Contrast blush is always a concern when seen on CT of the abdomen for trauma. It can represent one of two things, and both are bad:
Active extravasation of contrast
These two clinical issues can be distinguished by looking at the location of the contrast and its persistence. A pseudoaneurysm is located within the parenchyma, and the contrast will wash away, so it will not be visible on delayed images. Contrast that extends beyond the parenchyma or persists in delayed views represents active bleeding. In either case, the failure rate of nonoperative management exceeds 80% in adults without additional measures being taken.
Clinically, these patients usually act as if they are losing volume and require additional crystalloid and/or blood transfusion. The natural history in adults is for bleeding to continue or for the pseudoaneurysm to rupture, resulting in a quick trip to the operating room.
If vital signs can be maintained with fluids and blood, a trip to interventional radiology may solve the problem. Selective or nonselective embolization can be carried out and patients with only a few bleeding points can be spared operation. However, if multiple bleeding areas are seen, it is probably better to head to the OR for splenorrhaphy or splenectomy.
The image below shows likely areas of extravasation. They are a bit large to be pseudoaneurysms.
Children are different than adults. Extravasation from spleen injuries in prepubescent children frequently stops on its own. Angiography should only be used if the child is failing nonoperative management.
Spleen injury grading is not as complicated as people think! The grading system ranges from Grade I (very minor) to Grade V (shattered, devascularized).
There is one nuance that people frequently don’t appreciate: multiple injuries can increase the grade. Technically, multiple injuries advance the maximum grade by one point, up to a maximum of Grade 3. So Grade 1 + Grade 1 = Grade 2, but Grades 2+2 = 3! Weird arithmetic!
The vast majority of injuries are Grades 1 to 3, and they are actually the easiest to grade. I use this simple rule: 1 and 3, 10 and 50.
The first set of numbers indicates the depth of a laceration in centimeters.
Grade 1 – < 1 cm laceration depth
Grade 2 – 1-3 cm laceration depth
Grade 3 – >3 cm laceration depth
The second set of numbers refers to size of a subcapsular hematoma in percent of the total surface area of the spleen. Hint: most of these low grades are determined by laceration depth. Very few actually have sizable subcapsular hematomas. So memorize the 1-3 rule first!
Grade 1 – <10% subcapsular hematoma
Grade 2 – 10-50% subcapsular hematoma
Grade 3 – >50% subcapsular hematoma
Grades 4 and 5 use other criteria, but in general if it looks completely pulped it’s a 5, and if it’s a little less pulped, it’s a 4.
Grade 4 – hilar injury with >25% devascularization OR contrast blush (active bleeding)
Grade 5 – shattered spleen, or nearly complete devascularization
That’s it! Tomorrow I’ll talk about the real significance of the contrast blush.
This week I’ll be covering spleen injuries. The answer to the question “What is wrong with this spleen” is: 1. There is a spleen laceration (grade cannot be determined from this one slice) and 2. There is a contrast blush.
Today I’ll cover grading and tomorrow I’ll talk about the significance of blushes.
A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.
This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!
Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!
Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.
The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).
Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.
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