Role of contrast-enhanced ultrasound (CEUS) in the diagnosis and management of traumatic splenic injuries

Abstract

Splenic injuries are common emergencies in the setting of abdominal trauma, as the spleen is the second most frequently injured abdominal organ after the liver. The treatment of splenic injuries underwent a severe shift from operative to nonoperative due to an increased awareness of the double physiological function, both immunological and hematological, of the spleen. This, in turn, led to an increased application of splenic preservation techniques. The non-operative approach has been strengthened through radiological imaging and interventional radiology. While multidetector computed tomography is mandatory in the evaluation of hemodynamically stable patients after high-energy trauma, one ultrasound (US) can be used as a first-line technique to examine patients in cases of low-energy trauma. Unfortunately, baseline US has low sensitivity in the detection of traumatic injuries. With the introduction of contrast-enhanced ultrasound (CEUS) as a reliable alternative to baseline ultrasound for low-grade abdominal trauma, the sensitivity of the US technique in recognizing traumatic abdominal lesions has strongly increased, reaching levels of accuracy similar to those of the CT. It has also been strongly recommended for use with children, as it allows for the performance of imaging techniques with the lowest dose of radiation possible. In this review, the authors aim to present the typical appearance of traumatic splenic injuries, using enhanced CEUS capability to overcome baseline US limits, and to describe the different techniques applied according to the hemodynamic stability of the patient. Keywords Trauma • Trauma imaging • Traumatic splenic injuries • Splenic trauma • Blunt abdominal trauma • BAT • Contrast-enhanced ultrasound • CEUS • Multidetector computed tomography • MDCT • Non-operative management Sommario La milza è il secondo organo più comunemente sede di trauma nel contesto dei traumi chiusi dell'addome. Nel corso degli ultimi decenni il trattamento dei traumi splenici ha subito un rapido shift verso un approccio sempre meno aggressivo. Il razionale alla base di questo trend sta nel duplice ruolo svolto da quest'organo dal punto di vista fisiologico, sia immunologico che ematologico, che ha portato allo sviluppo di manovre terapeutiche sempre più conservative. Questo approccio nonoperativo è stato fortemente sostenuto dalle nuove metodiche di imaging e dal rapido evolversi delle tecniche di radiologia interventistica. Dal punto di vista dell'imaging, mentre la TC Multidetector è mandatoria nella valutazione del paziente che ha subito un trauma ad elevata energia e stabile emodinamicamente, nei traumi a bassa energia l'ecografia può essere utilizzata come metodica di primo approccio. Sfortunatamente essa è caratterizzata da una bassa sensibilità nell' individuazione delle lesioni traumatiche a carico degli organi addominali. Con l'introduzione dell'ecografia con mezzo di contrasto (CEUS) come alternativa alla sola ecografia nella valutazione dei traumi a bassa energia, la sensibilità di tale metodica è no...

A rare case of accessory spleen torsion in a child diagnosed by ultrasound (US) and contrast-enhanced ultrasound (CEUS)

“…Currently in Europe, CEUS in children is mostly "off-label" use, as many drugs, which are used off-label in pediatric patients; nowadays its use for the evaluation of vesico-ureteral reflux is accepted in Europe [11 -13]. However, its use, and its safety, have now been proven by numerous studies [14][15][16]; it has been proven that with the CEUS we can perform accurate diagnostic exam, in many cases, especially in pediatric patients, also comparable and sometimes superior to the performance of computed tomography (CT) and magnetic resonance imaging (MRI) [17][18][19][20][21]. CT and MRI, however, can provide different information: MRI is superior to US in identifying hemorrhagic areas in the infarcted spleen, while CT is better in demonstrating the twisting of the vascular pedicle.…”

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

“…CEUS application in children is currently still "off-label" except for a few indications including vesico-uereteral reflux, but it could be a very useful method in the non-ionizing imaging of young patients [6,[13][14][15][16][17]. Today, in the emergency setting, CEUS is used predominantly in the study of blunt or penetrating traumatic lesions, especially for the diagnosis and follow-up of the solid parenchymal organ (socalled "non-operative management") [8,[18][19][20][21][22]. Often CEUS is used after a baseline US examination, in an attempt to avoid radiation exposure a computed tomography (CT) examination, especially in hemodynamically stable minor trauma.…”

“…Furthermore, these contrast agents have a short half-life, are excreted rapidly from the lungs, and are very well tolerated. In fact, they can be injected into patients with renal insufficiency, hypotension, shock, without further preliminary laboratory tests, and are also indicated in critical patients 4 5 8 . CEUS contrast media are safe with a very low incidence of side effects.…”

“…Today, in the emergency setting, CEUS is used predominantly in the study of blunt or penetrating traumatic lesions, especially for the diagnosis and follow-up of the solid parenchymal organ (so-called “non-operative management”) 8 18 19 20 21 22 . Often CEUS is used after a baseline US examination, in an attempt to avoid radiation exposure a computed tomography (CT) examination, especially in hemodynamically stable minor trauma.…”

“…Often CEUS is used after a baseline US examination, in an attempt to avoid radiation exposure a computed tomography (CT) examination, especially in hemodynamically stable minor trauma. Furthermore, CEUS is a valid method that can help the radiologist make rapid decisions in case of an unstable major trauma that cannot be moved to the radiology emergency department and needs immediate surgical treatment 8 19 20 23 24 .…”