Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study

Laura Harmon; Ronald Bilow; Kathirkama Shanmuganathan; Margret Lauerman; S Rob Todd; Justin Cardenas; Christine E Haugen; Roxie Albrecht; Stephen Pittman; Mitchell Cohen; Krista Kaups; Rachel Dirks; Clay Cothren Burlew; Charles J Fox; Jorge Con; Kenji Inaba; Paul B Harrison; Gina M Berg; Christine J Waller; Kara J Kallies; Rosemary Ann Kozar

doi:10.1016/j.amjsurg.2019.06.025

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study

Am J Surg. 2019 Sep;218(3):579-583. doi: 10.1016/j.amjsurg.2019.06.025. Epub 2019 Jul 2.

Authors

Laura Harmon¹, Ronald Bilow², Kathirkama Shanmuganathan³, Margret Lauerman⁴, S Rob Todd⁵, Justin Cardenas⁶, Christine E Haugen⁷, Roxie Albrecht⁸, Stephen Pittman⁹, Mitchell Cohen¹⁰, Krista Kaups¹¹, Rachel Dirks¹², Clay Cothren Burlew¹³, Charles J Fox¹⁴, Jorge Con¹⁵, Kenji Inaba¹⁶, Paul B Harrison¹⁷, Gina M Berg¹⁸, Christine J Waller¹⁹, Kara J Kallies²⁰, Rosemary Ann Kozar²¹

Affiliations

¹ Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA. Electronic address: [email protected].
² Department of Radiology, UTHealth McGovern Medical School, Houston, TX, USA. Electronic address: [email protected].
³ Shock Trauma and Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: [email protected].
⁴ Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA. Electronic address: [email protected].
⁵ Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: [email protected].
⁶ Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: [email protected].
⁷ Department of Surgery, John Hopkins University, Baltimore, MD, USA. Electronic address: [email protected].
⁸ Oklahoma University, Oklahoma City, OK, USA. Electronic address: [email protected].
⁹ Oklahoma University, Oklahoma City, OK, USA. Electronic address: [email protected].
¹⁰ University of Colorado, Denver Health Medical Center, Denver CO, USA. Electronic address: [email protected].
¹¹ Department of Surgery, UCSF Fresno, CA, USA. Electronic address: [email protected].
¹² Department of Surgery, UCSF Fresno, CA, USA. Electronic address: [email protected].
¹³ University of Colorado, Denver Health Medical Center, Denver CO, USA. Electronic address: [email protected].
¹⁴ University of Colorado, Denver Health Medical Center, Denver CO, USA. Electronic address: [email protected].
¹⁵ Department of Surgery, New York Medical College-Westchester, Valhalla, NY, USA. Electronic address: [email protected].
¹⁶ University of Southern California, Los Angeles County, Los Angeles, CA, USA. Electronic address: [email protected].
¹⁷ Wesley Medical Center Trauma Services, Wichita, KS, USA. Electronic address: [email protected].
¹⁸ Wesley Medical Center Trauma Services, Wichita, KS, USA. Electronic address: [email protected].
¹⁹ Gundersen Health System, La Crosse, WI, USA. Electronic address: [email protected].
²⁰ Gundersen Health System, La Crosse, WI, USA. Electronic address: [email protected].
²¹ Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA. Electronic address: [email protected].

PMID: 31284948
DOI: 10.1016/j.amjsurg.2019.06.025

Abstract

Background: Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques.

Methods: Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected.

Results: Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques.

Conclusion: This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

Keywords: And imaging; CT scanning; Delayed bleeds; Spleen; Splenectomy; Splenic angioembolization; Splenic hemorrhage.

Publication types

Multicenter Study

MeSH terms

Adolescent
Adult
Aged
Female
Hemorrhage / epidemiology
Hemorrhage / etiology*
Humans
Incidence
Male
Middle Aged
Retrospective Studies
Spleen / diagnostic imaging*
Spleen / injuries*
Time Factors
Tomography, X-Ray Computed*
Young Adult