American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings

Prophylactic embolization versus observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis

OBJECTIVE

The objective of this systematic review was to compare the effectiveness of prophylactic angioembolization with observation as primary management strategies for patients with high-grade (grades 3-5) blunt trauma splenic injury.

INTRODUCTION

The spleen is frequently injured in abdominal trauma. Historical management practices involved splenectomy, but more recent evidence suggests an increased risk of severe infections and sepsis associated with this approach. Accordingly, non-operative management strategies, including prophylactic splenic artery embolization and clinical observation, have gained prominence. This systematic review with meta-analysis directly compares angioembolization with clinical observation for high-grade splenic injuries only, aiming to provide clarity on this matter amid ongoing debates and variations in clinical practice.

INCLUSION CRITERIA

This review included adult patients aged 15 years or older with high-grade splenic injuries (grade 3-5) due to blunt trauma. Outcomes of interest include the need for further intervention (failure of management), mortality, complications, red blood cell transfusion requirements, hospital length of stay, and intensive care unit length of stay.

METHODS

A comprehensive search of PubMed, Embase, and CINAHL (EBSCOhost), was performed with no restrictions on language or publication date. Gray literature was searched, including trial registries and relevant conference proceedings. After deduplication, 2 reviewers independently assessed titles and abstracts, and, subsequently, full-text articles for eligibility. Methodological quality of the included studies was assessed using standardized instruments from JBI. Data was extracted using predefined templates, and statistical meta-analysis was performed, where possible, using a random effects model. Heterogeneity was assessed using statistical methods, and potential publication bias was tested with a funnel plot. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

RESULTS

Sixteen studies were included in this review. Methodological quality assessment indicated some risk of bias in most studies, with concerns primarily related to differences in injury severity and potential confounding factors. Meta-analysis revealed that prophylactic angioembolization significantly reduced risk of management failure by 57% (OR 0.43, 95% CI 0.28-0.68, I2=53%, 15 studies) and decreased patient mortality by 37% (OR 0.63, 95% CI 0.43-0.93, I2=0%, 9 studies) compared with clinical observation alone. There was a 47% reduction in risk of complications associated with prophylactic embolization compared with clinical observation (OR 0.53, 95% CI 0.29-0.95, I2=0%, 4 studies). Some statistical heterogeneity was observed, with I2 ranging from 0% to 53%. No significant differences were observed between the 2 management strategies for red blood cell transfusion requirements and hospital length of stay.

CONCLUSIONS

The results of this study support the use of prophylactic embolization for high-grade blunt trauma splenic injuries, indicated by lower failure of management rates, reduced need for additional interventions, lower mortality, and fewer complications.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Value of interventional radiology and their contributions to modern medical systems

Interventional radiology (IR) is a unique specialty that incorporates a diverse set of skills ranging from imaging, procedures, consultation, and patient management. Understanding how IR generates value to the healthcare system is important to review from various perspectives. IR specialists need to understand how to meet demands from various stakeholders to expand their practice improving patient care. Thus, this review discusses the domains of value contributed to medical systems and outlines the parameters of success. IR benefits five distinct parties: patients, practitioners, payers, employers, and innovators. Value to patients and providers is delivered through a wide set of diagnostic and therapeutic interventions. Payers and hospital systems financially benefit from the reduced cost in medical management secondary to fast patient recovery, outpatient procedures, fewer complications, and the prestige of offering diverse expertise for complex patients. Lastly, IR is a field of rapid innovation implementing new procedural technology and techniques. Overall, IR must actively advocate for further growth and influence in the medical field as their value continues to expand in multiple domains. Despite being a nascent specialty, IR has become indispensable to modern medical practice.

Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans

Computed tomography (CT) is the most commonly used diagnostic modality for blunt abdominal trauma (BAT), significantly influencing management approaches. Deep learning models (DLMs) have shown great promise in enhancing various aspects of clinical practice. There is limited literature available on the use of DLMs specifically for trauma image evaluation. In this study, we developed a DLM aimed at detecting solid organ injuries to assist medical professionals in rapidly identifying life-threatening injuries. The study enrolled patients from a single trauma center who received abdominal CT scans between 2008 and 2017. Patients with spleen, liver, or kidney injury were categorized as the solid organ injury group, while others were considered negative cases. Only images acquired from the trauma center were enrolled. A subset of images acquired in the last year was designated as the test set, and the remaining images were utilized to train and validate the detection models. The performance of each model was assessed using metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value based on the best Youden index operating point. The study developed the models using 1302 (87%) scans for training and tested them on 194 (13%) scans. The spleen injury model demonstrated an accuracy of 0.938 and a specificity of 0.952. The accuracy and specificity of the liver injury model were reported as 0.820 and 0.847, respectively. The kidney injury model showed an accuracy of 0.959 and a specificity of 0.989. We developed a DLM that can automate the detection of solid organ injuries by abdominal CT scans with acceptable diagnostic accuracy. It cannot replace the role of clinicians, but we can expect it to be a potential tool to accelerate the process of therapeutic decisions for trauma care.

The prevalence of early contained vascular injury of spleen

Contained vascular injuries (CVI) of spleen include pseudoaneurysms (PSA) and arterio-venous fistulae (AV-fistulae), and their reported prevalence varies. Our purpose was to assess the prevalence of early splenic CVI seen on admission CT in patients with splenic trauma admitted to a single level 1 trauma center in 2013-2021, and its detection in different CT protocols. A retrospective, single-center longitudinal cohort study. Nine-year data (2013-2021) of all patients with suspected or manifest abdominal trauma were retrieved. All patients, > 15 years with an ICD code for splenic trauma (S36.0XX) were included. CT and angiographic examinations were identified. Reports and images were reviewed. Splenic CVI CT criterion was a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Number of CVIs and treatment was based on medical records and/or available angioembolization data. Of 2805 patients with abdominal trauma, 313 patients (313/2805; 11.2%) fulfilled the study entry criteria. 256 patients (256/313; 81.8%) had a CT examination. Sixteen patients had splenectomy before CT, and the final study group included 240 patients (240/313; 76.7%). Median New Injury Severity Score (NISS) was 27 and 87.5% of patients had NISS > 15. Splenic CVI was found in 20 patients, which yields a prevalence of 8.3% (20/240; 95% CI 5.2-12.6%). In those cases with both late arterial and venous phase images available, CVI was seen in 14.5% of cases (18/124, 95% CI 8.6-22.0%). None of the patients with CVI died within 30 days of the injury. The prevalence of early splenic CVI in patients with a splenic trauma was 8.3-14.5% (95% CI 5.2-22.0%). Our data suggests that both arterial and venous phase are needed for CT diagnosis. The 30-day outcome in terms of mortality was good.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis

BACKGROUND

This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE.

METHODS

Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared.

RESULTS

A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001).

CONCLUSION

Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Splenic trauma in the Northern Territory; the impact of an interventional radiology service on splenic trauma management and outcomes

Background

The spleen is the most commonly injured organ in abdominal trauma. Guidelines suggest non-operative management (NOM) is preferred over splenectomy for all haemodynamically stable patients, regardless of injury severity. The availability of splenic angioembolization has been shown to improve outcomes for high-grade splenic injuries by decreasing failure rates of NOM. Trauma incidence and fatality rates are higher in regional and remote areas, and rurality is associated with increased mortality from trauma. Additionally, rural hospitals have difficulty with staff retention and may offer less specialist services compared with urban centres.

Methods

A single-centre retrospective cohort study was conducted at the Royal Darwin Hospital, using the National Critical Care and Trauma Response Centre database. All patients with splenic injury admitted between January 2018 and December 2021 were selected, and divided into control and intervention cohorts, before and after January 1, 2020, correlating with interventional radiology availability. Demographic information included age, gender, mechanism of injury, AIS grade of splenic injury, injury severity score, and shock index. The primary outcome was management of splenic injury and failure rate of NOM. Secondary outcomes included mortality, ICU length of stay and hospital length of stay.

Results

Sixty-six patients met inclusion criteria, 32 controls and 34 interventions. Intervention and control groups were statistically similar for baseline demographics, and outcome measures of mortality and ICU length of stay. There was significant difference in the management of splenic injury, either OM or NOM, between intervention and control cohorts among high-grade splenic injury patients (AIS grade 4 and 5). In logistic regression analysis, the absence of interventional radiology was associated with increased OM (OR 12.8, SE 15.7, p = 0.04, 95%CI 1.15-142).

Conclusion

The absence of an interventional radiology service was associated with an increased risk of operative management, suggesting interventional radiology helps to prevent splenectomy, improving long term outcomes for splenic trauma patients in regional settings. The effects of availability of IR seen in international publications on decreased mortality and shorter length of stay were not replicated in this study.

Non-Operative Management of Polytraumatized Patients: Body Imaging beyond CT

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

Management of Intra-abdominal Traumatic Injury

Traumatic injuries occur from unintentional and intentional violent events, claiming an estimated 4.4 million lives annually (World Health Organization). Abdominal trauma is a common condition seen in many trauma centers accounting for roughly 15% of all trauma-related hospitalizations (Boutros and colleagues 35) and is associated with significant morbidity and mortality. Following the concepts of Damage Control Resuscitation can reduce mortality drastically. Ultrasound, computed tomography scans, and routine physical examinations are used to make prompt diagnoses, trend injuries, and recognize deterioration of clinical status. Clear, effective, and closed-loop communication is essential to provide quality care.

Toward automated interpretable AAST grading for blunt splenic injury

BACKGROUND

The American Association for the Surgery of Trauma (AAST) splenic organ injury scale (OIS) is the most frequently used CT-based grading system for blunt splenic trauma. However, reported inter-rater agreement is modest, and an algorithm that objectively automates grading based on transparent and verifiable criteria could serve as a high-trust diagnostic aid.

PURPOSE

To pilot the development of an automated interpretable multi-stage deep learning-based system to predict AAST grade from admission trauma CT.

METHODS

Our pipeline includes 4 parts: (1) automated splenic localization, (2) Faster R-CNN-based detection of pseudoaneurysms (PSA) and active bleeds (AB), (3) nnU-Net segmentation and quantification of splenic parenchymal disruption (SPD), and (4) a directed graph that infers AAST grades from detection and segmentation results. Training and validation is performed on a dataset of adult patients (age ≥ 18) with voxelwise labeling, consensus AAST grading, and hemorrhage-related outcome data (n = 174).

RESULTS

AAST classification agreement (weighted κ) between automated and consensus AAST grades was substantial (0.79). High-grade (IV and V) injuries were predicted with accuracy, positive predictive value, and negative predictive value of 92%, 95%, and 89%. The area under the curve for predicting hemorrhage control intervention was comparable between expert consensus and automated AAST grading (0.83 vs 0.88). The mean combined inference time for the pipeline was 96.9 s.

CONCLUSIONS

The results of our method were rapid and verifiable, with high agreement between automated and expert consensus grades. Diagnosis of high-grade lesions and prediction of hemorrhage control intervention produced accurate results in adult patients.

Splenic Artery Embolization in Conservative Management of Blunt Splenic Injury Graded by 2018 AAST-OIS: Results from a Hospital in Vietnam

Purpose

This study was conducted to evaluate the results of conservative management of blunt splenic trauma according to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) in 2018 by embolization.

Methods

This observational study included 50 patients (42 men and 8 women) with splenic injury who underwent multidetector computed tomography (MDCT) and embolization.

Results

According to the 2018 AAST-OIS, 27 cases had higher grades than they did according to the 1994 AAST-OIS. The grades of two cases of grade II increased to grade IV; those of 15 cases of grade III increased to grade IV; and four cases of grade IV increased to grade V. As a result, all patients underwent successful splenic embolization and were stable at discharge. No patients required re-embolization or conversion to splenectomy. The mean hospital stay was 11.8±7 days (range, 6-44 days), with no difference in length of hospital stay among grades of splenic injury (p >0.05).

Conclusion

Compared with the AAST-OIS 1994, the AAST-OIS 2018 classification is useful in making embolization decisions, regardless of the degree of blunt splenic injury with vascular lacerations visible on MDCT.

Variation in the utilization of angioembolization for splenic injury in hospitals: a nationwide cross-sectional study in Japan

Aim

Substantial variations in the utilization of angioembolization have been reported internationally. However, the existence of variations in the utilization of angioembolization in Japan is currently unknown.

Methods

This was a cross-sectional study using data from a nationwide trauma registry in Japan. Of the 4,896 registered adult patients with splenic injury, we investigated 3,319 patients in the top 25% of the hospitals that registered the highest number of splenic injury patients in the Japan Trauma Data Bank. The primary outcome of this study was initial angioembolization. We calculated the expected initial angioembolization rates using multiple regression analysis adjusted for patient factors. In addition, we evaluated the range of observed-to-expected initial splenic angioembolization ratio for each hospital. Moreover, we assessed whether this ratio was increased with time.

Results

The frequency of initial splenic angioembolization ranged from 0% to 52%. The median expected initial angioembolization rate, calculated through multiple logistic regression analysis, was 19.7%. The observed-to-expected initial splenic angioembolization ratio for each hospital ranged from 0 to 2.36. The observed initial angioembolization rate tended to increase with time (P < 0.001).

Conclusions

Despite adjustment for patient factors, substantial variations were observed in the utilization of splenic angioembolization among hospitals in Japan.

Interventional Radiology Workforce Shortages Affecting Small and Rural Practices: A Report of the SIR/ACR Joint Task Force on Recruitment and Retention of Interventional Radiologists to Small and Rural Practices

Radiology practices characterized as small and rural are challenged to recruit and retain interventional radiologists. Lack of access to interventional radiologic services results in a failure to meet the needs of patients, hospitals, and other community stakeholders. Acknowledging this challenge, the ACR's Commission on General, Small, Emergency and/or Rural Practice and Commission on Interventional and Cardiovascular Imaging and the Society of Interventional Radiology partnered to establish a joint task force to study this issue and identify strategies the ACR and the Society of Interventional Radiology should take to improve small and rural practice recruitment and retention of interventional radiologists. This report describes the deliberations and recommendations of the task force.

Single Center Retrospective Review of Post-laparotomy CT Abdomen and Pelvis Findings and Trends

Purpose

To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time.

Methods

Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in management were also recorded.

Results

In total 1,047 patients underwent exploratory laparotomy initially at our institution between 1/2006-2/2019. Of those, only 96 had a diagnostic CT of the abdomen and pelvis within 24 h after initial surgery, first occurring in 2010. Among these 96, there were 71 blunt and 25 penetrating injuries. Most common injuries recognized during exploratory laparotomy were bowel/mesentery (55), spleen (34), and liver (26). Regarding CT findings, all patients (96/96, 100%) had residual pneumoperitoneum, 84/96 (87.5%) had residual hemoperitoneum, 36/96 (37.5%) noted post-surgical changes or additional injuries to the spleen, 36/96 (37.5%) to the bowel/mesentery, and 32/96 (33.3%) to the liver, and 34/96 (35.4%) were noted to have pelvic fractures. After CT, 31/96 (32.3%) went back to the OR for relook laparotomy and additional surgical intervention and 7/96 (7.3%) went to IR for embolization. Most common procedures during relaparotomy involved the bowel (8) and solid organs (6).

Conclusions

CT examination within 24 h post damage control laparotomy was exceedingly rare at our institution prior to 2012 but has steadily increased. Frequency now averages 20.5% yearly. Damage control laparotomy is an uncommon clinical scenario; however, knowledge of frequent injuries and common post-operative changes will aid in radiologist detection of additional injuries helping shape next step management and provide adequate therapy.