represent an alternative to CT in stable children with blunt abdominal trauma (BAT). Nonetheless, CEUS in pediatrics remains limited by the lack of strong evidence. The purpose of this study was to offer a systematic review on the use of CEUS in pediatric abdominal trauma.

METHODS

Electronic search of PubMed, EMBASE and Cochrane databases of studies investigating CEUS for abdominal trauma in children. The risk of bias was assessed using the ROBINS-I tool.

RESULTS

This systematic review included 7 studies. CEUS was performed with different ultrasound equipment, always with a curvilinear transducer. Six out of seven studies used a second-generation contrast agent. No immediate adverse reactions were reported. The dose of contrast agent and the scanning technique varied between studies. All CEUS exams were performed by radiologists, in the radiology department or at the bedside. No standard training was reported to become competent in CEUS. The range of sensitivity and specificity of CEUS were 85.7 to 100% and 89 to 100%, respectively.

CONCLUSION

CEUS appears to be safe and accurate to identify abdominal solid organ injuries in children with BAT. Further research is necessary to assess the feasibility of CEUS by non-radiologists, the necessary training, and the benefit-cost ratio of CEUS as a tool to potentially reduce CT scans.

Contrast-enhanced ultrasound of blunt abdominal trauma in children

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.

Value of Contrast-Enhanced Ultrasound in the Differential Diagnosis of Focal Splenic Lesions

Purpose

To identify and validate contrast-enhanced ultrasound (CEUS) features for differentiating malignant from benign splenic lesions.

Patients and Methods

Splenic lesions in 123 patients who underwent conventional ultrasound (B-mode US) and CEUS were included in this study. Two radiologists evaluated the sonograms of B-mode and CEUS. Statistical analysis was performed to identify significant imaging predictors for splenic malignant lesions. Two other radiologists independently reviewed B-mode and CEUS sonograms and diagnosed the lesions based on proposed criteria as 1) benign, 2) probably benign, 3) probably malignant or 4) malignant. The diagnostic efficiency between B-mode US and CEUS was compared.

Results

Common imaging findings of malignant lesions included hypoechoic, ill-defined margin, absence of cystic/necrotic portion, presence of splenomegaly on B-mode US, and hypoenhancement, rapid washout and presence of intralesional vessels on CEUS (P < 0.05). Among them, three independent features were identified using multivariate logistic regression analysis: hypoechoic pattern, hypoenhancement pattern and intralesional vessels. When three of these findings were combined as a predictor for splenic malignant lesions, 22 (55.0%) of 40 malignant splenic lesions were identified with a specificity of 100%. The diagnostic performance of two readers using receiver operating characteristic curve analysis was 0.622 and 0.533, respectively, for B-mode US, which was significantly improved to 0.908 and 0.906 for CEUS (P < 0.001). The degree of other diagnostic efficiency and inter-reader agreement also increased with CEUS compared to B-mode US.

Conclusion

CEUS may provide more useful information than B-mode US and improve the diagnosis efficiency for distinguishing malignant from benign splenic lesions.

Interventional Ultrasound Assisted Early Local Hemostatic Drug Therapy in Traumatic Intracerebral Hemorrhage

This article aims to test a minimally invasive interventional approach by real-time transcranial contrast-enhanced ultrasound (CEUS) through a small bur hole to achieve an early local hemostatic drug therapy in a novel traumatic intracerebral hematoma (ICH) model of pigs with hemostatic abnormalities. The effects of hemostasis in the hemocoagulase atrox (HA) injection group and saline injection group groups were observed by transcranial CEUS at three time points: 0 s, 10 s, 2nd. We successfully established a novel traumatic ICH model of pigs with hemostatic abnormalities by the methods of interventional ultrasound techniques and observed the effect of hemostasis by using HA in a local injection method with the assistance of minimally invasive interventional ultrasound technique. At 0 s, four pigs (100%) were observed that active bleeding was significantly weakened, and the range of hematoma became smaller in the HA group. At 10 s, four pigs (100%) were observed that active bleeding became much weaker, and the range of hematoma became further smaller in the HA group. At 2nd, zero pigs (0/4, 0%) were observed that active bleeding could be clearly identified and four pigs (100%) with ICH could also be observed in the HA group. We believe this useful technique could minimize the invasiveness and be operated at the bedside, which would bring much more benefits for traumatic ICH patients.

Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma

Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.

Spontaneous and Traumatic Splenic Rupture: Retrospective Clinical, B-Mode and CEUS Analysis in 62 Patients

Introduction

Both B-mode ultrasound and contrast-enhanced ultrasound (CEUS) are well established procedures when diagnosing traumatic splenic ruptures (TSR). To date, there are no data about CEUS patterns in spontaneous splenic ruptures (SSR). It remains unknown whether TSR and SSR differ with respect to clinical characteristics, B-mode and CEUS characteristics.

Patients and Methods

Between 12/2003 and 2/2010, n=33 SSRs and n=29 TSRs were diagnosed in a tertiary referral center. All patients were examined with B-mode and CEUS, and clinical data and the outcome were retrospectively analyzed.

Results

Patients with SSR were significantly older than patients with TSR (62 years vs. 44 years; p=0.01). The 4-week mortality was significantly higher in SSR than in TSR (36% vs. 0%; p=0.001). No differences between the grading of TSR and SSR could be shown in B-mode or in CEUS. Notably, CEUS was significantly superior to B-mode with respect to the grading of splenic ruptures (p=0.01). Therefore, therapeutic management was influenced by CEUS.

Conclusion

There are differences between SSR and TSR, especially concerning clinical data (age, course of disease and mortality). Regarding the sonographic pattern, SSR and TSR show identical grading. When splenic rupture is suspected, CEUS should always be performed to identify patients at risk who require interventional procedures.

Common and uncommon features of focal splenic lesions on contrast-enhanced ultrasound: a pictorial review

The characterization of focal splenic lesions by ultrasound can be quite challenging. The recent introduction of contrast-enhanced ultrasound (CEUS) has come to play a valuable role in the field of imaging splenic pathologies, offering the possibility of an ionizing radiation-free investigation. Because CEUS has been incorporated into everyday clinical practice, malignant diseases such as focal lymphomatous infiltration, metastatic deposits, benign cysts, traumatic fractures, and hemangiomas can now be accurately depicted and characterized without the need for further imaging. More specifically, splenic traumatic fractures do not require additional imaging by computed tomography (with ionizing radiation exposure) for follow-up, because splenic fractures and their complications are safely imaged with CEUS. In the new era of CEUS, more patients benefit from radiation-free investigation of splenic pathologies with high diagnostic accuracy.

Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis

We aimed to investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in evaluating blunt abdominal trauma for patients presenting to the emergency department. Electronic search of Scopus and Pubmed was performed from inception to September 2016. Human studies investigating the diagnostic accuracy of CEUS in identifying abdominal solid organ injuries were included. Risk of bias was assessed using the QUADAS tool. A total of 10 studies were included in the study and 9 of them were included for meta-analysis. The log(DOR) values ranged from 3.80 (95% CI: 2.81-4.79) to 8.52 (95% CI: 4.58-12.47) in component studies. The combined log(DOR) was 6.56 (95% CI: 5.66-7.45). The Cochran's Q was 11.265 (p = 0.793 with 16 degrees of freedom), and the Higgins' I² was 0%. The CEUS had a sensitivity of 0.981 (95% CI: 0.868-0.950) and a false positive rate of 0.018 (95% CI: 0.010-0.032) for identifying parenchymal injuries, with an AUC of 0.984. CEUS performed at emergency department had good diagnostic accuracy in identifying abdominal solid organ injuries. CEUS can be recommended in monitoring solid organ injuries, especially for patients managed with non-operative strategy.

Diagnostic imaging of blunt abdominal trauma in pediatric patients

Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.

Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma

Baseline ultrasound is essential in the early assessment of patients with a huge haemoperitoneum undergoing an immediate abdominal surgery; nevertheless, even with a highly experienced operator, it is not sufficient to exclude parenchymal injuries. More recently, a new ultrasound technique using second generation contrast agents, named contrast-enhanced ultrasound (CEUS) has been developed. This technique allows all the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients with low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. Several studies demonstrated its ability to detect lesions occurring in the liver, spleen, pancreas and kidneys and also to recognize active bleeding as hyperechoic bands appearing as round or oval spots of variable size. Its role seems to be really relevant in paediatric patients, thus avoiding a routine exposure to ionizing radiation. Nevertheless, CEUS is strongly operator dependent, and it has some limitations, such as the cost of contrast media, lack of panoramicity, the difficulty to explore some deep regions and the poor ability to detect injuries to the urinary tract. On the other hand, it is timesaving, and it has several advantages, such as its portability, the safety of contrast agent, the lack to ionizing radiation exposure and therefore its repeatability, which allows follow-up of those traumas managed conservatively, especially in cases of fertile females and paediatric patients.

International guidelines for contrast-enhanced ultrasonography: ultrasound imaging in the new millennium

The intent of this review is to discuss and comment on common clinical scenarios in which contrast-enhanced ultrasonography (CEUS) may play a decisive role and to illustrate important points with typical cases. With the advent of CEUS, the scope of indications for ultrasonography has been dramatically extended, and now includes functional imaging and tissue characterization, which in many cases enable tumor diagnosis without a biopsy. It is virtually impossible to imagine the practice of modern medicine as we know it in high-income countries without the use of imaging, and yet, an estimated two thirds of the global population may receive no such care. Ultrasound imaging with CEUS has the potential to correct this inequity.

Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma

PURPOSE

The purpose of this study was to retrospectively investigate the application of emergency contrast-enhanced ultrasonography (CEUS) in blunt pancreatic trauma.

MATERIALS AND METHODS

Twenty-two consecutive patients with blunt pancreatic trauma were examined using CEUS from March 2007 to June 2012. The findings of CEUS were compared with those of contrast-enhanced computed tomography scans at level-1 diagnostic tests.

RESULTS

Out of the 22 patients, 21 were diagnosed with blunt pancreatic injury using CEUS, including 8 patients with lesions in the neck of pancreas, 9 in the body, 3 in the tail and 1 in the head. The injury sites appeared as anechoic and/or hypoechoic perfusion defect regions with irregular borders in parenchyma and capsule on CEUS images. The lesion sizes measured by CEUS were 1.88 ± 0.81 cm, which were consistent with the 1.93 ± 0.77 cm measured by CT (p > 0.05). Using CT as a reference standard, the detection rate of CEUS in blunt pancreatic trauma was 95.5 % (21/22).

CONCLUSIONS

CEUS findings can be used to provide a reliable diagnosis for blunt pancreatic trauma. CEUS is thus promising in the assessment of blunt pancreatic trauma, especially in institutions where emergency CEUS is used as an initial diagnostic instrument.

Evaluation of blunt pancreatic injury with contrast-enhanced ultrasonography in comparison with contrast-enhanced computed tomography

The aim of the present study was to evaluate acute blunt pancreatic injury using contrast-enhanced ultrasonography (CEUS) in comparison with contrast-enhanced computed tomography (CECT). Superficial and deep lesions were established by blunt pancreatic injury in 40 Chinese Guangxi Bama miniature pigs. Conventional ultrasound (US), CEUS and CECT were performed to detect traumatic lesions in the pancreas. A total of 40 lesions were established, including 20 deep lesions and 20 superficial lesions. US identified 21 of the 40 lesions, including 7 of the 20 superficial and 14 of the 20 deep lesions. CEUS identified 34 of the 40 lesions, including 14 of the 20 superficial and 20 of the 20 deep lesions. CECT identified 33 of the 40 lesions, including 13 of the 20 superficial and 20 of the 20 deep lesions. The detection rate of acute blunt pancreatic injury using CEUS was significantly higher compared with that using US (85 vs. 52.5%, P<0.05), however there was no significant difference in the detection rate of pancreatic lesions between CEUS and CECT (85 vs. 82.5%, P>0.05). CEUS improves the diagnostic levels of conventional US and is comparable with CECT scans in the diagnosis of blunt pancreatic injury.

Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma

AIM: To evaluate the efficacy of computed tomography scan in diagnosing and grading the pattern of pancreatic injuries in children.

METHODS: We conducted a retrospective study to review medical files of children admitted with blunt pancreatic injuries to the Maternity and Children Hospital Al-Madina Al-Munawwarah, Kingdom of Saudi Arabia. The demographic details and mechanisms of injury were recorded. From the database of the Picture Archiving and Communication System of the radiology department, multidetector computed tomography (MDCT) images of the pancreatic injuries, severity, type of injuries and grading of pancreatic injuries were established.

RESULTS: Seven patients were recruited in this study over a period of 5 years; 5 males and 2 females with a mean age of 7 years (age range 5-12 years). Fall from height was the most frequent mechanism of injury, reported in 5 (71%), followed by road traffic accident (1 patient, 14%) and cycle handlebar (1 patient, 14%) injuries. According to the American Association for the Surgery of Trauma grading system, 1 (14%) patient sustained Grade I, 1 (14%) Grade II, 3 (42%) Grade III and 2 (28%) patients were found to have Grade V pancreatic injuries. This indicated a higher incidence of severe pancreatic injuries; 5 (71.4%) patients were reported to have Grade III and higher on the injury scale. Three (42%) patients had associated abdominal organ injuries.

CONCLUSION: Pediatric pancreatic injuries due to blunt abdominal trauma are rare. The majority of the patients sustained extensive pancreatic injuries. MDCT findings are helpful and reliable in diagnosing and grading the pancreatic injuries.

Contrast-enhanced sonography in blunt scrotal trauma()

The scope of this study was to determine whether contrast-enhanced ultrasonography (CEUS), compared with basic US, can increase diagnostic confidence and provide relevant information on blunt scrotal trauma. Over a period of 75 months we examined 40 patients seen consecutively for blunt scrotal trauma using high-resolution US, color-power Doppler, low mechanical index CEUS, and power Doppler after IV administration of contrast medium (SonoVue(®)). In the 24 cases that were positive, concordance between basal US and CEUS findings was grade 0 (absent) in 4 cases, grade 1 (low) in 3, grade 2 (moderate) in 8, and grade 3 (high) in 9. The relevance of the additional information provided by CEUS was classified as follows: high in 4/40 (10%), moderate 7/40 (17,5%), low 13/40 (32,5%), none in 14/40 (35%). Our findings demonstrate that CEUS is appreciably more sensitive in detecting damage caused by blunt scrotal trauma, particularly small lesions. It is also useful for differential diagnosis and marginalization of corpuscular fluid collections, fractures, and above all ruptures, which require immediate surgery. In our series 2 out of 3 (67%) patients with testicular rupture were diagnosed only by CEUS. We feel that the use of CEUS can significantly improve diagnostic confidence in cases of closed scrotal trauma although these conclusions need to be confirmed in larger case series.

Characterization of nontraumatic focal splenic lesions using contrast-enhanced sonography

PURPOSE

To compare contrast-enhanced sonography (CEUS) with contrast-enhanced CT in the assessment of nontraumatic focal lesions of the spleen.

METHODS

CEUS and CT findings in 22 patients with fever of unknown origin and ultrasound-detected splenic focal lesions were analyzed retrospectively. CEUS was performed using an ultrasound unit equipped with a 3.6-MHz probe and contrast-specific software. A 4-ml bolus of second-generation contrast medium was used. The CEUS examinations included a 4-minute recording following injection of the contrast medium. MRI, splenic biopsy, or ultrasound follow-up were used if findings from CT were inconclusive.

RESULTS

The final diagnoses were as follows: seven splenic infarcts, five hemangiomas, three lacerations, two benign cysts, one lymphoma, one granuloma, one abscess, and two lesions of unknown etiology. CEUS and CT had the same specificity (77.2%). Both CEUS and CT failed to characterize nodular hypovascular lesions with a hypoenhancing pattern.

CONCLUSIONS

CEUS is as effective as CT for characterizing nontraumatic focal lesions of the spleen. If CEUS findings are consistent with a benign splenic lesion, CT seems to be of limited additional value.

Contrast enhanced ultrasound of splenic lymphoma involvement

OBJECTIVE

The aim of this study was to compare the value of contrast-enhanced ultrasonography (CEUS) with standard B-mode ultrasound (US) for diagnosis of splenic lymphoma involvement.

METHODS

From 04/2005 to 10/2008 n=250 lymphoma patients were investigated by standard B-mode US. A homogeneous splenic echotexture was found in 199 patients (79%). To clarify the benefit of CEUS in this group a pilot series was performed with 16 of the 199 lymphoma patients. All patients with an abnormal splenic echotexture on standard B-Mode US (n=51) including focal hypoechoic splenic lesions (n=41) and an inhomogeneous splenic texture (n=10) were studied by CEUS. CEUS data were retrospectively evaluated. The diagnoses included indolent lymphoma (n=27), aggressive lymphoma (n=14), and Hodgkin's disease (n=10). Number and size of lesions were determined by B-mode US and CEUS. The visualisation of splenic lymphoma involvement by CEUS in comparison to B-mode US was classified as worse, equal, or better.

RESULTS

All patients with a homogeneous spleen on B-mode US (n=16) had no visible focal lesions on CEUS. Study patients with focal lesions (n=41) had a hypoechoic (n=22) or isoechoic (n=19) enhancement during the arterial phase, and a hypoechoic enhancement during the parenchymal phase (n=41). The visualisation of focal splenic lymphoma was equal (n=32), better (n=6), or worse (n=3). In all study patients with an inhomogeneous spleen on B-mode US (n=10) no focal lesions were found by CEUS and the value of CEUS therefore was classified as worse.

CONCLUSION

CEUS has no clear advantage for diagnosis of splenic lymphoma involvement.

CEUS in abdominal trauma: multi-center study

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

Ultrasound enhanced with sulphur-hexafluoride-filled microbubbles agent (SonoVue) in the follow-up of mild liver and spleen trauma

PURPOSE

This study assessed the role of contrast-enhanced ultrasound (CEUS) in the follow-up of patients with a diagnosis of traumatic liver or spleen lesions.

MATERIALS AND METHODS

Between April 2006 and February 2008, 18 patients (13 males and five females, age range 8-42 years) with blunt abdominal trauma were evaluated with computed tomography (CT) and CEUS at the emergency department of our institution. Seven were diagnosed as surgical emergencies and were excluded from the study. The remaining 11 were treated conservatively and were monitored with CEUS at variable time intervals, depending on their clinical needs.

RESULTS

CEUS confirmed lesion sites identified on presentation and allowed us to follow all phases of the repair process until complete resolution.

CONCLUSIONS

The conservative management of abdominal lesions in both adults and children is increasingly widespread but requires accurate follow-up over time. As a noninvasive, versatile, easy to perform and repeatable technique with a low rate of adverse reactions, CEUS is ideally suited for this purpose and allowed us to reduce the number of CT scans, especially in the follow-up of young patients.

Contrast-enhanced ultrasonography with SonoVue: differentiation between benign and malignant lesions of the spleen

OBJECTIVE

We investigated the ability of contrast-enhanced ultrasonography with SonoVue (Bracco SpA, Milan, Italy), a sulfur hexafluoride microbubble contrast agent, to reveal differences between benign and malignant focal splenic lesions.

METHODS

In a prospective study we investigated 35 lesions in 35 patients (24 male and 11 female; mean age +/- SD, 54 +/- 15 years) with focal splenic lesions detected by B-mode ultrasonography. After intravenous injection of 1.2 to 2.4 mL of SonoVue, the spleen was examined continuously for 3 minutes using low-mechanical index ultrasonography with contrast-specific software. The final diagnosis was established by histologic examination, computed tomography, or magnetic resonance imaging.

RESULTS

In 14 patients, the splenic lesions were malignant (metastasis, n = 6; non-Hodgkin lymphoma, n = 6; and Hodgkin lymphoma, n = 2). In 21 patients, the focal splenic lesions were benign (ischemic lesion, n = 6; echogenic cyst, n = 5; abscess, n = 4; hemangioma, n = 3; hematoma, n = 1; hemophagocytosis syndrome, n = 1; and splenoma, n = 1. Typical findings for benign lesions were 2 arrival patterns: no contrast enhancement (neither in the early nor in the parenchymal phase; P < .05) and the beginning of contrast enhancement in the early phase followed by contrast enhancement in the parenchymal phase 60 seconds after injection. In contrast, the combination of contrast enhancement in the early phase followed by rapid wash-out and demarcation of the lesion without contrast enhancement in the parenchymal phase (60 seconds after injection) was typical for malignant lesions (P < .001).

CONCLUSIONS

Contrast-enhanced ultrasonography is helpful in the differentiation between benign and malignant lesions of the spleen.

Comparison of gray-scale contrast-enhanced ultrasonography with contrast-enhanced computed tomography in different grading of blunt hepatic and splenic trauma: an animal experiment

To compare the diagnostic value of contrast-enhanced ultrasonography (CEUS) with contrast-enhanced computed tomography (CECT) for the detection of different grading of solid organ injuries in blunt abdominal trauma in animals. A self-made miniature tools were used as models to simulate a blunt hepatic or splenic trauma in 16 and 14 anesthetized dogs, respectively. Baseline ultrasound, CEUS and CECT were used to detect traumatic injuries of livers and spleens. The degree of injuries was determined by CEUS according to the American Association for the Surgery of Trauma (AAST) scale and the results compared with injury scale based on CECT evaluation. CEUS showed 22 hepatic injury sites in 16 animals and 17 splenic injury sites in other 14 animals. According to AAST scale, 2 grade I, 4 grade II, 3 grade III, 5 grade IV and 2 grade V hepatic lesions were present in 16 animals; 2 grade I, 4 grade II, 6 grade III and 2 grade IV splenic lesions in 14 animals. On CECT scan, 21 hepatic and 17 splenic injuries were demonstrated. According to Becker CT scaling for hepatic injury, 1 grade I, 2 grade II, 4 grade III, 5 grade IV and 2 grade V hepatic injuries were present. On the basis of Buntain spleen scaling, 2 grade I, 5 grade II, 5 grade III, 2 grade IV splenic injuries were showed. After Spearman rank correlation analysis, the agreement of CEUS with CECT on the degree of hepatic and splenic injury is 93.3% and 92.9%, respectively. CT is currently considered as the reference method for grading blunt abdominal trauma, according to experiment results, CEUS grading showed high levels of concordance with CECT. CEUS can accurately determine the degree of injury and will play an important role in clinical application.

Percutaneous injection therapy for blunt splenic trauma guided by contrast-enhanced ultrasonography

OBJECTIVE

The purpose of this study was to investigate the application of contrast-enhanced ultrasonography (CEUS) in managing blunt splenic trauma and the effectiveness of CEUS-guided percutaneous injection therapy.

METHODS

Six patients with grade 3 or 4 splenic injuries as determined by CEUS and contrast-enhanced computed tomography were given hemocoagulase atrox and absorbable cyanoacrylate percutaneously, which were injected into the injury region and active bleeding site, respectively, under CEUS guidance. Immediately after the procedure and 1 and 3 days, 1 and 2 weeks, and 1 and 6 months after the procedure, follow-up CEUS up was performed in all patients.

RESULTS

Among the 6 patients, 4 cases of CEUS-guided hemostatic injection were successful without complications. Rehemorrhage occurred in 1 patient, and a traumatic arteriovenous fistula occurred in another; repeated injection therapy in these 2 patients was effective. During the follow-up, there were no complications, and spleen perfusion recovered gradually.

CONCLUSIONS

Contrast-enhanced ultrasonography can be used to guide percutaneous injection therapy and therefore achieve the goal of using interventional ultrasonography in managing splenic trauma.

Blunt abdominal trauma: diagnostic performance of contrast-enhanced US in children--initial experience

PURPOSE

To prospectively compare the sensitivity and specificity of ultrasonography (US) with those of contrast material-enhanced US in the depiction of solid organ injuries in children with blunt abdominal trauma, with contrast-enhanced computed tomography (CT) as the reference standard.

MATERIALS AND METHODS

The study protocol was approved by the ethics board, and written informed consent was obtained from parents. US, contrast-enhanced US, and contrast-enhanced CT were performed in 27 consecutive children (19 boys, eight girls; mean age, 8.9 years +/- 2.8 [standard deviation]) with blunt abdominal trauma to determine if solid abdominal organ injuries were present. Sensitivity, specificity, agreement, accuracy, number of lesions correctly identified, and positive and negative predictive values were determined for US and contrast-enhanced US, as compared with contrast-enhanced CT.

RESULTS

In 15 patients, contrast-enhanced CT findings were negative. Contrast-enhanced CT depicted 14 solid organ injuries in 12 patients. Lesions were in the spleen (n = 7), liver (n = 4), right kidney (n = 1), right adrenal gland (n = 1), and pancreas (n = 1). Contrast-enhanced US depicted 13 of the 14 lesions in 12 patients with positive contrast-enhanced CT findings and no lesions in the patients with negative contrast-enhanced CT findings. Unenhanced US depicted free fluid in two of 15 patients with negative contrast-enhanced CT findings and free fluid, parenchymal lesions, or both in eight of 12 patients with positive contrast-enhanced CT findings. Overall, the diagnostic performance of contrast-enhanced US was better than that of US, as sensitivity, specificity, and positive and negative predictive values were 92.2%, 100%, 100%, and 93.8%, respectively.

CONCLUSION

Contrast-enhanced US was almost as accurate as contrast-enhanced CT in depicting solid organ injuries in children.

Hemorrhage control using high intensity focused ultrasound

Hemorrhage control is a high priority task in advanced trauma care, because hemorrhagic shock can result in less than a minute in cases of severe injuries. Hemorrhage was found to be solely responsible for 40-50% of traumatic civilian and battlefield deaths in recent years. The majority of these deaths were due to abdominal and pelvic injuries with hidden and inaccessible bleeding of solid organs such as liver, spleen, and kidneys, as well as major blood vessels. High intensity focused ultrasound (HIFU) offers a promising method for hemorrhage control. An important advantage of HIFU is that it can deliver energy to deep regions of tissue where hemorrhage is occurring, allowing cauterization at depth of parenchymal tissues, or in difficult-to-access anatomical regions, while causing no or minimal biological effects in the intervening and surrounding tissues. Moreover, HIFU can cause both thermal and mechanical effects that are shown to work synergistically for rapid hemorrhage control. The major challenges of this method are in development of bleeding detection techniques for accurate localization of the injury sites, delivery of large HIFU doses for profuse bleeding cases, and ensuring safety when critical structures are in the vicinity of the injury. Future developments of acoustic hemostasis technology are anticipated to be for applications in peripheral vascular injuries where an acoustic window is usually available, and for applications in the operating room on exposed organs.

Contrast-Enhanced Ultrasound for Blunt Abdominal Trauma

Sonography is widely used in the initial diagnostic assessment of blunt abdominal trauma in adults and children. It has been formally incorporated worldwide into the routine armamentarium available for emergency diagnosis and treatment as a means of rapid detection of free abdominal fluid, normally referred to as FAST (Focused Assessment with Sonography in Trauma). However, there is some controversy regarding its value because free abdominal fluid may be lacking in patients with abdominal organ injuries from blunt trauma. More recently, a new ultrasound technique has been developed using contrast agents. Contrast-enhanced ultrasound performs better than the non-contrast-enhanced technique for the detection of abdominal solid organ injuries and can play an important role in the prompt evaluation of patients with blunt trauma. Furthermore, contrast-enhanced ultrasound can be used in the follow-up of patients who have solid organ lesions and are managed with nonoperative treatment, avoiding radiation and iodinated contrast medium exposure.

Contrast-enhanced sonography of the spleen

Sonography is frequently the first imaging modality employed to evaluate the spleen. Nevertheless, splenic abnormalities frequently determine subtle changes in echogenicity and may be overlooked. Additionally, splenic disorders have a nonspecific appearance, mostly appearing as hypoechoic defects. Difficulties in differential diagnosis are not uncommon, with splenic infarctions resembling, for example, focal lesions. Color Doppler is usually of limited additional value. Instead, the spleen is optimally suited for contrast-enhanced sonography, being superficial, small, and homogeneous, and showing intense and persistent contrast enhancement. Scarcely evident abnormalities become evident after contrast medium injection. Additional information can be obtained in many clinical scenarios, including blunt trauma, left flank pain, lymphoma, and incidental detection of splenic abnormalities.

Detection of bleeding in injured femoral arteries with contrast-enhanced sonography

OBJECTIVE

The purpose of this study was to investigate the feasibility of detecting acute arterial bleeding by means of contrast-enhanced sonography.

METHODS

Puncture injury was produced transcutaneously with an 18-gauge needle in 26 femoral arteries (13 in the control group and 13 in the contrast-enhanced group) of rabbits. A sonographic contrast agent (Optison; Mallinckrodt Inc, St Louis, MO) was administered intravenously at a dose of 0.06 to 0.07 mL/kg. Sonography of the femoral arteries was performed before and after injury, both before and after injection of Optison, with B-mode imaging, color Doppler imaging, and pulse inversion harmonic imaging (PIHI).

RESULTS

The specific location of active bleeding could not be visualized in B-mode and PIHI scans in the control group (no Optison injection). After administration of Optison, the bleeding site was visualized because of the increased echogenicity of the extravasated blood at the puncture site in both B-mode imaging and PIHI. In color Doppler images, bleeding sites were localized successfully in 84.6% of the cases in the presence of Optison and in 30.8% of the cases without Optison. Histologic examination (light microscopy) of the hematoma confirmed the presence of contrast agent microbubbles in the extravascular space surrounding the artery.

CONCLUSIONS

Contrast-enhanced sonography may provide an effective method for detecting arterial bleeding.

Appearance of Solid Organ Injury with Contrast-Enhanced Sonography in Blunt Abdominal Trauma: Preliminary Experience

OBJECTIVE

The purpose of this study was to compare the detection rate of injury and characterize imaging findings of contrast-enhanced sonography and non-contrast-enhanced sonography in the setting of confirmed solid organ injury.

SUBJECTS AND METHODS

This prospective study involved identifying hepatic, splenic, and renal injuries on contrast-enhanced CT. After injury identification, both non-contrast-enhanced sonography and contrast-enhanced sonography were performed to identify the possible injury and to analyze the appearance of the injury. The sonographic appearance of hepatic, splenic, and renal injuries was then analyzed, and the conspicuity of the injuries was graded on a scale from 0 (nonvisualization) to 3 (high visualization).

RESULTS

Non-contrast-enhanced sonography revealed 11 (50%) of 22 injuries, whereas contrast-enhanced sonography depicted 20 (91%) of 22 injuries. The average grade for conspicuity of injuries was increased from 0.67 to 2.33 for spleen injuries and from 1.0 to 2.2 for liver injuries comparing non-contrast-enhanced with contrast-enhanced sonography, respectively, on a scale from 0, being nonvisualization, to 3, being high visualization. The splenic injuries appeared hypoechoic with occasional areas of normal enhancing splenic tissue within the laceration with contrast-enhanced sonography. Different patterns were observed in liver injuries including a central hypoechoic region. In some liver injuries there was a surrounding hyperechoic region.

CONCLUSION

Contrast-enhanced sonography greatly enhances visualization of liver and spleen injuries compared with non-contrast-enhanced sonography. Solid organ injuries usually appeared hypoechoic on contrast-enhanced sonography, but often a hyperechoic region surrounding the injury also was identified with liver injuries.

Active abdominal bleeding: contrast-enhanced sonography

Active contrast medium extravasation is a recognized and important angiographic and computed tomographic (CT) sign of bleeding. It is an indicator of active, ongoing, and potentially life-threatening hemorrhage and, hence, of the need for an immediate surgical or interventional treatment. Sonography (US) is frequently used as the first imaging option for screening patients with traumatic and nontraumatic abdominal emergencies. Owing to the current possibilities of low-mechanical index, real-time, contrast-specific systems, it is now possible to detect a contrast leakage by using US. This finding opens new possibilities in the assessment and management of several abdominal emergencies, including trauma (initial workup and monitoring), spontaneous hematomas, and rupture of aneurysms or masses. This article describes the technique, findings, possibilities, and limitations of contrast-enhanced US in the evaluation of active abdominal bleeding.

Blunt abdominal trauma: emergency contrast-enhanced sonography for detection of solid organ injuries

OBJECTIVE

The objective of our study was to prospectively compare the diagnostic value of sonography and contrast-enhanced sonography with CT for the detection of solid organ injuries in blunt abdominal trauma patients.

SUBJECTS AND METHODS

Sonography, contrast-enhanced sonography, and CT were performed to assess possible abdominal organ injuries in 69 nonconsecutive hemodynamically stable patients with blunt abdominal trauma and a strong clinical suspicion of abdominal lesions. Sonography and contrast-enhanced sonography findings were compared with CT findings, the reference standard technique.

RESULTS

Thirty-two patients had 35 abdominal injuries on CT (10 kidney or adrenal lesions, seven liver lesions, 17 spleen lesions, and one retroperitoneal hematoma). Sixteen lesions were detected on sonography, and 32 were seen on contrast-enhanced sonography. The sensitivity and specificity of sonography were 45.7% and 91.8%, respectively, and the positive and negative predictive values were 84.2% and 64.1%, respectively. Contrast-enhanced sonography had a sensitivity of 91.4%, a specificity of 100%, and positive and negative predictive values of 100% and 92.5%, respectively.

CONCLUSION

Contrast-enhanced sonography was found to be more sensitive than sonography and almost as sensitive as CT in the detection of traumatic abdominal solid organ injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma.

Colour Doppler ultrasound patterns and clinical follow-up of incidentally found hypoechoic, vascular tumours of the spleen: evidence for a benign tumour

Between January 1990 and January 2005, incidental hypoechoic, vascular tumours of the spleen were identified in 13 patients using B-mode and colour Doppler ultrasound (CDS). All lesions found were well demarcated, intrasplenically located, and ranged in size between 1 cm and 4 cm. The increased vascular pattern on CDS was confirmed in 9 of the 13 cases by contrast enhanced ultrasound (CES), while two patients showed reduced vascularity on CES. In 10 patients, lesions were confirmed by contrast enhanced CT. Histological examination was performed in three patients with the diagnosis of capillary haemangioma (n = 2) and hamartoma (n = 1). In the remaining cases, ultrasound follow-up was performed (range 4 months to 13 years) and demonstrated no evidence of tumour growth in all but one patient. During a 4 year follow-up, one lesion increased in size from 1.0 cm to 1.5 cm and in the same patient an additional 0.5 cm sized hypoechoic increased vascular lesion was also found. In the spleen a hypoechoic lesion with an increased vascular pattern incidentally found by ultrasound most likely indicates a benign tumour with capillary haemangioma/hamartoma as the most likely diagnosis. However, it should be emphasised that in all cases a careful ultrasound follow-up is warranted.

Contrast-enhanced ultrasound in non-operative management of pancreatic injury in childhood

We report a 5-year-old child with pancreatic trauma from a blunt abdominal injury that was monitored with contrast-enhanced sonography. Unenhanced US failed to demonstrate the abnormality that was recognized by CT and MRI. The injury was well demonstrated by contrast-enhanced US which was therefore used for follow-up until its healing.

Contrast-enhanced sonography for differential diagnosis of an inhomogeneous spleen of unknown cause in patients with pain in the left upper quadrant

OBJECTIVE

Second-generation contrast agents have shown spleen-specific uptake. The aim of this study was to investigate the ability of contrast-enhanced sonography (CES) to demarcate splenic lesions in patients with pain in the left upper quadrant (LUQ) and an inhomogeneous splenic texture.

METHODS

From October 2003 to July 2005, 31 consecutive patients with pain in the LUQ and splenic inhomogeneity on B-mode sonography were studied by CES using a second-generation contrast agent (SonoVue; Bracco SpA, Milan, Italy). The following data were retrospectively evaluated: extent of enhancement (EE) of the spleen and focal splenic lesions was determined and classified, with the EE of surrounding tissue used as an in vivo reference. Focal splenic lesions were classified after CES as round or wedge shaped, solitary or multiple, and anechoic, hypoechoic, or hyperechoic.

RESULTS

The EE of the spleen after CES was anechoic (n = 1), hypoechoic (n = 1), or hyperechoic (n = 29). In 16 of 31 patients, focal lesions were seen after CES. The EE of the lesions was anechoic (n = 11) or hypoechoic (n = 5). Lesions were solitary (n = 6) or multiple (n = 10) and round (n = 5) or wedge shaped (n = 11). Final clinical diagnoses of splenic abnormalities were no specific diagnosis (n = 13), complete autosplenectomy (n = 2), splenic lymphoma (n = 5), and splenic infarction (n = 11). The CES diagnoses were confirmed by computed tomography (n = 21), scintigraphy (n = 2), magnetic resonance imaging (n = 1), and clinical follow-up (n = 7).

CONCLUSIONS

In patients with pain in the LUQ and splenic inhomogeneity, CES enables visualization of splenic abnormalities in more than 50% of the patients; in this group, splenic infarction was the most common diagnosis.

Second-Generation Sonographic Contrast Agent for Differential Diagnosis of Perisplenic Lesions

OBJECTIVE

On contrast-enhanced sonography, second-generation contrast media have shown a spleen-specific uptake of the microbubble contrast agent. To date, there is little data about the diagnostic value of contrast-enhanced sonography in perisplenic lesions.

CONCLUSION

In patients with a perisplenic tumor of unknown cause, contrast-enhanced sonography enables the diagnosis or exclusion of accessory spleens.

Real-time, contrast-enhanced sonography: a new tool for detecting active bleeding

BACKGROUND

Active contrast medium extravasation is a known angiographic and computed tomographic sign of ongoing, potentially life-threatening hemorrhage. Sonography (US) is frequently the first imaging option for screening patients with abdominal emergencies. Because of the current possibilities of low-mechanical-index, real-time, contrast-specific systems, it is possible to detect contrast leakage by using US. The purpose of this article is report our pilot experience in the evaluation of active traumatic and nontraumatic bleeding with contrast-enhanced US.

METHODS

In a 2-year period, we performed 153 consecutive emergent contrast-enhanced US studies. Traumatic emergencies accounted for 83 examinations and nontraumatic emergencies accounted for 70. We used the contrast-specific mode Contrast Tuned Imaging and the contrast medium SonoVue. A 2.4- to 4.8-mL contrast medium bolus was injected with continuous US acquisition, starting immediately after contrast injection and lasting 1 to 6 minutes.

RESULTS

Contrast extravasation was found in 20 cases (13%). These included spleen injury (n = 8), liver injury (n = 3), kidney injury (n = 1), abdominal aortic aneurysm rupture (n = 5), splenic angiosarcoma rupture (n = 1), postsurgical bleeding after abdominal aortic aneurysm repair (n = 1), and postsplenectomy bleeding (n = 1). Active extravasation appeared as a round, hyperechoic pool or as a fountain-like, hyperechoic jet.

CONCLUSION

Our retrospective clinical study shows for the first time how US can detect contrast medium extravasation, a significant indicator of active hemorrhage and of need for prompt surgical or interventional treatment.

Spleen and Retroperitoneum

This is a survey of normal variants and pathologic conditions involving the spleen and retroperitoneum. The study focuses on the various sonographic appearances of trauma, infection, and neoplasm involving these areas in an attempt to complement works dealing specifically with the pancreas, kidneys, and great vessels. Ultrasound-guided intervention (biopsy, drainage) is included.

Contrast-enhanced sonography of the spleen

OBJECTIVE

Combined use of low-mechanical-index technologies and non-air-filled contrast media allows real-time sonographic assessment of the spleen. This pictorial essay focuses on several aspects of contrast-enhanced sonography of the spleen, including examination technique, clinical indications, normal findings obtained through all vascular phases, abnormal findings (splenomegaly, infarction, abscess, benign tumors, lymphoma, metastasis, injuries, and accessory spleen), limitations, and pitfalls.

CONCLUSION

Real-time, contrast-enhanced sonography is a novel technique allowing depiction of a wide range of splenic abnormalities.