Professional Documents
Culture Documents
SECTION 6: Spleen: and Overview
SECTION 6: Spleen: and Overview
Congenital
Asplenia and Polysplenia 1-6-6
Accessory Spleen 1-6-10
Infection
Splenic Infection and Abscess 1-6-12
Vascular
Splenic Infarction 1-6-16
Trauma
Splenic Trauma 1-6-20
Neoplasm
Splenic Cyst 1-6-22
Splenic Tumors 1-6-26
Splenic Metastases and Lymphoma 1-6-30
Miscellaneous
Splenomegaly and Hypersplenism 1-6-34
SPLEEN ANATOMY AND IMAGING ISSUES
Graphic shows some of the variations in splenic shape Axial CECT shows prominent medial lobulation of the
on axial sections. spleen, a common variant.
DIFFERENTIAL DIAGNOSIS
Primary benign splenic tumors Splenic cyst - solitary or multiple
• Hemangioma • Congential cyst
• Lymphangioma • Post-traumatic cyst
• Hamartoma • Parasitic cyst (hydatid)
• Lipoma • Abscess
• (Inflammatory pseudotumor) • Metastasis
• Intrasplenic pseudocyst
Splenic tumors: Malignant - primary
• Lymphoma Multiple complex or solid masses
• Hemangiopericytoma • Lymphoma, leukemia
• Angiosarcoma • Abscesses (immunocompromised)
• Hemangioendothelioma • Candida, mycobacterial, Pneumocystis, etc.
• Angiosarcoma
Splenic tumors: Malignant - metastatic • Sarcoidosis
• Melanoma (50% of cases) • Metastases
• Breast, lung, ovary, etc. • Multiple hemangiomas or lymphangioma
Axial CECT shows a splenic cyst with a calcified wall. Surgical photograph of splenectomy specimen shows a
splenic cyst with a calcified wall.
6
5
Axial CECT in a patient with asplenia shows midline Axial CECT in patient with asplenia shows left-sided IVC
enlarged (congested) liver + right-sided stomach (arrow).
(arrow). Extensive cardiac anomalies.
Key Facts
• ASP-gastrointestinal anomalies: Situs inversus,
Terminology
imperforate anus, ectopic liver, annular pancreas,
• Abbreviations: Asplenia (ASP); polysplenia (PSP)
esophageal varices, GB agenesis, Hirschsprung
• ASP: Asplenia syndrome; lvemark syndrome; bilateral
disease, duplication/hypoplasia of stomach
right-sidedness
• PSP-gastrointestinal: Esophageal/duodenal atresia,
• PSP: Polysplenia syndromei bilateralleft-sidedness
TEF, semi annular pancreas, gastric duplication, short
Imaging Findings bowel, absent GB, biliary atresia, malrotation
• ASP: Absence of spleen, abdominal aorta & lVC on
Top Differential Diagnoses
same side (usually right) & bilateral distribution of
right-sided viscera • Splenectomy
• PSP: Multiple small splenic masses, intrahepatic • Splenosis
interruption of IVC with continuation of azygos vein, • Accessory spleens
bilateral distribution of left-sided viscera Diagnostic Checklist
• Location: PSP, right & left upper abdominal • Centrally located left lobe of liver can simulate as
quadrants spleen on US & diagnosis of ASP may be missed
• PSP: Number of spleens varies from 2-16 • Differentiate PSP from accessory spleens & splenosis
I IMAGE GALLERY
Typical
(Left) Axial NECT in patient
with polysplenia shows
absent IVe, azygous
continuation. (Right) Axial
CECTshows polysplenia and
congenital absence of all but
the head of the pancreas
(arrow).
Typical
(Left) Axial CECT in patient
with polysplenia shows situs
ambiguous, absent 1Ve,
azygous continuation.
(Right) Axial CECT in a
patient with polysplenia
shows retroaortic right renal
vein leading to azygous
continuation.
6
9
Typical
(Left) Axial CECT in patient
with polysplenia shows liver
abnormalities and azygous
continuation. (Right) Axial
CECT in patient with
polysplenia shows prior
resection of small intestine
due to volvulus and
infarction.
ACCESSORY SPLEEN
Axial CECT shows small spherical accessory spleen Axial CECT shows hypertrophied accessory spleen,
(arrow) near splenic hilum. following splenectomy.
Key Facts
Terminology Top Differential Diagnoses
• Ectopic splenic tissue of congenital origin • Metastases
• Visceral mass
Imaging Findings
• Best diagnostic clue: Small nodule with same texture Diagnostic Checklist
and enhancement of normal spleen • Accessory spleen is common, can be mistaken for
• Best imaging tool: CT followed by nuclear tumor
scintigraphy • Hypertrophic accessory spleen may occur after
splenectomy
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I CLINICAL ISSUES
Presentation
• Most common signs/symptoms: Asymptomatic (most
cases)
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• Diagnosis
o Incidentally at surgery, autopsy or imaging
o May be mistaken for tumor (Left) Axial CECT shows one (arrow) of several accessory spleens,
o Hypertrophic accessory spleen may be site of hypertrophied following splenectomy. (Right) Axial CECT shows 2 of
residual lymphoma or hypersplenism several accessory spleens (arrows), hypertrophied following
splenectomy.
SPLENIC INFECTION AND ABSCESS
Pyogenic splenic abscess on CECT. Note low Pyogenic splenic abscess on axial CECT. Note thin
attenuation abscess bulging splenic parenchyma septations within abscess (arrows),
(arrow).
ITERMINOlOGY CT Findings
Definitions • NECT
o Low attenuation ill-defined lesion within splenic
• Focal collection of liquified pus within splenic
parenchyma
parenchyma
o May rarely contain gas bubbles or air-fluid levels
• CECT: Low attenuation, nonenhancing complex fluid
collection; may extend to subcapsular location, rarely
[IMAGING FINDINGS causes splenic rupture with generalized peritonitis
General Features MR Findings
• Best diagnostic clue: Rounded low attenuation
6 complex fluid collection with mass effect
• Tl WI: Low or intermediate signal lesion
• T2WI: High signal lesion
• Location: Variable; may be located anywhere within • TI C+: Low signal lesion with peripheral enhancement
12 splenic parenchyma
• Size: Variable; typically 3-5 cm for pyogenic abscesses; Ultrasonographic Findings
microabscesses (often fungal) < 1.5 cm • Real Time
• Morphology o Typical pyogenic abscess
o Rounded or with irregular borders • Hypoechoic with internal septations, low-level
o May have multiple locules similar to hepatic "cluster echoes representing pus or debris
sign" of pyogenic abscess • May have little distal acoustic enhancement
o Mass effect on splenic capsule o Atypical pyogenic abscess
o Internal septations common • Reverberation artifacts from gas
• Echogenic
Radiographic Findings o Microabscesses
• Radiography • Target or "bull's eye" appearance similar to hepatic
o Rarely gas bubbles within abscess microabscesses
o Associated with left lower lobe atelectasis and left • Color Doppler
pleural effusion on chest x-ray o Typical pyogenic abscess shows no internal flow
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Splenic Infarct Splenic Tumor Splenic Trauma Sarcoidosis
SPLENIC INFECTION AND ABSCESS
Key Facts
Terminology • Splenic trauma
• Focal collection of liquified pus within splenic • Infiltrating disorders
parenchyma Pathology
Imaging Findings • General path comments: Liquified pus, splenomegaly
• Best diagnostic clue: Rounded low attenuation • Genetics: Hemoglobinopathies (sickle cell) predispose
complex fluid collection with mass effect Clinical Issues
• CECT: Low attenuation, non enhancing complex fluid • Percutaneous drainage for unilocular unruptured
collection; may extend to subcapsular location, rarely abscesses
causes splenic rupture with generalized peritonitis • Splenectomy for multiple pyogenic abscesses and/or
• Protocol advice: 150 ml of l.V. contrast injected at 2.5 abscess rupture
ml!sec; 5 mm slice thickness with 5 mm
reconstruction interval Diagnostic Checklist
• Infarct; necrotic or cystic mets; lymphoma
Top Differential Diagnoses
• Splenic infarct
• Splenic tumor
I SELECTED REFERENCES
1. Tasar M et al: Computed tomography-guided percutaneous
drainage of splenic abscesses. Clin Imaging. 28(1):44-8,
2004
2. Chiang IS et al: Splenic abscesses: review of 29 cases.
Kaohsiung] Med Sci. 19(10):510-5,2003
3. Kaushik R et al: Splenic abscess. Trop Doct. 32(4):246-7,
2002
4. Thanos L et al: Percutaneous CT-guided drainage of splenic
SPLENIC INFECTION AND ABSCESS
[IMAGE GAllERY
Typical
(Left) Axial CECT of fungal
microabscesses. Note
numerous hypodense
lesions; cultures grew
Candida. (Right) Axial CECT
demonstrates splenic
microabscesses. Note small
< 7 cm lesions diffusely
throughout the spleen.
Typical
(Left) Cas-forming splenic
pyogenic abscess on
transverse sonogram. Note
linear high amplitude echoes
representing gas (arrows).
(Right) Cas-forming
pyogenic splenic abscess on
transverse sonogram. Note
ring down artifacts from gas
bubbles (arrow).
6
15
Typical
(Left) Pyogenic splenic
abscess on transverse
sonogram. Note hypoechoic
abscess (arrow) with little
distal acoustic enhancement.
(Right) Multiple pyogenic
splenic abscesses on
transverse sonogram. Note
multiple hypoechoic round
lesions (arrows).
SPLENIC INFARCTION
Axial CECT of embolic splenic infarction. Note apical Axial CECT of embolic splenic infarct. Note low
thrombus in left ventricle (arrow). attenuation defect with linear margins (arrow).
ITERMINOlOGY CT Findings
• NECT: Poorly visualized without contrast
Definitions
• CECT
• Global or segmental parenchymal splenic ischemia & o Segmental: Wedge-shaped or rounded low
necrosis caused by vascular occlusion attenuation area on CECT
o Global: Complete non enhancement of spleen with
or without "cortical rim sign" on CECT
IIMAGING FINDINGS
MR Findings
General Features
• TlWI
• Best diagnostic clue: Peripheral wedge-shaped o High signal areas of hemorrhagic infarction if recent
6 non enhancing areas on CECT within splenic o Low signal if chronic
parenchyma in patient with LUQ pain • T2WI: High signal within area of infarct
16 • Location • Tl C+: Wedge-shaped area of low signal
o Variable
o Entire spleen may be infarcted or more commonly Ultrasonographic Findings
segmental areas • Real Time: Hypoechoic or anechoic wedge-shaped or
• Size rounded parenchymal defect
o Variable; global or segmental • Color Doppler: Absent flow in areas of infarction with
o Spleen mayor may not demonstrate splenomegaly color Doppler
• Morphology
o Most commonly wedge-shaped when segmental
Angiographic Findings
o Straight margins indicating vascular lesion • Conventional: Main splenic artery occlusion or
o May be rounded (atypical) segmental emboli
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Splenic Abscess Splenic Lymphoma Splenic Laceration Splenic Cyst
SPLENIC INFARCTION
Key Facts
Terminology • Splenic tumor
• Splenic laceration
• Global or segmental parenchymal splenic ischemia &
necrosis caused by vascular occlusion Pathology
Imaging Findings • Genetics: Predisposition among some hematologic
causes such as sickle cell disease, sickle cell trait
• Best diagnostic clue: Peripheral wedge-shaped
non enhancing areas on CECT within splenic Clinical Issues
parenchyma in patient with LUQ pain • LUQ pain and chills
• Segmental: Wedge-shaped or rounded low • Asymptomatic: No treatment
attenuation area on CECT • Symptomatic: Splenectomy for increasing pain or
• Global: Complete nonenhancement of spleen with or splenic rupture
without "cortical rim sign" on CECT
• Protocol advice: 150 ml of LV. contrast at 2.5 ml!sec; Diagnostic Checklist
5 mm collimation with 5 mm reconstruction interval • Consider splenic abscess or tumor
Top Differential Diagnoses
• Splenic abscess
I SELECTED REFERENCES
1. Wilkinson NW et al: Splenic infarction following
laparoscopic Nissen fundoplication: management
strategies. JSLS. 7(4):359-65, 2003
2. Sodhi KSet al: Torsion of a wandering spleen: acute
abdominal presentation. J Emerg Med. 25(2):133-7, 2003
SPLENIC INFARCTION
I IMAGE GALLERY
Typical
(Left) Global splenic
infarction on axial CECT.
Note complete lack of
enhancement of splenic
parenchyma (arrow). (Right)
Axial CECT of global splenic
infarction demonstrates
peripheral "cortical rim
sign".
Typical
(Left) Axial CECT of acute
splenic infarction
demonstrates peripheral
wedge-shaped infarct
(arrow). (Right) Axial CECT
of chronic splenic infarction
demonstrates calcification
(arrow).
6
19
Typical
(Left) Axial CECT of splenic
infarcts demonstrates
multiple peripheral
wedge-shaped emboli
(arrows). (Right) Axial CECT
demonstrates lack of
enhancement of upper pole
of spleen (arrow).
SPLENIC TRAUMA
Axial CECT of splenic fracture with active bleeding. Axial CECT of splenic fracture shows jet of active
Note area of high attenuation arterial extravasation hemorrhage in left paracolic gutter (arrow).
(arrows).
Key Facts
Terminology Pathology
• Parenchymal injury to spleen with or without • Associated abnormalities: Injuries to left thorax, tail
capsular disruption of pancreas, left liver lobe and/or mesentery
Imaging Findings Diagnostic Checklist
• Best imaging tool: CECT • Congenital cleft if no hemoperitoneum
• Protocol advice: 150 ml IV contrast @ 2.5 ml/sec with • Innocuous injury may lead to life-threatening
5 mm collimation delayed hemorrhage, especially with anticoagulation
I DIAGNOSTIC CHECKLIST
I PATHOLOGY
Consider
General Features
• Congenital cleft if no hemoperitoneum
• General path comments: Laceration, fractures or
subcapsular hematoma Image Interpretation Pearls
• Etiology: Blunt trauma with blow to LUQ • Innocuous injury may lead to life-threatening delayed
• Epidemiology: Most common abdominal organ injury hemorrhage, especially with anticoagulation
requiring surgery
• Associated abnormalities: Injuries to left thorax, tail of
pancreas, left liver lobe and/or mesentery I SELECTED REFERENCES
Gross Pathologic & Surgical Features 1. Jeffrey RBJr et al: Detection of active intraabdominal
arterial hemorrhage: value of dynamic contrast-enhanced
• Varies according to extent of injury
CT. AJR AmJ Roentgenol. 156(4):725-9, 1991 6
Microscopic Features 2. Jeffrey RBJr: CT diagnosis of blunt hepatic and splenic
injuries: a look to the future. Radiology. 171(1):17-8, 1989 21
• Necrotic injured tissue with surrounding hematoma 3. Federle MP et al: Splenic trauma: evaluation with CT.
Staging, Grading or Classification Criteria Radiology. 162(1 Pt 1):69-71, 1987
• Grading may be misleadingi minor injuries may go on
to devastating delayed bleed
o Grade 1: Subcapsular hematoma or laceration < 1 I IMAGE GALLERY
em
o Grade 2: Subcapsular hematoma or laceration 1-3
em
o Grade 3: Capsular disruptioni hematoma> 3 cmi
parenchymal hematoma> 3 em
o Grade 4A: Active parenchymal or subcapsular
bleeding, pseudoaneurysm or arteriovenous fistulai
shattered spleen
o Grade 4B: Active intraperitoneal bleed
I CLINICAL ISSUES
Presentation (Left) Axial CECT of splenic laceration with active bleeding. Note low
• Most common signs/symptoms: Blunt abdominal attenuation area of parenchymal laceration (open arrow) with
adjacent active bleeding (arrow). (Right) Axial CECT of splenic
traumai LUQ paini hypotension
fracture with active bleeding. Note non-enhancing area of splenic
Natural History & Prognosis fracture (open arrow) and high-density active bleeding (arrow).
• Prone to develop delayed hemorrhagei excellent
prognosis with early diagnosis & intervention (surgery
or embolization)
SPLENIC CYST
Axial CECT shows a water density cyst, plus calcified Axial CECT shows water density splenic cyst.
granulomas (old histoplasmosis).
Key Facts
Imaging Findings Pathology
• Best diagnostic clue: Sharply defined spherical lesion • Congenital (true) epidermoid: Genetic defect of
of water density mesothelial migration
• Location: Usually in lower pole; subcapsular (65%) • Post-traumatic: End stage of splenic hematoma
• Congenital (primary or true) cyst: Epidermoid • Pathogenesis: Liquefactive necrosis, cystic change
• Acquired (false or pseudo) cyst: Post-traumatic • Epidemiology: 7.6 per 10,000 people
• Anechoic, smooth borders, non-detectable walls ± • Congenital (true) cyst: Endothelial lining present
trabeculation (36%) congenital • Post-traumatic (false) cyst: Endothelial lining absent
• Small, anechoic or mixed with internal echoes,
echogenic wall (calcification) acquired Diagnostic Checklist
• Rule out infective, vascular & neoplastic cystic lesions
Top Differential Diagnoses • Congenital: Large, well-defined, water density with
• Inflammatory or infection thin wall & no rim or intracystic enhancement
• Vascular • Acquired (post-traumatic): Usually small, sharply
• Neoplastic defined, near water HU with thick wall ± calcification
• Intrasplenic pseudocyst • Differentiation by imaging alone is often impossible
I IMAGE GALLERY
Typical
(Left) Axial cECT shows a
splenic cyst with a calcified
capsule. (Right) Axial NECT
shows a rim-calcified splenic
cyst.
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Typical
(Left) Axial CECT in a
woman with
cardiomyopathy shows
acquired splenic cyst that
developed after prior splenic
infarctions. (Right) Axial
T2WI MR shows
hyperintense splenic cyst
JL (arrow).
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SPLENIC TUMORS
Axial CECT shows splenomegaly due to non-Hodgkin Axial CECT shows a multi-cystic mass; lymphangioma.
lymphoma.
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Cyst (+ Granulomas) Hematoma Artifact (Perfusion)
SPLENIC TUMORS
Key Facts
Imaging Findings Top Differential Diagnoses
• Best diagnostic clue: Solid or cystic, solitary or • Splenic cyst
multiple splenic masses • Splenic hematoma
• "Cystic" splenic metastases: Melanoma; • Splenic infection
adenocarcinoma of breast, ovary & endometrium • Splenic sarcoidosis
• Early peripheral & late central enhancement (not as
reliable as for liver hemangioma) Clinical Issues
• Small: Isodense or hypodense (hamartoma) • Most common signs/symptoms: LUQ pain, palpable
• Solitary mass; multifocal or diffuse infiltration mass, splenomegaly, fever, weight loss
(lymphoma) • Complications: Hemorrhage, rupture
• Solitary or multiple, nodular, irregular margins • Prognosis: Good (benign tumors); poor (malignant)
(angiosarcoma) Diagnostic Checklist
• Multiple, solid (common) or cystic, t attenuation
• Must rely on clinical setting & biopsy, if necessary
(metastases)
• Imaging findings alone are unreliable in
• Metastases: Iso-/hypo-/hyperechoic, "target"/"halo" distinguishing solid from pseudocystic splenic masses
6
29
Typical
(Left) Axial CECT in a patient
with cavernous
hemangiomas in the spleen,
liver, and body wall. (Right)
Axial CECT shows malignant
fibrous histiocytoma in the
spleen.
SPLENIC METASTASES AND LYMPHOMA
Axial CECT in June, 2003 shows splenomegaly due to Repeat Axial CECT in August, 2003 shows marked
non-Hodgkin lymphoma (NHL). reduction of splenic size following treatment for NHL.
Key Facts
Imaging Findings Pathology
• Best diagnostic clue: Solitary or multiple solid lesions • Splenic metastases: Breast (21%), lung (18%), ovary
(metastases); diffuse infiltrative lesions (lymphoma) (8%), stomach (7%), melanoma (6%), prostate (6%)
• Central or peripheral enhancement (metastases) • Hodgkin (HD) & non-Hodgkin lymphoma (NHL)
• Calcification (rare) except mucinous colon cancer • Primary lymphoma; secondary (more common)
• Solitary mass; multifocal or diffuse infiltration • Primary: Usually non-Hodgkin lymphoma (NHL)
(lymphoma) • Secondary: Extension from generalized lymphoma
• Focal lesions: AIDS-related lymphoma> common
• Splenic hilum nodes: NHL (59%); HD (uncommon) Diagnostic Checklist
• Lymphadenopathy: Abdominal or retroperitoneal • To look for primary cancer, generalized adenopathy
• Splenic lymphoma (MR nonspecific) • HD (45-66%); NHL (70%) show diffuse infiltration
making difficult to detect by US, CT & MR
Top Differential Diagnoses • Splenic size is not a reliable clinical & imaging
• Splenic primary tumor indicator of presence or absence of disease
• Splenic infection • Imaging impbrtant to suggest & stage malignancy,
• Granulomatous evaluate tumor volume/monitor response to therapy
I IMAGE GALLERY
Typical
(Left) Axial CECT shows
splenic, nodal and adrenal
masses due to NHL. (Right)
Axial CECT shows splenic
metastasis from
choriocarcinoma.
6
33
Typical
(Left) Axial CECT shows
splenic and liver metastases
from melanoma. (Right)
Axial CECTshows splenic
metastases from melanoma.
SPLENOMEGALY AND HYPERSPLENISM
Axial CECT shows heterogeneous enlargement of liver Axial CECT shows splenomegaly due to chronic
and spleen due to amyloidosis. lymphocytic leukemia.
ITERMINOLOGY • Morphology
o Enlarged spleen tends to become directed anteriorly
Abbreviations and Synonyms o Splenic tip extends below tip of right lobe of liver
• Splenomegaly (SMG); hypersplenism (HS) o Mild, moderate or marked splenomegaly
Key Facts
Terminology Top Differential Diagnoses
• Splenomegaly (SMG); hypersplenism (HS) • Other LUQ masses
• Splenomegaly: Enlarged spleen; volume> 500 cm3 • Lymphoma & metastases
• Hypersplenism: Syndrome consisting of • Primary splenic tumor
splenomegaly & pancytopenia in which bone marrow
is either normal or hyperreactive Diagnostic Checklist
• SMG, most common cause of left upper quadrant
Imaging Findings mass
• Best diagnostic clue: Increased volume of spleen with • SMG, usually a systemic cause rather than primary
convex medial border • US can confirm presence of enlarged spleen or space
• Normal spleen in adult measures up to 13 cm; occupying lesions
enlarged if it is 14 cm or longer • CT & MR can further clarify abnormalities in size,
• Splenic tip below 12th rib shape & define parenchymal pathology
• Marked SMG may displace stomach medially • Radioisotope scanning can diagnose HS & provide
• Displacement of splenic flexure of colon (splenic functional status of spleen
flexure usually anterior to spleen)
o Primary hemochromatosis
• Density of spleen is normal (unlike that of liver) Ultrasonographic Findings
o Secondary hemochromatosis • Real Time
• Increased attenuation values in liver & spleen o SMG with normal echogenicity
• Space occupying lesions: Cysts, abscess, tumor • Infection, congestion (portal HT), early sickle cell
• Splenic infarction (veno-occlusion caused by sickling) • H. spherocytosis, hemolysis, Felty syndrome
o SMG with focal infarcts; peripheral areas of low • Wilson disease, polycythemia, myelofibrosis,
attenuation & hemorrhage associated with SMG leukemia
• Hemosiderosis o SMG with hyperechoic pattern
o 1 Attenuation of spleen (hemosiderin deposition) • Leukemia, post chemo & radiation therapy
o Consequence of multiple blood transfusions • Malaria, TB, sarcoidosis, polycythemia
(thalassemia, hemophilia) • Hereditary spherocytosis, portal vein thrombosis,
• Splenic trauma hematoma, metastases
o Splenic laceration or subcapsular hematoma
o Surrounding perisplenic hematoma (> 30 HU)
o SMG with hypo echoic pattern
• Lymphoma, multiple myeloma, chronic
6
• Extramedullary hematopoiesis lymphocytic leukemia
35
o Spleen may be diffusely enlarged • Congestion from portal HT, noncaseating
o CECT: Focal masses of hematopoietic tissue that are granulomatous infection
isoattenuating relative to normal splenic tissue o Sickle cell disease: Immediately after sequestration,
peripheral hypoechoic areas seen
MR Findings o Gaucher disease: Multiple, well-defined, discrete
• Congestive SMG hypoechoic lesions; fibrosis or infarction
o Portal hypertension
• Multiple tiny (3-8 mm) foci of decreased signal Nuclear Medicine Findings
• Hemosiderin deposits; organized hemorrhage • Chromium 51-labeled RBCs or platelets
(Gamna-Gandy bodies or siderotic nodules) o HS is diagnosed if injected RBCs exhibit shortened
o Sickle cell disease (splenic sequestration) half-life (average half-life of 25-35 days)
• Areas of abnormal signal intensity • Tc99m sulfur colloid scan: Detect splenic function
• Hyperintense with dark rim on Tl WI (subacute Imaging Recommendations
hemorrhage)
• Best imaging tool: Helical CT
o Hemochromatosis
• Primary: Normal signal & size of spleen
• Secondary: Marked signal loss; enlarged spleen
o Gaucher disease: Increased signal intensity on Tl WI
I DIFFERENTIAL DIAGNOSIS
o Infarction Other lUQ masses
• Peripheral, wedge-shaped areas of abnormal signal • E.g., gastric, renal, adrenal tumor
• Low signal resulting from iron deposition
o Hemosiderosis lymphoma & metastases
• ! Signal intensity of spleen on both Tl & T2WI • Lymphoma: Various patterns of splenic involvement
o Extramedullary hematopoiesis o Homogeneous enlargement without discrete mass
• Focal hypointense nodules o Solitary or multifocallesions: Discrete! HU lesions
o Diffuse infiltration with SMG
• Metastases
SPLENOMEGALY AND HYPERSPLENISM
o I Attenuation; "cystic" or solid masses; SMG o Extramedullary hematopoiesis: Osteopetrosis,
o "Cystic" metastases: "Homogeneous & hypodense" myelofibrosis
• E.g., melanoma, ovary, breast & endometrium o Collagen disease: SLE, RA, Felty syndrome
o Splenic trauma; sarcoidosis; hemodialysis
Primary splenic tumor • Associated abnormalities: HS seen in association with
• Benign tumor hemoglobinopathies & autoimmune diseases
o Hemangioma
• Homogeneously solid or multiple cystic masses Microscopic Features
• Central punctate or peripheral curvilinear Ca++ • Varies depending on underlying etiology
• Slight hypodense on NECT & isodense on CECT
o Hamartoma
• Iso-hypodense on NECT; variable enhancement I CLINICAL ISSUES
• Central star-like scar or necrosis, focal calcification
o Lymphangioma Presentation
• Thin-walled low density lesions; sharp margins • Most common signs/symptoms
• CECT: Enhancement of walls but not contents o Asymptomatic, splenomegaly, abdominal pain
• Usually subcapsular in location; ± calcification o Signs & symptoms related to underlying cause
• Malignant tumor • Lab data: Abnormal CBC, LFT, antibody titers, cultures
o Angiosarcoma or bone marrow exam
• Solitary or multiple, nodular, irregular margins
Natural History & Prognosis
• Heterogeneous density; variable enhancement
• Enlarged spleen; ± hemorrhage & calcification • Complications
o Splenic rupture, shock & death
• ± Multiple liver or distant metastases
• HS: Usually develops as a result of SMG
• ± Hematoma: Intrasplenic/subcapsular/perisplenic
o Hyperfunctioning spleen removes normal RBC,
Splenic infection WBC & platelets from circulation
• Pyogenic (bacterial) • Prognosis
o Abscess o Splenic rupture, sequestration in SC disease: Poor
• Low density lesion with thick, irregular dense rim
Treatment
• ± Gas within fluid collection, left pleural effusion
• Treatment varies based on underlying condition
• Fungal (e.g., Candida, Aspergillus, Cryptococcus)
• Splenectomy in symptomatic & complicated cases
o Solitary/multiple; small/large; low density lesions
o May show minimal peripheral enhancement
o Candida: Microabscesses (nonenhancing lesions)
I DIAGNOSTIC CHECKLIST
6 • AIDS: Pneumocystis, mycobacterial (e.g., MAl)
o Focal low attenuation splenic lesions Consider
o Large lesions: Calcification, rim-like or punctate type
36 • SMG, most common cause of left upper quadrant mass
Granulomatous • SMG, usually a systemic cause rather than primary
• TB: Micro & macronodular lesions of low attenuation Image Interpretation Pearls
• Sarcoidosis • us can confirm presence of enlarged spleen or space
o SMG with low density intra splenic lesions
occupying lesions
o Abdominal & pelvic lymphadenopathy • CT & MR can further clarify abnormalities in size,
• Mycobacterium avium intracellulare (in AIDS patients) shape & define parenchymal pathology
o Low density splenic lesions; marked SMG • Radioisotope scanning can diagnose HS & provide
functional status of spleen
I PATHOLOGY
General Features I SELECTED REFERENCES
• Etiology 1. Peck-Radosavljevic M: Hypersplenism. Em J Gastroenterol
o Congestive SMG Hepatol. 13(4):317-23,2001
• CHF, portal HT, cirrhosis, cystic fibrosis, splenic 2. McCormick PA et al: Splenomegaly, hypersplenism and
coagulation abnormalities in liver disease. Clin
vein thrombosis, sickle cell (SC) sequestration
Gastroenterol. 14(6):1009-31,2000
o Neoplasm: Leukemia, lymphoma, metastases, 3. Paterson A et al: A pattern-oriented approach to splenic
primary neoplasm, Kaposi sarcoma imaging in infants and children. Radiographies.
o Storage disease: Gaucher, Niemann-Pick, gargoylism, 19(6):1465-85, 1999
amyloidosis, DM, hemochromatosis, histiocytosis 4. Bowdler AJ: Splenomegaly and hypersplenism. Clin
o Infection: Hepatitis, malaria, mononucleosis, TB, Haematol. 12(2):467-88, 1983
typhoid, kala-azar, schistosomiasis, brucellosis 5. Mittelstaedt CA et al: Ultrasonic-pathologic classification of
o Hemolytic anemia: Hemoglobinopathy, hereditary splenic abnormalities: gray-scale patterns. Radiology.
134(3):697-705, 1980
spherocytosis, primary neutropenia,
thrombocytopenic purpura
SPLENOMEGALY AND HYPERSPLENISM
I IMAGE GALLERY
Typical
(Left) Axial CECT shows
acquired splenic cyst
following infarct (cardiac
assist device). (Right) Axial
NECT shows splenomegaly
due to myeloproliferative
disorder.
Typical
(Left) Axial CECT in June,
2003 shows splenomegaly
due to non-Hodgkin
lymphoma. (Right) Axial
CECT in August, 2003 shows
marked reduction in splenic
size following treatment for
lymphoma.
6
37
Typical
(Left) Axial CECT shows
spontaneous rupture of
spleen due to leukemia.
(Right) Axial CECT shows
splenomegaly due to
cirrhosis and portal
hypertension.