By Heather J. Wichman, MD, and Venkataramu Krishnamurthy, MBBS

History

A 75-year-old man presented to our emergency department with a complicated medical history, including atrial fibrillation, congestive heart failure, and chronic pancreatitis. His chief complaint was shortness of breath and dizziness. Initial laboratory findings were significant for a low hemoglobin level (7.5 mg/dL).

A review of his outside medical records indicated that, three months prior to this visit, he was found to have a hemoglobin level of 6.4 mg/dL and a left hemothorax. The hemothorax was attributed to spontaneous bleeding due to supratherapeutic anticoagulation from warfarin therapy for atrial fibrillation.

Findings

Due to the history of supratherapeutic anticoagulation and anemia, a noncontrast abdomenal/pelvic CT was performed. The scan revealed a perisplenic hematoma and round low-density lesion contiguous with the upper pole of the spleen (Figure A).

An ultrasound exam then was performed to determine the cystic or solid characteristics of the splenic lesion. A 4.6- X 3.9-cm anechoic lesion with two jets of arterial flow within it was found on color Doppler imaging, corresponding to the low-density CT lesion (Figure B).

Diagnosis

Intraparenchymal pseudoaneurysm

Treatment

The patient was taken to the interventional radiology suite for transarterial coil embolization. The initial arteriogram was performed using carbon dioxide as the contrast agent. The intraparenchymal pseudoaneurysm was clearly demonstrated with small feeding arteries from proximal hilar branches (Figure C). Selective coil embolization of the feeding upper pole artery branch was performed. The angiogram done using iodinated contrast demonstrated complete occlusion of the pseudoaneurysm (Figure D).

Discussion

Trauma is the most common cause of splenic rupture. Nontraumatic or spontaneous splenic rupture is rare and most commonly related to massive splenomegaly or anticoagulant/thrombolytic therapy.1,2 Anticoagulant or thrombolytic therapy causing splenic rupture carries a 24% mortality rate.3 A rare cause of splenic rupture is acute or chronic pancreatitis.1

Splenic intraparenchymal pseudoaneurysm is a complication of spontaneous splenic rupture.4,5 Intraparenchymal pseudoaneurysm occurs in 12% of patients with sonographically detected spontaneous splenic rupture.6

Traumatic or spontaneous rupture is treated with various methods, including splenectomy, transcatheter embolization, or conservative management.5,7 Increasing success rates have shifted endovascular treatment as first line therapy for splenic injury to conserve splenic function.

— Heather J. Wichman, MD, is a radiologist in Denver, Iowa.