Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS)

Abstract

BackgroundPseudoaneurysm (PA) formation following blunt and penetrating abdominal trauma is a recognized complication in solid organ injury, usually diagnosed by contrast-enhanced CT (CECT) imaging. Delayed rupture is a potentially life-threatening event, although its frequency is not known in pediatric trauma. Contrast enhanced ultrasound (CEUS) is a novel radiation-free alternative to CECT with the potential to identify PA. MethodsA retrospective review of consecutive cases of significant liver and splenic injuries admitted to single institution (tertiary and quaternary referrals) over more than a 12year period was performed. From 2011, CEUS was performed routinely postinjury (5–10days) using SonoVue™ as contrast. Initially, CECT and CEUS were performed in tandem to ensure accurate correlation. ResultsFrom January 2002–December 2014, 101 (73M) children [median age was 14.2 (1.3–18)years] with liver and splenic injuries were admitted. Injuries included: liver [n=57, grade 3 (1–5)], splenic [n=35, grade 3 (1–5)], and combined liver/spleen [n=8, (1–4)]. Median Injury Severity Score (ISS) was 13 (2–72). The predominant mechanisms of injury were blunt trauma n=73 (72%) and penetrating trauma n=28 (28%). Seventeen children (17%) developed PA. Six children became symptomatic (35%), and five went on to have embolization [at 7 (3–11)days]. These were detected by CECT (n=4) and CEUS (n=2). Eleven children remained asymptomatic [detected by CECT (n=8) and CEUS (n=3) at median 5 (4–8)days]. One underwent embolization owing to evidence of interval bleeding.Sensitivity of CEUS at detection of PA was 83%, with specificity of 92% (PPV=71%, NPV=96%). There was no association between grade of injury and presence of PA in either liver or splenic trauma (P=0.4), nor was there an association between size of PA and symptoms (P=0.68). Children sustaining splenic PA were significantly younger than those with hepatic PA (P=0.03). Follow-up imaging confirmed resolution of PA in 16 cases. One child was lost to follow-up. ConclusionsThe incidence of PA is higher than previously reported in the pediatric literature (<5%). Postinjury imaging appears mandatory, and CEUS appears to be highly sensitive and specific for diagnosis and follow-up.