SECTION 6: Spleen

Introduction and Overview

Spleen Anatomy and Imaging Issues 1-6-2

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.

• Splenic red pulp

I IMAGING ANATOMY o Comprises the vascular tissue of the spleen
location • Splenic cords (plates of cells) lie between
• Usually left upper quadrant sinusoidsi red pulp veins drain sinuses
• Intraperitoneal o Most common source of primary
• Supported by gastrosplenic and splenorenalligaments nonhematolymphoid tumors
o Mottled enhancement, typical of early phase
Anatomic Relationships enhanced CT or MR is due to variable flow rates
• Diaphragm through cords and sinuses of red pulp
o Supero-Iaterally • Can simulate or hide splenic pathology on arterial
• Left kidney phase imaging
6 o Posterio-medially • Splenic white pulp
• Pancreas o Comprises the lymphatic tissues, organized similar
2 o Medially to lymph nodes
• Stomach o Gives rise to lymphatic tumors
o Anterio-medially • Most common splenic tumor, lymphoma
• Tail of pancreas inserts into spleno-renalligament • Frequently has notches and indentations on surface
o Pancreatic tail becomes intraperitoneal o On axial CT/MR sections may simulate laceration
o Pancreatitis involving tail can spread directly to the o Key differential feature is absence of perisplenic
spleen, lead to intra splenic pseudocyst hemorrhage
Key Concepts or Questions
I ANATOMY-BASED IMAGING ISSUES I • MR appearance of spleen
o Spleen has relatively long T1 and T2 relaxation
Normal Measurements times
• Size can vary widely among individuals o Appears dark relative to liver on T1 WI
oRange 100 to 250 cm3 , mean ISO cm3 in adults • Similar to renal cortex
• Size varies even in one person • Becomes abnormally dark with iron deposition
o Age, state of nutrition, body habitus, blood volume (transfusion hemochromatosis)
o Average about 12 cm length, 7 cm breadth by 4 cm o Liver metastases often similar in signal to normal
width spleen
o Length x width x breath should not exceed 470 cm3 • Spleen texture
o Can measure volume accurately by CT computation o Soft and pliable, relatively mobile
and summation of splenic area on sequential scans o Easily indented and displaced by masses and even
(limited clinical value) loculated fluid collections
o Splenomegaly often results in convexity of (usually o Changes position in response to resection of
concave) visceral surface adjacent organs
• Structure: Branching trabeculae subdivide the spleen • (E.g., post nephrectomy)
into communicating compartments • Splenic lymphatic tumors
o Branches of arteries, veins, nerves, lymphatics travel o Most common
through trabeculae o Lymphoma, leukemia
 SPLEEN ANATOMY AND IMAGING ISSUES

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

o Imaging appearance: Splenomegaly (often massive • Splenic infection

in leukemia, NHL)
• Splenic metastases
o Usually multiple and part of widespread disease
o Variety of sources, especially melanoma
o Contiguous spread (stomach, pancreas)
o Retrograde spread through splenic vein
• Primary vascular tumors
o Hemangioma
• Peripheral or solid enhancement
o Hamartoma
• Homogeneous hypervascular
o Lymphangioma
• Multicystic, subcapsular
o Littoral cell angioma
• Splenomegaly, multiple nodules
o Peliosis
• Multifocal, heterogeneous masses
o Hemangiopericytoma and hemangioendothelioma
• Solid mass with necrosis
o Angiosarcoma
• Multiple, heterogeneous, hypervascular; also in
liver
• Incidental splenic mass
o Patient with known malignancy
• Very aggressive tumor (e.g., melanoma), or tumor
affecting portal venous system (e.g., pancreatic
cancer); suspect metastasis
o No known primary tumor
• At high risk for lymphoma (e.g., AIDS, transplant
recipient, associated lymphadenopathy); suspect
lymphoma
• Immunosuppressed, chronically ill; suspect
opportunistic infection, peliosis, lymphoma
o Asymptomatic, healthy adult
• Echogenic or peripherally or uniform enhancing
mass; probable hemangioma
• Subcapsular, multicystic mass; probably
lymphangioma
o Symptomatic splenic mass not meeting these crite.ria
• Probably primary vascular tumor
• Probably requires splenectomy for diagnosis and
management
o Histoplasmosis and tuberculosis (TB) commonly
affect spleen
o Otherwise, uncommon, except in
immunocompromised patients
• AIDS, transplant recipients, leukemic, alcoholic
o Multiple small abscesses
• Candida (and other fungal), TB, Pneumocystis
o Single large abscess
• Usually bacterial
o Calcification
• Seen in treated abscesses (TB, fungal,
Pneumocystis)
• Splenic Infarction
o Relatively common cause of acute left upper
6
quadrant pain 3
o Appears as sharply marginated, wedge-shaped,
poorly-enhancing lesions abutting splenic capsule
o Etiologies
• Sickle cell and other hemoglobinopathies
• "Spontaneous" in any cause of splenomegaly
• Embolic (e.g., LV. drug abuse, endocarditis, atrial
fibrillation)
Imaging Pitfalls
• Heterogeneous enhancement of the spleen may
simulate or hide pathology
• Any mass or splenic parenchymal lesion suspected on
the basis of an arterial phase CT/MR image should be
confirmed on venous/parenchymal phase scans
TERMINOLOGY
Embryologic Events
• from dorsal mesogastrium during fifth fetal week
• Normally rotates to left
• Usually fixed into left subphrenic location by
peritoneal reflections linking it to the diaphragm,
abdominal wall, kidney, stomach
• Usually develops as one main "fused" mass of tissue
 SPLEEN ANATOMY AND IMAGING ISSUES

Axial CECT shows a splenic cyst with a calcified wall. Surgical photograph of splenectomy specimen shows a
splenic cyst with a calcified wall.

o Splenic artery ± aneurysm

Practical Implications
• Uncommon
• Failure of fusion o Infarcts
o Accessory spleen found in 10 to 30% of population o Hydatid disease
o Usually small (pea size) and near splenic hilum o Cysts
o Accessory spleen may be aberrant in location, may o Amyloid
increase in size, especially after splenectomy o Healed abscesses
• May enlarge after splenectomy performed for o Hamartomas
hypersplenism or tumor, resulting in relapse o Sickle cell anemia
• Enlarged or ectopic accessory spleen can simulate
tumor Splenomegaly
6 • May present as mass in pancreatic tail
• Diagnosis by radionuclide sulfur colloid or tagged
• Congestive
o E.g., cirrhosis, heart failure
4 RBC scan (more sensitive) • Neoplastic
• Spleen may be on long mesentery o E.g., lymphoma, leukemia, metastases
o "Wandering spleen" may result • Infection
o Spleen may be found in any intraperitoneal location o E.g., hepatitis, HIV, malaria
of the abdomen or pelvis • Hemolytic anemias
o May simulate a mass o E.g., thalassemia, heterozygous sickle cell
o May torse and cause acute splenic infarction • Extramedullary hematopoiesis
• Failure to develop o E.g., polycythemia vera, myelofibrosis
o Asplenia often associated with other congenital • Collagen vascular disease
anomalies including situs inversus and cardiac o E.g., Felty syndrome, rheumatoid arthritis
anomalies • Storage diseases
• High mortality, especially early death from sepsis o E.g., Gaucher, amyloid
• Polysplenia
o Also associated with cardiac and other anomalies,
azygous continuation of IVC I SELECTED REFERENCES
o Also associated with early mortality
1. Abbott RM et al: From the archives of the AFIP:primary
o Can be simulated by splenosis (heterotopic vascular neoplasms of the spleen: radiologic-pathologic
implantation and subsequent growth of splenic correlation. Radiographies. 24(4):1137-63, 2004
tissue following traumatic rupture of spleen) 2. Gore RM et al: Textbook of gastrointestinal radiology:
Spleen: differential diagnosis. 2nd ed. Philadelphia, WB
Saunders. pp 1925-1928, 2000
I CUSTOM DIFFERENTIAL DIAGNOSISI 3. Diihnert W: Radiology review manual. 4th ed,
Philadelphia, Lippincott, Williams and Wilkins, 2000
Multiple splenic lesions: Calcified 4. Reeder MM: Reeder and Felson's gamuts in radiology .3rd
ed. New York, Springer Verlag, 1993
• Common 5.. Warnke R et al: Tumors of the lymph nodes and spleen.
o Granulomas (TB, histoplasmosis) Washington, DC, Armed Forces Institute of Pathology.
o Opportunistic infection 1995
• Pneumocystis, mycobacterial
 SPLEEN ANATOMY AND IMAGING ISSUES
I IMAGE GALLERY

(Left) Axial NECT shows

heterogeneously calcified
spleen in a patient with
sickle cell anemia. (Right)
Photograph of surgical
specimen shows
discoloration of the splenic
parenchyma and capsule
due to chronic infarction and
calcification.

(Left) Axial CECT shows

multiple calcified granulomas
from healed histoplasmosis.
(Right) Axial CECT shows
innumerable focal splenic
lesions and splenomegaly;
sarcoidosis.

6
5

(Left) Axial CECT shows one

of several focal splenic
lesions; metastatic
melanoma. (Right) Axial
CECT shows multiple
wedge-shaped,
capsular-based
nonenhancing lesions;
infarcts due to cardiac assist
pump.
 ASPLENIA AND POLYSPLENIA

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.

• Size: PSP: Varied size of splenic masses

ITERMINOlOGY
Abbreviations and Synonyms
• Abbreviations: Asplenia (ASP); polysplenia (PSP)
• Synonyms
o ASP: Asplenia syndrome; Ivemark syndrome;
bilateral right-sidedness
o PSP: Polysplenia syndrome; bilateralleft-sidedness
Definitions
• ASP: Congenital absence of splenic tissue, situs
6 ambiguous & associated anomalies
• PSP: Congenital abnormality characterized by multiple
6 small splenic masses, situs ambiguous & associated
anomalies
IIMAGING FINDINGS
General Features
• Best diagnostic clue
o ASP: Absence of spleen, abdominal aorta & IVC on
same side (usually right) & bilateral distribution of
right-sided viscera
o PSP: Multiple small splenic masses, intrahepatic
interruption of IVC with continuation of azygos
vein, bilateral distribution of left-sided viscera
• Location: PSP, right & left upper abdominal quadrants
• Morphology
o Polysplenia
• PSP: Number of spleens varies from 2-16
• Key concepts
o Asplenia syndrome: Right isomerism
• Situs ambiguous + bilateral right-sidedness
• Cardiovascular malformations (50%): Total
anomalous pulmonary venous return (almost
100%); endocardial cusion defect (85%); single
ventricle (51 %), transposition of great vessels
(58%), pulmonary stenosis or atresia (70%),
dextrocardia(42%), mesocardia, ventricular septal
defect, single atrioventricular valve, bilateral
superior vena cavae; absent coronary sinus
• Pulmonary: Abnormal distribution of lobes,
bilateral trilobed lungs
• ASP-gastrointestinal anomalies: Situs inversus,
imperforate anus, ectopic liver, annular pancreas,
esophageal varices, GB agenesis, Hirschsprung
disease, duplication/hypoplasia of stomach
• Genitourinary (15%): Horseshoe kidney, bilobed
urinary bladder, hydroureter, double collecting
system, cystic kidney
• Miscellaneous: Cleft palate, cleft lip, fused or
horseshoe adrenal, absent left adrenal, scoliosis,
bicornuate uterus, single umbilical artery, lumbar
myelomeningocele

DDx: More or less Than One Spleen

Splenosis Splenosis Splenosis Accessory Spleen

 ASPLENIA AND POLYSPLENIA
Key Facts
Terminology
• Abbreviations: Asplenia (ASP); polysplenia (PSP)
• ASP: Asplenia syndrome; lvemark syndrome; bilateral
right-sidedness
• PSP: Polysplenia syndromei bilateralleft-sidedness
Imaging Findings
• ASP: Absence of spleen, abdominal aorta & lVC on
same side (usually right) & bilateral distribution of
right-sided viscera
• PSP: Multiple small splenic masses, intrahepatic
interruption of IVC with continuation of azygos vein,
bilateral distribution of left-sided viscera
• Location: PSP, right & left upper abdominal
quadrants
• PSP: Number of spleens varies from 2-16
o Polysplenia syndrome: Left isomerism
• Situs ambiguous + bilateralleft-sidedness
• Cardiac: Continuation of azygos vein (65%);
transposition of great vessels (13%), double outlet
right ventricle (13%), pulmonary valvular stenosis
(23%), sub aortic stenosis or atresia
• PSP-gastrointestinal: Esophageal/duodenal atresia,
TEF, semi annular pancreas, gastric duplication,
short bowel, absent GB, biliary atresia,
malrotation
• GU anomalies: Renal agenesis, renal/ovarian cysts
Radiographic Findings
• Radiography
o Asplenia: Show situs ambiguous, situs solitus or situs
inversus
• Spleen: No distinct visible splenic contour
• Liver: Symmetric & midline in its position
• Stomach: Right, left or central in position
• Malrotation of bowel
• Cardia: Mesocardia or dextrocardia
• Right-sided bronchial pattern & a minor fissure
may be seen bilaterally
• Superior mediastinal widening (due to bilateral
superior vena cava)
• Both pulmonary arteries anterior to trachea (on
lateral chest film)
• Bronchography: Bilateral eparterial bronchi on
frontal view (pulmonary arteries inferior to
bronchi)
o Polysplenia
• Frontal view: Para tracheal soft tissue prominence
(dilated azygos or hemiazygos vein) mimicking a
mediastinal mass
• Chest lateral view: Both pulmonary arteries
posterior to trachea & absence of lVC
CT Findings
• Asplenia
o NECT
• Absence of spleen
• Situs abnormalities: Liver, gallbladder, stomach,
bowel, heart, trilobed lungs
• ASP-gastrointestinal anomalies: Situs inversus,
imperforate anus, ectopic liver, annular pancreas,
esophageal varices, GB agenesis, Hirschsprung
disease, duplication/hypoplasia of stomach
• PSP-gastrointestinal: Esophageal/duodenal atresia,
TEF, semi annular pancreas, gastric duplication, short
bowel, absent GB, biliary atresia, malrotation
Top Differential Diagnoses
• Splenectomy
• Splenosis
• Accessory spleens
Diagnostic Checklist
• Centrally located left lobe of liver can simulate as
spleen on US & diagnosis of ASP may be missed
• Differentiate PSP from accessory spleens & splenosis
o CECT
• Vascular anatomy well depicted
• IVC & abdominal aorta lie on same side of spine
(usually right side with aorta lying posteriorly)
• Polysplenia
o NECT
• 2-16 splenic masses in right & left upper
quadrants
• ± Asymmetric liver & midgut malrotation
• ± Abdominal situs solitus or situs inversus
o CECT
• Absence of IVC between renal & hepatic veins
with independent drainage of hepatic veins into
right atrium
• Prominent azygos or hemiazygos vein
6
• Crossing of IVC in front of aorta to enter a 7
common atrium on right ("crossover", not unique
to ASP)
Angiographic Findings
• Conventional
o Asplenia
• Splenic artery absent; entire celiac axis may arise
from superior mesenteric artery
• IVC & abdominal aorta lie on same side (usually
right): Virtually pathognomonic feature of ASP
o Polysplenia
• Multiple spleens + common splenic/celiac artery
• Variations in course of IVC: Absence of
intrahepatic segment of IVCi crossover of IVC in
front of aorta
Nuclear Medicine Findings
• Asplenia
o Tc sulfur colloid or tagged RBC scan
• Absence of spleen
• Hepatic symmetry, prominent left lobe of liver
• Polysplenia: Multiple splenic tissues
o Tc99m labeled heat-damaged RBC scan
• More sensitive in detecting splenic tissue
o Hepatobiliary imaging
• Differentiate hepatic from splenic tissue
• Presence & position of gallbladder
 ASPLENIA AND POLYSPLENIA
Imaging Recommendations • 10-15% may not present clinically until adulthood
• Acute abdominal pain: Due to splenic infarction
• Best imaging tool
o Asplenia: Helical CT & Tc99m RBC scan Demographics
o Polysplenia • Age
• CT; US; MR can demonstrate size, position, o ASP: Newborn or infant
number of spleens & relationship to liver & bowel o PSP: Infant or adult age group
• Gender
o Asplenia: M > F
I DIFFERENTIAL DIAGNOSIS o Polysplenia: M < F
Splenectomy Natural History & Prognosis
• No splenic visualization after surgical splenectomy • Asplenia
o Patients are prone to overwhelming septicemia
Splenosis post-operatively
• Traumatized splenic tissue scattered in abdominal o Prognosis: Usually poor
cavity, where it attaches to adjacent peritoneal surface o Mortality rate: 80% die by end of 1st year of life due
• Multiple small encapsulated sessile implants (few to cardiac failure & post-operative complications
mm-3 cm in size) • Polysplenia
o Prognosis: Usually good
Accessory spleens
o Mortality rate
• Range from one to six in number
• 50-60% mortality in first year of life
• Usually found near splenic hilum along course of
• 25% of patients live up to 5 years of age
splenic vessels or within layers of omentum
• 10% survive to midadolescence
• Imaging findings identical to normal splenic tissue
Treatment
• Asplenia: Prophylactic antibiotics (not needed in PSP)
!PATHOLOGY o Associated cardiac disease: Surgical correction
General Features
• Etiology I DIAGNOSTIC CHECKLIST
o Uncertain
o Asplenia: Delayed embryonic body curvature Image Interpretation Pearls
o Polysplenia: Accelerated embryonic body curvature • Centrally located left lobe of liver can simulate as
o Altered timing in development of embryonic body spleen on US & diagnosis of ASP may be missed
6 curvature leads to visceroatrial situs abnormalities • Differentiate PSP from accessory spleens & splenosis
o Pressure of adjacent structures may interfere with
8 splenic blood supply
• Epidemiology: Asplenia: 1 in 40,000 live births I SELECTED REFERENCES
• Associated abnormalities: Pulmonary, cardiovascular,
1. Combs LSet al: Evaluation of spleen in children with
gastrointestinal, genitourinary & miscellaneous heterotaxia and congenital heart disease. Tenn Med.
anomalies 97(4):161-3,2004
2. Fulcher ASet al: Abdominal manifestations of situs
Gross Pathologic & Surgical Features anomalies in adults. Radiographies. 22(6):1439-56, 2002
• ASP: Congenital absence of spleen 3. Paterson A et al: A pattern-oriented approach to splenic
• PSP: Multiple splenic tissues in upper quadrants imaging in infants and children. Radiographies.
19(6):1465-85, 1999
Microscopic Features 4. Applegate KEet al: Situs revisited: imaging of the
• ASP: Heinz or Howell-Jolly bodies (absent in PSP) heterotaxy syndrome. Radiographies. 19(4):837-52;
o RBC inclusions discussion 853-4, 1999
5. Ruscazio M et al: Interrupted inferior vena cava in asplenia
syndrome and a review of the hereditary patterns of
I CLINICAL ISSUES visceral situs abnormalitie~. AmJ Cardiol. 81(1):111-6,
1998
6. Nakada K et al: Digestive tract disorders associated with
Presentation asplenia/polysplenia syndrome. J Pediatr Surg. 32(1):91-4,
• Most common signs/symptoms 1997
o ASP: Cardiopulmonary disease (83%); cyanosis in 7. Freeman JL et al: CT of congenital and acquired
neonatal period or infancy; bowel obstruction (17%) abnormalities of the spleen. Radiographies. 13(3):597-610,
o PSP 1993
• Cardiac disease; acyanotic left-to-right shunts such 8. Chitayat D et al: Prenatal diagnosis of asplenia/polysplenia
as septal defects syndrome. AmJ Obstet Gynecol. 158(5):1085-7, 1988
• Heart murmur, congestive heart failure, occasional
cyanosis, heart block
• Jaundice (extrahepatic biliary obstruction)
• Bowel malrotation, obstruction, pain (infarction)
 ASPLENIA AND POLYSPLENIA

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.

ITERMINOlOGY o Same enhancement as normal main spleen

o ± Supplying branch of splenic artery
Definitions
MR Findings
• Ectopic splenic tissue of congenital origin
• T1WI: Hypointense; T2WI: Hyperintense
Ultrasonographic Findings
I IMAGING FINDINGS • Real Time
o Splenic artery and vein (90% of cases)
General Features o Parenchymal bridges between main spleen and
• Best diagnostic clue: Small nodule with same texture accessory spleen
and enhancement of normal spleen
6 • Location Angiographic Findings
o In or near splenic hilum or ligaments (most cases) • Conventional: Blood supplied by a branch of splenic
10 o Anywhere in abdomen or retroperitoneum (20% of artery and drained into splenic veins
cases), especially around tail of pancreas
o Embedded within pancreatic tail (rare) Nuclear Medicine Findings
o Usually left upper quadrant, above renal pedicle; • Technetium sulfur colloid
may also be in paratesticular, diaphragmatic, o Functional splenic tissue, differentiate from bleeding
pararenal and gastric sites by consistent size, shape & location
o 1 focus (88%), 2 foci (9%), > 2 foci (3%); multiple Imaging Recommendations
foci usually clustered in 1 location
• Best imaging tool: CT followed by nuclear scintigraphy
• Size: Varies from mm to several em, usually < 2.5 em
• Morphology: Same texture as main spleen
CT Findings I DIFFERENTIAL DIAGNOSIS
• NECT: Single/multiple, round/ovoid, uniform soft
Splenosis
tissue
• Usually result of trauma, portions of disrupted spleen
• CECT
implant anywhere including abdomen, pelvis, chest

DDx: left Upper Quadrant "Mass"

Splenosis Splenosis Polysplenia Polysplenia

 ACCESSORY SPLEEN

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

• Implanted splenic tissue continues to function;

Natural History & Prognosis
enlarged "splenules"
• Complications: Spontaneous rupture, infarction,
Polysplenia torsion
• Congenital disorder with multiple small spleens, • Prognosis: Good
bilateral "left-sidedness" of abdominal viscera,
cardiovascular anomalies
Treatment
• Surgical resection: Complications, recurrence of
Metastases lymphoma or hypersplenism
• E.g., omental, peritoneal metastases
Visceral mass I DIAGNOSTIC CHECKLIST
• E.g., intramural benign gastric tumors, renal, adrenal
or primary retroperitoneal mass, mass in tail of Consider
pancreas • Accessory spleen is common, can be mistaken for
tumor

I PATHOLOGY Image Interpretation Pearls

• Hypertrophic accessory spleen may occur after
General Features splenectomy
• Etiology
o Congenital
o Pathogenesis I SELECTED REFERENCES
6
• Failure of embryonic splenic buds to unite within 1. Harris GN et al: Accessory spleen causing a mass in the tail 11
dorsal mesogastrium of the pancreas: MR imaging findings. AJR Am J
• Extreme lobulation of spleen with pinching off of Roentgenol. 163(5):1120-1, 1994
splenic tissue 2. Freeman JL et al: CT of congenital and acquired
• Epidemiology: Incidence: 10-30% patients at autopsy abnormalities of the spleen. Radiographies. 13(3):597-610,
• Associated abnormalities 1993
o Hypertrophied accessory spleen: Enlarged due to 3. Ambriz P et al: Accessory spleen compromising response to
splenectomy for idiopathic thrombocytopenic purpura.
disease and/or splenectomy
Radiology. 155(3):793-6, 1985
o Splenic neoplasms (e.g., recurrent lymphoma)
o Hematologic diseases (e.g., idiopathic
thrombocytopenic purpura, hereditary
spherocytosis, acquired autoimmune hemolytic
[IMAGE GALLERY
anemia): Recurs after splenectomy
Gross Pathologic & Surgical Features
• Structurally normal splenic tissues r-~l"i\ ,,
~.
t.

. ..:,
' .••.•

.
~

~
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms: Asymptomatic (most
cases)
•a ~/
• 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

DDx: Splenic lesions Mimicking Infection

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, ' ,

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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

o Hypoechoic nodular avascular microabscesses

!PATHOlOGY
Nuclear Medicine Findings
• PET: Increased isotope uptake from hypermetabolic
General Features
focus • General path comments: Liquified pus, splenomegaly
• WBC Scan • Genetics: Hemoglobinopathies (sickle cell) predispose
o Increased isotope uptake • Etiology
o Generalized septicemia
Imaging Recommendations o Septic emboli
• Best imaging tool: CECT, US • Endocarditis
• Protocol advice: 150 ml of l.V. contrast injected at 2.5 o Immunosuppression
ml!sec; 5 mm slice thickness with 5 mm • Fungal microabscesses
reconstruction interval o Secondary infection of traumatic splenic hematoma
or infarct
o Hematologic disorders 6
I DIFFERENTIAL DIAGNOSIS • Epidemiology
o Rare: 0.2% of reported autopsies 13
Splenic infarct o 25% are immunocompromised patients
• Wedge-shaped, but may occasionally be rounded in • Associated abnormalities
configuration o Post-operative state
• Low attenuation o Endocarditis
• Peripheral location o Immunocompromised state
• Nonenhancement with contrast o Pancreatitis, colon cancer
Splenic tumor Gross Pathologic & Surgical Features
• Single or multiple lesions • Necrotic areas of liquified pus
• Solid: Lymphoma, melanoma
• Cystic: Ovarian carcinoma, germ cell tumors or Microscopic Features
sarcoma • Liquefactive necrosis
• . Benign: Lymphangioma, hemangioma • Pus with leukocyte debris
• Rounded with variable enhancement • Gram stain for pyogenic abscess
o Fungal stain for mycotic organism
Splenic trauma o TB stains for tuberculous abscesses
• History of blunt injury o Pyogenic: 57% aerobic
• Associated with perisplenic hematoma and • Staphylococcus
hemoperitoneum • Strep E. coli
• May have active arterial extravasation • Salmonella
• Arterial clot adjacent to spleen in small lacerations o Fungal
Infiltrating disorders • Candida most common
• Aspergillus and cryptococcus
• Sarcoid • Tuberculosis (TB) and mycobacterium avium
o Multiple low attenuation lesions
intracellulari (MAl) in AIDS patient
• Gaucher disease
o Multiple low attenuation lesions
 SPLENIC INFECTION AND ABSCESS
abscess. A]R Am] Roentgenol. 179(3):629-32, 2002
Staging, Grading or Classification Criteria 5. Ng KKet al: Splenic abscess: diagnosis and management.
• Pyogenic Hepatogastroenterology. 49(44):567-71, 2002
o Unilocular (65%) 6. Loualidi A et al: Splenic abscess caused by
o Multilocular or multiple (20%) Peptostreptococcus species, diagnosed with the aid of
• Fungal abdominal computerized tomography and treated with
o Microabscesses < 1.5 cm (25%) percutaneous drainage and antibiotics: a case report. Neth]
Med. 59(6):280-5, 2001
• Parasitic
7. Green BT:Splenic abscess: report of six cases and review of
o Echinococcus granulosa the literature. Am Surg. 67(1):80-5, 2001
8. Smyrniotis V et al: Splenic abscess. An old disease with new
interest. Dig Surg. 17(4):354-7,2000
I CLINICAL ISSUES 9. Poggi SH et al: Puerperal splenic abscess. Obstet Gynecol.
96(5 Pt 2):842, 2000
Presentation 10. Mehanna 0 et al: Cat scratch disease presenting as splenic
• Most common signs/symptoms abscess. Aust N Z] Surg. 70(8):622-4, 2000
o Fever 11. Drevelengas A: The spleen in infectious disorders. ]BR-BTR.
83(4):208-10,2000
o Chills
12. Murray AW et al: A case of multiple splenic abscesses
o LUQpain managed non-operatively.] R ColI Surg Edinb.
o Splenomegaly 45(3):189-91, 2000
• Clinical profile 13. Frumiento C et al: Complications of splenic injuries:
o Lab data expansion of the nonoperative theorem. ] Pediatr Surg.
• Leukocytosis 35(5):788-91,2000
• Positive blood cultures 14. Nakao A et al: Portal venous gas associated with splenic
abscess secondary to colon cancer. Anticancer Res.
Demographics 19(6C):5641-4, 1999
15. Bernabeu-Wittel M et al: Etiology, clinical features and
• Age: Adult patients with predisposing factors
outcome of splenic microabscesses in HIV-infected patients
• Gender: M = F with prolonged fever. Eur] Clin Microbiollnfect Dis.
• Ethnicity: No known predilection 18(5):324-9, 1999
16. Duggal RKet al: Splenic abscess as a complication of acute
Natural History & Prognosis pancreatitis.] Assoc Physicians India. 47(3):338-9, 1999
• Variable 17. Alterman P et al: Splenic abscess in geriatric care.] Am
• Excellent prognosis for pyogenic abscesses in Geriatr Soc. 46(11):1481-3, 1998
immunocompetent patient 18. de Bree E et al: Splenic abscess: a diagnostic and
• Guarded prognosis in immunocompromised patients therapeutic challenge. Acta Chir Belg. 98(5):199-202, 1998
with fungal microabscesses 19. AI-Salem AH et al: Splenic abscess and sickle cell disease.
6 Treatment 20.
Am] Hematol. 58(2):100-4,1998
Wang Y et al: CT findings in splenic tuberculosis. ] BeIge
14 • Options, risks, complications Radiol. 81(2):90-1, 1998
21. Kumar N et al: Splenic abscess caused by Clostridium
o Percutaneous drainage for unilocular unruptured
difficile. Eur] Clin Microbiol Infect Dis. 16(12):938-9, 1997
abscesses 22. Vleminckx WG et al: Splenic abscess with Clostridium
• Reported success rate of 67-100% novyi bacteraemia and sepsis. Eur] Gastroenterol Hepatol.
o Splenectomy for multiple pyogenic abscesses and/or 9(3):303-5, 1997
abscess rupture 23. Rypens F et al: Splenic parenchymal complications of
• Mortality post-splenectomy 6% pancreatitis: CT findings and natural history. ] Comput
Assist Tomogr. 21(1):89-93, 1997
24. Yelon]A et al: Splenic abscess associated with
osteomyelitis. Eur] Surg. 162(11):913-4, 1996
I DIAGNOSTIC CHECKLIST 25. Liang]T et al: Splenic abscess: a diagnostic pitfall in the
ED. Am] Emerg Med. 13(3):337-43, 1995
Consider
• Infarct; necrotic or cystic mets; lymphoma
Image Interpretation Pearls
• Single or multiple low attenuation lesions in febrile
patient
• Morphology variable

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

Radiographic Findings Imaging Recommendations

• Radiography: May be associated with left pleural • Best imaging tool: CECT
effusion on chest x-ray • Protocol advice: 150 ml of LV. contrast at 2.5 ml!sec; 5
mm collimation with 5 mm reconstruction interval

DDx: Splenic lesions Mimicking Infarction

):
~_/
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

• Secondary cysts most often due to infection, infarction

I DIFFERENTIAL DIAGNOSIS or trauma
Splenic abscess • Primary cysts may be due to parasitic infection
• Complex fluid collection (echinococcal) or epidermoid cysts
• Internal septations and debris • Calcification of cyst wall in 14% of primary cysts, 50%
• Low level echoes on sonography of secondary cysts
• Multiple gas bubbles • Low-level echoes and thin septations on US in both
• Rounded, mass effect primary and secondary cysts
• Multiple small lesions (microabscesses) in fungal
infections in immunocompromised patients
I PATHOLOGY
Splenic tumor
• Primary malignant General Features
o Angiosarcoma
o Hypervascular lesions with prominent areas of
• General path comments: Liquefactive necrosis
• Genetics: Predisposition among some hematologic
6
necrosis causes such as sickle cell disease, sickle cell trait 17
• Primary benign • Etiology
o Hemangioma o Embolic
o May have contrast-enhancement pattern similar to • Atrial fibrillation
hepatic hemangiomas • Aortic atherosclerotic disease
• Secondary • Aortic valve emboli from subacute bacterial
o Lymphoma endocarditis
o Melanoma o Hematologic
o Ovarian carcinoma • Sickle hemoglobinopathies
o Often complex cystic masses • Myelofibrosis
o May have perisplenic cystic implants • Any cause of hypersplenism
• Hypercoagulable states
Splenic laceration • Leukemia and lymphoma
• History of trauma o Splenic vascular disease
• Associated hemoperitoneum • Aneurysm
• May have high attenuation active arterial • Aortic dissection
extravasation on CECT • Splenic venous thrombosis
• High attenuation perisplenic hematoma o Anatomic causes
• Intra-parenchymal low attenuation hematoma on • Splenic torsion
CECT • Torsion secondary to wandering spleen
o Miscellaneous
Splenic cyst
• Pancreatic disease, pseudocysts
• Non-neoplastic cysts divided into two categories • Collagen vascular disease
o True epithelial cysts ("primary") • Gastric tumors invading gastro-splenic ligament
o "Pseudocysts" or "secondary cysts" lacking an • Epidemiology
epithelial lining o Embolic
• Epidermoid cysts are 10-25% of all splenic cysts • Elderly cardiac patients with atrial fibrillation
o Hematologic
 SPLENIC INFARCTION
• Younger patients with sickle hemoglobinopathy 3. Romero JR et al: Wandering spleen: a rare cause of
or myeloproliferative disease abdominal pain. Pediatr Emerg Care. 19(6):412-4, 2003
4. Gorg C et al: Chronic recurring infarction of the spleen:
Gross Pathologic & Surgical Features sonographic patterns and complications. Ultraschall Med.
• Acute infarction 24(4):245-9, 2003
o Hemorrhagic or bland necrosis 5. Sodhi KSet al: Torsion of a wandering spleen: acute
• Chronic infarction abdominal presentation. J Emerg Med. 25(2):133-7, 2003
o Fibrous scar 6. Hatipoglu AR et al: A rare cause of acute abdomen: splenic
infarction. Hepatogastroenterology. 48(41):1333-6, 2001
o Rarely calcifies 7. Toth PP et al: Spontaneous splenic infarction secondary to
Microscopic Features diabetes-induced microvascular disease. Arch Fam Med.
9(2):195-7, 2000
• Coagulative necrosis 8. Barzilai M et al: Noninfectious gas accumulation in an
• Hemorrhage infarcted spleen. Dig Surg. 17(4):402-4,2000
9. Andrews MW: Ultrasound of the spleen. World J Surg.
Staging, Grading or Classification Criteria 24(2):183-7, 2000
• Segmental 10. Nores M et al: The clinical spectrum of splenic infarction.
o Wedge-shaped or round segmental lesion Am Surg. 64(2):182-8, 1998
o Straight margins typical 11. Argiris A: Splenic and renal infarctions complicating atrial
• Global fibrillation. Mt Sinai J Med. 64(4-5):342-9, 1997
o Entire spleen is avascular 12. Rypens F et al: Splenic parenchymal complications of
pancreatitis: CT findings and natural history. J Comput
o May demonstrate "cortical rim" sign Assist Tomogr. 21(1):89-93, 1997
13. Beeson MS: Splenic infarct presenting as acute abdominal
pain in an older patient. J Emerg Med. 14(3):319-22, 1996
I CLINICAL ISSUES 14. Frippiat F et al: Splenic infarction: report of three cases of
atherosclerotic embolization originating in the aorta and
Presentation retrospective study of 64 cases. Acta Clin Belg.
• Most common signs/symptoms 51(6):395-402, 1996
o LUQ pain and chills 15. Collie DA et al: Case report: computed tomography
features of complete splenic infarction, cavitation and
o 69% of patients have fever in embolic infarction
spontaneous decompression complicating pancreatitis. BrJ
• Clinical profile Radiol. 68(810):662-4, 1995
o Anemia in 53% of patients 16. Chin JK et al: Liver/spleen scintigraphy for diagnosis of
o Leukocytosis in 41 % of patients splenic infarction in cirrhotic patients. Postgrad Med J.
o Elevated platelet count in 7% of patients 69(815):715-7, 1993
17. Valentine RJ et al: Splenic infarction after splenorenal
Demographics arterial bypass. J Vasc Surg. 17(3):602-6, 1993
6 • Age: 2-87 yrs, mean age 54 18. Orringer EP et al: Case report: splenic infarction and acute
splenic sequestration in adults with hemoglobin SC
• Gender: Occurs with equal frequency in males and
18 females disease. AmJ Med Sci. 302(6):374-9,1991
19. Ting W et al: Splenic septic emboli in endocarditis.
Natural History & Prognosis Circulation. 82(5 Suppl):IV105-9, 1990
20. Goerg C et al: Splenic infarction: sonographic patterns,
• Highly variable
diagnosis, follow-up, and complications. Radiology. 174(3
o May require no treatment Pt 1):803-7, 1990
o Surgery for increased pain or rupture 21. HaftJI et al: Computed tomography of the abdomen in the
diagnosis of splenic emboli. Arch Intern Med.
Treatment 148(1):193-7, 1988
• Options, risks, complications 22. O'Keefe JH Jr et al: Thromboembolic splenic infarction.
o Asymptomatic: No treatment Mayo Clin Proc. 61(12):967-72, 1986
o Symptomatic: Splenectomy for increasing pain or 23. Jaroch MT et al: The natural history of splenic infarction.
splenic rupture Surgery. 100(4):743-50, 1986
24. Shirkhoda A et al: Computed tomography and
ultrasonography in splenic infarction. J Can Assoc Radiol.
36(1):29-33, 1985
I DIAGNOSTIC CHECKLIST 25. Balthazar EJ et al: CT of splenic and perisplenic
abnormalities in septic patients. AJRAm J Roentgenol.
Consider
144(1):53-6, 1985
• Consider splenic abscess or tumor
Image Interpretation Pearls
• Wedge-shaped peripheral area of nonenhancement

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).

o Splenic fracture: Deep laceration extending from

ITERMINOlOGY outer capsule through splenic hilum
Abbreviations and Synonyms o Active arterial extravasation: High attenuation focus
• Splenic laceration, splenic fracture, subcapsular isodense with aorta; surrounded by lower
hematoma of spleen attenuation clot or hematoma

Definitions Ultrasonographic Findings

• Parenchymal injury to spleen with or without capsular • Real Time: Hypo- or isoechoic hematoma or laceration
disruption Angiographic Findings
• Avascular parenchymal laceration; flattened lateral
6 I IMAGING FINDINGS contour 2° subcapsular hematoma; rounded contrast
collections (pseudoaneurysms); amorphous
General Features parenchymal extravasation
20
• Best diagnostic clue: Low attenuation splenic Imaging Recommendations
laceration with high density active bleeding • Best imaging tool: CECT
• Morphology: Lacerations: Linear or jagged edges; • Protocol advice: 150 ml LV. contrast at 2.5 ml/sec with
subcapsular hematoma: Flattened contour of splenic 5 mm collimation
parenchyma; fracture: Laceration extending from
outer cortex to hilum
CT Findings I DIFFERENTIAL DIAGNOSIS
• NECT: High attenuation (> 30 HU) hemoperitoneum Splenic abscess
or perisplenic clot (> 45 HU) • Rounded, irregular, low attenuation lesion; clinical
• CECT signs of infection
o Subcapsular hematoma: Compresses lateral margin
of parenchyma Splenic infarct
o Parenchymal laceration: Jagged linear area of • Wedge-shaped area of low attenuation; associated with
non enhancement due to hematoma splenomegaly; systemic embolization

DDx: Splenic Lesions Mimicking Trauma

Infarct Cyst Lymphoma

 SPLENIC TRAUMA

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

Splenic cyst Treatment

• Rounded hypoechoic lesion on USi definable cyst walli • Non-operative management for minor injuriesi
no internal enhancement on CECT angiographic embolization if active arterial
extravasation on CTi splenectomy or splenorrhaphy
lymphoma when surgery required
• Single or multiple hypodense lesionsi splenomegaly

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
granulomas (old histoplasmosis).
ITERMINOLOGY
Definitions
• Cystic masses of spleen
I IMAGING FINDINGS
General Features
• Best diagnostic clue: Sharply defined spherical lesion
of water density
6 • Location: Usually in lower pole; subcapsular (65%)
• Size: Varies (congenital usually large, acquired small)
22 • Key concepts
o Cystic masses do not commonly occur in spleen
o Classification of splenic cysts based on etiology
• Congenital (primary or true) cyst: Epidermoid
• Acquired (false or pseudo) cyst: Post-traumatic
o Congenital (primary or true) cyst: Epidermoid
• Inner cellular lining (endothelial lining) present
• Account for 10-25% of all splenic cysts
o Acquired (secondary or false or pseudo) cyst:
Post-traumatic (end stage of hematoma)
• Inner cellular lining absent, but has a fibrous wall
• Accounts for 80% of splenic cysts
• Wall calcification seen in 38-50% of cases
• Cystic nature: Due to liquefactive necrosis
DDx: low Density Splenic Mass
Hydatid Cyst Metastatic Melanoma
Axial CECT shows water density splenic cyst.
Radiographic Findings
• Radiography
o Large acquired splenic cysts
• Curvilinear or plaque-like wall calcification
CT Findings
• Congenital (primary or true) cyst: Epidermoid
o Solitary, well-defined, spherical, unilocular, cystic
lesion (water HU)
o Thin wall + sharp interface to normal splenic tissue
o Hemorrhagic, infected, 1 protein: 1 Attenuation
o No rim or intracystic enhancement
o May rarely have calcified wall
• Acquired (false or pseudo) cyst: Post-traumatic
o False or pseudocyst (end stage of splenic hematoma)
• Usually small, solitary, sharply defined, water HU
• ± Wall calcification (may resemble eggshell)
o Hematoma (evolving)
• I HU, clear cut margins, nonspecific cystic lesion
• CECT: No enhancement of contents
MR Findings
• Congenital (primary or true) cyst: Epidermoid
o T1WI: Hypointense
• Variable intensity: Infected or hemorrhagic
o T2WI: Hyperintense
• Acquired (false or pseudo) cyst: Post-traumatic
o T1WI: Hypointense; variable intensity (blood)
Lymphoma Pseudocyst
 SPLENIC CYST
Key Facts
Imaging Findings
• Best diagnostic clue: Sharply defined spherical lesion
of water density
• Location: Usually in lower pole; subcapsular (65%)
• Congenital (primary or true) cyst: Epidermoid
• Acquired (false or pseudo) cyst: Post-traumatic
• Anechoic, smooth borders, non-detectable walls ±
trabeculation (36%) congenital
• Small, anechoic or mixed with internal echoes,
echogenic wall (calcification) acquired
Top Differential Diagnoses
• Inflammatory or infection
• Vascular
• Neoplastic
• Intrasplenic pseudocyst
o T2WI: Hyperintense
o Calcification or hemosiderin deposited in wall
• Hypointense (both Tl & T2WI)
o Hematoma: Varied intensity based on age &
evolution of blood products
• After 3 weeks appears as a cystic mass: T1WI
hypointense; T2WI hyperintense
Ultrasonographic Findings
• Real Time
o Congenital (primary or true) cyst: Epidermoid
• Anechoic, smooth borders, non-detectable walls ±
trabeculation (36%) congenital
• No septations or nodules
• Complicated: Septations, internal echoes (debris),
thickened wall ± calcification
o Acquired (false or pseudo) cyst: Post-traumatic
• Small, anechoic or mixed with internal echoes,
echogenic wall (calcification) acquired
• ± Trabeculation of cyst wall (15%)
Angiographic Findings
• Conventional: Avascular mass; stretched or normal
appearing capsular & intra splenic vessels
Imaging Recommendations
• Helical NE + CECT; US; MR
I DIFFERENTIAL DIAGNOSIS
Inflammatory or infection
• Pyogenic abscess
o Solitary, multiple, well-defined, irregular borders
o 20-40 HU (due to proteinaceous material)
o CECT: ± Rim & no central enhancement
o T1WI: Hypointense; variable intensity (protein or
hemorrhagic content)
o T2WI: Hyperintense
• Fungal abscess
o E.g., Candida, Aspergillus, Cryptococcal
o Usually microabscesses: Multiple, small,
well-defined, low attenuation, no rim-enhancement
o Tl WI hypointense; T2WI hyperintense
Pathology
• Congenital (true) epidermoid: Genetic defect of
mesothelial migration
• Post-traumatic: End stage of splenic hematoma
• Pathogenesis: Liquefactive necrosis, cystic change
• Epidemiology: 7.6 per 10,000 people
• Congenital (true) cyst: Endothelial lining present
• Post-traumatic (false) cyst: Endothelial lining absent
Diagnostic Checklist
• Rule out infective, vascular & neoplastic cystic lesions
• Congenital: Large, well-defined, water density with
thin wall & no rim or intracystic enhancement
• Acquired (post-traumatic): Usually small, sharply
defined, near water HU with thick wall ± calcification
• Differentiation by imaging alone is often impossible
• Granulomatous abscesses
o E.g., Mycobacterium & atypical TB; cat-scratch
o Multiple, small, well-defined, low attenuation, no
rim-enhancement
o T1WI hypointense; T2WI hyperintense
• Parasitic: Echinococcal or hydatid cyst
o Pathology: Inner germinal layer + outer pericyst
o Large unilocular or multilocular; well-defined near
water density cyst
o ± Area of 1 density within cyst (hydatid sand)
o Daughter cysts: j Density than mother cyst
o Curvilinear ring-like calcification (common)
o CECT: Enhancement of cyst wall + septations
o TlWI
• Matrix: Hypointense, rarely hyperintense (j water)
6
• Rim: Hypointense (fibrosis); daughter cyst j signal 23
o T2WI
• Mother & daughter cysts: Hyperintense
• Floating membrane: Low-intermediate signal
o Ultrasound findings
• Well-defined anechoic cyst ± hydatid sand
(internal echoes)
• Multiseptate cyst + daughter cysts
• "Water lily" sign: Cyst + floating membrane +
detached endocyst
o Look for "cysts" in liver & peritoneal cavity
Vascular
• Infarction (arterial or venous)
o Acute phase: Well-defined areas of j attenuation
o Subacute & chronic phases: Near water HU
• Due to liquefactive necrosis
o CECT: No enhancement
o MR findings
• Acute & subacute phases: Vary with age &
evolution of blood products
• Chronic phase: Cystic intensity (due to necrosis)
• T1WI hypointense; T2WI hyperintense
• Peliosis
o Multiple, low HU, rounded lesions of varied size
o CECT: Early peripheral nodular & delayed
centripetal enhancement
o T1WI hypointense; T2WI hyperintense
 SPLENIC CYST
o T1 C+: Same as CECT
Neoplastic
• Benign: E.g., hemangioma & lymphangioma
o Hemangioma
• Have overlapping & variable CT features
preventing accurate diagnosis
• Usually not confused with simple cyst or
metastases
o Lymphangioma
• NECT: Solitary or multiple well-defined, I HU
• CECT: No enhancement
• T1WI hypo intense; T2WI hyperintense
• 1 Signal on Tl WI: Subacute hemorrhage or
proteinaceous fluid
• Malignant: E.g., Lymphoma & metastases
o Lymphoma
• NECT: Miliary multifocal or solitary, I attenuation
• CECT: Mild enhancement
• Necrosis within lesion: Near water density (rare)
• T1WI hypo intense; T2WI hyperintense
• 1 Signal on T2WI: Areas of necrosis
o Metastases
• Relatively common
• E.g., Malignant melanoma, pancreatic & ovarian
cancer may cause "cystic" splenic metastases
• NECT: Ill-/well-defined, unilocular I or water HU
• CECT: Peripheral & septal enhancement
• T1WI hypointense; T2WI hyperintense
• 1 Signal on Tl WI: Subacute hemorrhage, melanin
• 1 Signal on T2WI: Water, necrosis, old bleed
Intrasplenic pseudocyst
• Pancreatitis ~ intrasplenic pseudocyst or abscess
6 • Seen in 1.1-5% of patients with pancreatitis
• Pathogenesis
o Direct extension of pancreatic pseudocyst
24
o Secondary to digestive effects of enzymes on splenic
vessels or parenchyma along splenorenalligament
• Imaging
o Well-defined rounded cystic mass + enlarged spleen
o Density varies: Amount of debris + hemorrhage
o Associated inflammatory changes of pancreas seen
• Peripancreatic fluid collection (especially near tail)
I PATHOLOGY
General Features
• Etiology
o Congenital (true) epidermoid: Genetic defect of
mesothelial migration
o Post-traumatic: End stage of splenic hematoma
• Pathogenesis: Liquefactive necrosis, cystic change
• Epidemiology: 7.6 per 10,000 people
Gross Pathologic & Surgical Features
• Congenital (true) epidermoid cyst
o Usually large, glistening smooth walls
• Post-traumatic (false or pseudocyst)
o Smaller than true cysts, debris, wall calcification
Microscopic Features
• Congenital (true) cyst: Endothelial lining present
• Post-traumatic (false) cyst: Endothelial lining absent
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Asymptomatic; mild pain, palpable mass in LUQ
o Tenderness in LUQ; splenomegaly
Demographics
• Age: 2/3rd below 40 years old
• Gender: M:F = 2:3
Natural History & Prognosis
• Complications: Hemorrhage, rupture, infection
• Prognosis
o Good: Noncomplicated cases; after surgical removal
o Poor: Complicated cases
Treatment
• Small & asymptomatic: No treatment
• Small & symptomatic: Surgery
• Large (> 6 cm): Surgical removal (debatable)
I DIAGNOSTIC CHECKLIST
Consider
• Rule out infective, vascular & neoplastic cystic lesions
Image Interpretation Pearls
• Congenital: Large, well-defined, water density with
thin wall & no rim or intracystic enhancement
• Acquired (post-traumatic): Usually small, sharply
defined, near water HU with thick wall ± calcification
• Differentiation by imaging alone is often impossible
I SELECTED REFERENCES
1. Ito K et al: MR imaging of acquired abnormalities of the
spleen. AJRAm J Roentgenol. 168(3):697-702, 1997
2. Urrutia M et al: Cystic masses of the spleen:
radiologic-pathologic correlation. Radiographies.
16(1):107-29, 1996
3. Shirkhoda A et al: Imaging features of splenic epidermoid
cyst with pathologic correlation. Abdom Imaging.
20(5):449-51, 1995
4. Freeman JI. et al: CT of congenital and acquired
abnormalities of the spleen. Radiographies. 13(3):597-610,
1993
von Sinner WN et al: Hydatid disease of the spleen.
5.
Ultrasonography, CT and MR imaging. Acta Radiol.
33(5):459-61, 1992
6. Maves CK et al: Splenic and hepatic peliosis: MR findings.
AJRAmJ Roentgenol. 158(1):75-6, 1992
7. Dachman AH et al: Nonparasitic splenic cysts: a report of
52 cases with radiologic-pathologic correlation. AJRAm J
Roentgenol. 147(3):537-42, 1986
8. Chintapalli K et al: Differential diagnosis of
low-attenuation splenic lesions on computed tomography.
J Comput Tomogr. 9(4):311-9, 1985
9. Faer MJ et al: Traumatic splenic cyst: radiologic-pathologic
correlation from the Armed Forces Institute of Pathology.
Radiology. 134(2):371-6, 1980
 SPLENIC CYST

I IMAGE GALLERY
Typical
(Left) Axial cECT shows a
splenic cyst with a calcified
capsule. (Right) Axial NECT
shows a rim-calcified splenic
cyst.

(Left) Radiograph shows

"eggshell" calcification of a
splenic cyst. (Right) Axial
N ECT shows "eggshell"
\
- calcification of a splenic cyst.

•~,~ ~ / 6
,,~, WI' 25
~

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).

~" ..

~r~~~
 SPLENIC TUMORS

Axial CECT shows splenomegaly due to non-Hodgkin Axial CECT shows a multi-cystic mass; lymphangioma.
lymphoma.

ITERMINOlOGY •Rare benign tumor of spleen; no sex predilection

•Autopsy incidence: 0.13%; solitary or multiple
Abbreviations and Synonyms •Incidental at autopsy & exploratory laparotomy
• Splenic mass or lesion •Contain anomalous mixtures of normal elements
of splenic tissue
Definitions o Lymphangioma
• Space occupying benign or malignant tumor of spleen • Rare benign splenic neoplasm (common in neck)
• Solitary/multiple; usually subcapsular in location
• Lymphangiomatosis: Diffuse lymphangiomas
I IMAGING FINDINGS • Most lymphangiomas occur in childhood
o Malignant tumors
6 General Features • Lymphoma, AIDS-related lymphoma
• Best diagnostic clue: Solid or cystic, solitary or • Angiosarcoma, metastases
26 multiple splenic masses • Rare malignant splenic tumors: Malignant fibrous
• Key concepts histiocytoma, leiomyosarcoma & fibrosarcoma
o Classification based on pathology & histology o Lymphoma
• Benign & malignant tumors • Most common malignant tumor of spleen
o Benign tumors • Hodgkin (HD) & non-Hodgkin lymphoma (NHL)
• Hemangioma, hamartoma, lymphangioma • Presence or absence of splenic involvement may
o Hemangioma determine type of therapy
• Most common primary benign neoplasm of spleen • Spleen: Considered as "nodal organ" in Hodgkin &
• Autopsy incidence: 0.03-14% "extranodal organ" in non-Hodgkin lymphoma
• Usually incidental on radiologic studies • Manifest: Focal lesions (> 1 cm) or diffuse (typical)
• Primarily affect adults; peak age 35-55 y • Staging laparotomy or splenectomy: Uncommonly
• Multiple as part of a generalized angiomatosis necessary to determine splenic involvement
(Klippel-Trenaunay-Weber syndrome) • Initial involvement: 23-39% (Hodgkin); 30-40%
• Hemangiomatosis: Diffuse splenic hemangiomas (non-Hodgkin)
o Hamartoma • Primary lymphoma; secondary (more common)

DDx: Splenic Mass

...
,
l
~

--
Q

I
"'V- ,
Cyst (+ Granulomas) Hematoma Artifact (Perfusion)
 SPLENIC TUMORS
Key Facts
Imaging Findings
• Best diagnostic clue: Solid or cystic, solitary or
multiple splenic masses
• "Cystic" splenic metastases: Melanoma;
adenocarcinoma of breast, ovary & endometrium
• Early peripheral & late central enhancement (not as
reliable as for liver hemangioma)
• Small: Isodense or hypodense (hamartoma)
• Solitary mass; multifocal or diffuse infiltration
(lymphoma)
• Solitary or multiple, nodular, irregular margins
(angiosarcoma)
• Multiple, solid (common) or cystic, t attenuation
(metastases)
• Metastases: Iso-/hypo-/hyperechoic, "target"/"halo"
• Primary splenic lymphoma: Typically represents
NHL (B-cell origin)
• Age: Primary (young age); secondary (older age)
o AIDS-related lymphoma
• Intra-abdominal involvement: Seen in 2/3rd cases
• 86% extranodal disease, half involve GI tract
• Histologic subtypes: Small noncleaved (Burkitt &
non-Burkitt type)
o Angiosarcoma
• Very rare malignant tumor of spleen; seen in
patients with previous exposure to Thorotrast
• Most common primary nonlymphoid vascular
malignant tumor of spleen
• Poor prognosis with early, widespread metastases
• Metastases: Liver (70%); lung, pleura, nodes, bone,
brain (30%)
• Usually affect older individuals (mean age at
diagnosis is 50s; M = F)
• Most patients die within 1 year of diagnosis
o Metastases
• Relatively uncommon (autopsy incidence, 7.1%
with malignancy)
• May be multiple (60%), solitary (31.5%), nodular
& diffuse (8.5%)
• Common route: Hematogenous spread (splenic
arterial blood flow)
• Retrograde « common): Via splenic vein (portal
HTN) & lymphatics
• Common primary sites & metastases to spleen:
Breast (21%), lung (18%), ovary (8%), stomach
(7%), melanoma (6%), prostate (6%)
• Frequency of splenic metastases by primary
tumor: Melanoma (34%), breast (12%), lung (9%)
• "Cystic" splenic metastases: Melanoma;
adenocarcinoma of breast, ovary & endometrium
o Peritoneal implants to surface of spleen: Carcinoma
of ovary, GIT, pancreas
o Direct invasion of spleen: Uncommon
• E.g., gastric, colonic, pancreatic tail, left renal
cancer, retroperitoneal sarcoma
CT Findings
• Benign tumors
Top Differential Diagnoses
• Splenic cyst
• Splenic hematoma
• Splenic infection
• Splenic sarcoidosis
Clinical Issues
• Most common signs/symptoms: LUQ pain, palpable
mass, splenomegaly, fever, weight loss
• Complications: Hemorrhage, rupture
• Prognosis: Good (benign tumors); poor (malignant)
Diagnostic Checklist
• Must rely on clinical setting & biopsy, if necessary
• Imaging findings alone are unreliable in
distinguishing solid from pseudocystic splenic masses
o Hemangioma
• Homogeneous, hypodense, solid or cystic masses
• Central punctate or peripheral curvilinear Ca++
• Early peripheral & late central enhancement (not
as reliable as for liver hemangioma)
• Heterogeneous: Cystic + avascular components
o Hamartoma
• Small: Isodense or hypodense (hamartoma)
• Large: Area of t HU (scar or necrosis); calcification
• Enhancement: Variable; uniform on delayed scans
o Lymphangioma
• Thin-walled low density lesions; sharp margins
• Wall enhances; usually subcapsular in location
• Malignant tumors
o Lymphoma
6
• Homogeneously enlarged spleen, no discrete mass 27
• Solitary mass; multi focal or diffuse infiltration
(lymphoma)
• Focal lesions: AIDS-related lymphoma> common
• t HU lesions + minimal enhancement; ± ascites
• Rarely necrosis ± air or cystic mimicking abscess
• Lymphadenopathy: Abdominal or retroperitoneal
o Angiosarcoma
• Solitary or multiple, nodular, irregular margins
(angiosarcoma)
• Heterogeneous density; variable enhancement
• Enlarged spleen; ± hemorrhage & calcification
• ± Hematoma: Intrasplenic/subcapsular/perisplenic
• ± Multiple liver or distant metastases
o Metastases
• Multiple, solid (common) or cystic, I attenuation
(metastases)
• Malignant melanoma: Solid or cystic
• Ovary, breast & endometrium: Hypodense, solid
• Central or peripheral enhancement
• Calcification (rare) except mucinous colon cancer
MR Findings
• Benign tumors
o Hemangioma
• T1WI: Hypointense; T2WI: Hyperintense
• T1 C+: Uniform or heterogeneous enhancement
o Hamartoma
 SPLENIC TUMORS
• Tl WI: Isointensej T2WI: Hypo-to hyperintense
• Tl C+: Variablej uniform on delayed scans Splenic infection
o Lymphangioma • Tuberculosis, fungal (microabscesses) & pyogenic
• TlWI: Hypointense; T2WI: Markedly hyperintense • Solitary or multiple, small or large, low density lesions
• Septa: T2WIj hypointense; enhances on Tl C+ • May show minimal peripheral enhancement
• Malignant tumors Splenic sarcoidosis
o Lymphoma
• Low density splenic nodules ranging from 0.3-2.0 cm
• MR not reliable due to similar Tl, T2 relaxation
• Periaortic & retrocrural adenopathy (small & discrete)
times & proton densities of spleen/lymphoma
• Associated mediastinal, hilar nodes & lung lesions
• SPIO-enhanced MR: Altered signal intensity of
spleen + overall less uptake of SPIO Artifact
o Angiosarcoma • Heterogeneous enhancement during arterial phase of
• Tl & T2WI: Variable signal due to hemorrhage, imaging
necrosis & calcification
• Tl C+: Variable or ring-like enhancement
o Metastases !PATHOLOGY
• Tl WI: Isointense to hypointense
• T2WI: Hyperintense General Features
• Tl C+: Enhancement depends on type of primary • Etiology: Primary splenic tumor (unknown)j
metastases (underlying malignancy)
Ultrasonographic Findings • Epidemiology: Incidence varies based on type of tumor
• Real Time
o Hemangioma Gross Pathologic & Surgical Features
• Echogenic masses with areas of complex echoes • Varies depending on type of tumor
• Complex masses: Solid & cystic areas
o Hamartoma Microscopic Features
• Well-defined, homogeneous echogenic mass • Varies based on histology of tumor
o Lymphangiomas
• Grossly enlarged spleen; multicystic appearance
• Intracystic internal echoes: Proteinaceous material I CLINICAL ISSUES
o Lymphoma
Presentation
• Typically diffuse or focal hypoechoic lesions
• Anechoic/mixed echoicj small or large nodules • Most common signs/symptoms: LUQ pain, palpable
o Angiosarcoma: Solid, mixed echogenic mass mass, splenomegaly, fever, weight loss
6 o Metastases: Iso-/hypo-/hyperechoic, "target"/"halo" Natural History & Prognosis
Angiographic Findings • Complications: Hemorrhage, rupture
28 • Prognosis: Good (benign tumors)j poor (malignant)
• Conventional
o Hemangioma Treatment
• "Cotton wool" appearance: Pooling of contrast • Surgical resection: Primary benign, malignant tumors
• No neovascularity or arteriovenous shunting
• Typically retain contrast beyond venous phase
o Hamartoma & angiosarcoma: Hypervascular I DIAGNOSTIC CHECKLIST
Nuclear Medicine Findings
Consider
• Hemangioma • Must rely on clinical setting & biopsy, if necessary
o Tc-99m labeled RBC scan with SPECT
• Early dynamic scan: Focal defect or less uptake Image Interpretation Pearls
• Delayed scans (over 30-50 min): Persistent filling • Imaging findings alone are unreliable in
distinguishing solid from pseudocystic splenic masses
Imaging Recommendations
• Helical NE + CECTj MR with Tl C+
I SELECTED REFERENCES
I DIFFERENTIAL DIAGNOSIS 1. Abott RM et al: Primary vascular neoplasms of the spleen:
radiologic-pathologic correlation. Radiographies. 24:
Splenic cyst 1137-63,2004
2. Urban BA et al: Helical CT of the spleen. Am.].
• Low density, sharp margins, no enhancement
Roentgenol. 170: 997-1003, 1998
• Rim of dense calcification; anechoic on ultrasound 3. Rabushka 1.5et al: Imaging of the spleen: CT with
Splenic hematoma supplemental MR examination. Radiographies.
14(2):307-32, 1994
• Subcapsular: Low attenuation, crescentic fluid
collection along lateral surface of spleen
• Intrasplenic: Irregular low density fluid collection
 SPLENIC TUMORS
I IMAGE GALLERY
Typical
(Left) Axial CECT in a 20
year old man shows partially
calcified splenic mass;
non-Hodgkin lymphoma
(untreated). (Right) Surgical
photograph of specimen of
spleen from a 20 year old
man with non-Hodgkin
lymphoma.

(Left) Axial CECT shows

innumerable hepatic masses;
angiosarcoma in a young
man. (Right) Axial CECT of a
young man with hepatic
angiosarcoma shows one of
several splenic tumors with
similar appearance.

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
non-Hodgkin lymphoma (NHL).
ITERMINOlOGY
Definitions
• Splenic metastases from other primary cancer site
• Splenic lymphoma: Malignant tumor of lymphocytes
I IMAGING FINDINGS
General features
• Best diagnostic clue: Solitary or multiple solid lesions
6 (metastases); diffuse infiltrative lesions (lymphoma)
• Size
30 o Splenic metastases: One-third are microscopic
nodules, two-thirds are grossly visible at autopsy
o Splenic lymphoma: Solitary mass or multifocal
lesions 1 cm or greater are detectable on CT
• Key concepts
o Splenic metastases
• Relatively uncommon (autopsy incidence, 7.1%)
• May be multiple (60%), solitary (31.5%), nodular
or diffuse infiltrative lesions (8.5%)
• Common route: Hematogenous (splenic artery)
• Retrograde « common): Via splenic vein (portal
HTN) & lymphatics
• Common primary sites & metastases to spleen:
Breast (21 %), lung (18%), ovary (8%), stomach
(7%), melanoma (6%), prostate (6%)
DDx: Multiple low Density Splenic lesions
Angiosarcoma
Repeat Axial CECT in August, 2003 shows marked
reduction of splenic size following treatment for NHL.
• Frequency of splenic metastases by primary
tumor: Melanoma (34%), breast (12%), lung (9%)
• "Cystic" metastases: Melanoma, adenocarcinoma
of breast, ovary & endometrium
• Serosal implants: Peritoneal carcinomatosis
secondary to ovarian, GIT, pancreatic cancers
• Direct invasion: Uncommon; may occur in large
gastric, colon, pancreatic tail cancer, left renal cell
cancer, neuroblastoma or retroperitoneal sarcoma
o Splenic lymphoma
• Most common malignant tumor of spleen
• Hodgkin (HD) & non-Hodgkin lymphoma (NHL)
• Primary lymphoma; secondary (more common)
• Primary splenic lymphoma: NHL (B-cell origin)
• Initial splenic involvement: Hodgkin (23-34%);
non-Hodgkin (30-40%)
• Spleen: Considered as "nodal organ" in Hodgkin &
"extranodal organ" in non-Hodgkin lymphoma
• Manifest: Focal lesions (> 1 cm) or diffuse (typical)
• Age: Primary (young age); secondary (older age)
• Presence or absence of splenic involvement may
determine type of therapy
• Staging laparotomy or splenectomy: Uncommonly
necessary to determine splenic involvement
o AIDS-related lymphoma
• Histologic subtypes: Small noncleaved (Burkitt &
non-Burkitt type)
• Splenic involvement: NHL > common than HD
Artifact (Perfusion)
 SPLENIC METASTASES AND LYMPHOMA
Key Facts
Imaging Findings
• Best diagnostic clue: Solitary or multiple solid lesions
(metastases); diffuse infiltrative lesions (lymphoma)
• Central or peripheral enhancement (metastases)
• Calcification (rare) except mucinous colon cancer
• Solitary mass; multifocal or diffuse infiltration
(lymphoma)
• Focal lesions: AIDS-related lymphoma> common
• Splenic hilum nodes: NHL (59%); HD (uncommon)
• Lymphadenopathy: Abdominal or retroperitoneal
• Splenic lymphoma (MR nonspecific)
Top Differential Diagnoses
• Splenic primary tumor
• Splenic infection
• Granulomatous
CT Findings
• Splenic metastases
o Decreased attenuation in relation to normal spleen
o Usually appear as well-defined masses
o Multiple, solid (more common) or "cystic", decreased
attenuation (metastases)
o Malignant melanoma: Solid or "cystic"
o Ovary, breast & endometrium: "Cystic"
(homogeneous & hypodense)
o Central or peripheral enhancement (metastases)
o Calcification (rare) except mucinous colon cancer
• Splenic lymphoma
o Homogeneously enlarged spleen, no discrete mass
o Solitary mass; multifocal or'diffuse infiltration
(lymphoma)
o Focal lesions: AIDS-related lymphoma> common
o j HU lesions + minimal enhancement; ± ascites
o Organ specific contrast agent: Ethiodol-Oil-Emulsion
(EOE-13) potentially increase detection rate
o Rarely necrosis ± air or cystic mimicking abscess
o Splenic hilum nodes: NHL (59%); HD (uncommon)
o Lymphadenopathy: Abdominal or retroperitoneal
MR Findings
• Splenic metastases
o T1WI: Isointense to hypointense
o T2WI: Hyperintense
o T1 C+: Enhancement depends on type of primary
• Conspicuity 1 with SPIO-enhanced imaging
• Splenic lymphoma (MR nonspecific)
o MR not reliable due to similar T1 & T2WI relaxation
times, proton densities of normal spleen/lymphoma
Ultrasonographic Findings
• Real Time
o Splenic metastases
• Iso-/hypoechoic, hyperechoic, "target" or "halo"
• Larger lesions more complex than smaller ones
• Echogenic lesions (rare): E.g" plasmacytoma,
hepatoma, melanoma, prostate & ovarian cancer
o Splenic lymphoma
• Typically diffuse or focal hypoechoic lesions
• Anechoic/mixed echoic; small or large nodules
Pathology
• Splenic metastases: Breast (21%), lung (18%), ovary
(8%), stomach (7%), melanoma (6%), prostate (6%)
• Hodgkin (HD) & non-Hodgkin lymphoma (NHL)
• Primary lymphoma; secondary (more common)
• Primary: Usually non-Hodgkin lymphoma (NHL)
• Secondary: Extension from generalized lymphoma
Diagnostic Checklist
• To look for primary cancer, generalized adenopathy
• HD (45-66%); NHL (70%) show diffuse infiltration
making difficult to detect by US, CT & MR
• Splenic size is not a reliable clinical & imaging
indicator of presence or absence of disease
• Imaging impbrtant to suggest & stage malignancy,
evaluate tumor volume/monitor response to therapy
• Large & necrotic: Heterogeneous appearance
• AIDS-related lymphoma: Uniform decreased
echogenicity or focal hypoechoic lesions
Angiographic Findings
• Conventional
o Splenic metastases
• Typically hypovascular or avascular
• Less frequently hypervascular
o Splenic lymphoma
• Nonspecific findings: May be normal; single or
multiple parenchymal defects
Nuclear Medicine Findings
• Tc99m sulfur colloid scintigraphy (liver-spleen scan) 6
o Splenic metastases: Areas of focal defects
o Splenic lymphoma: Nonspecific findings 31
• Areas of decreased tracer uptake within spleen
• Total lack of uptake ("functional asplenia")
• Altered splenic contour (encasement by tumor)
Imaging Recommendations
• Best imaging tool: Helical CT
I DIFFERENTIAL DIAGNOSIS
Splenic primary tumor
• Benign tumor
o Hemangioma
• Homogeneously solid. or multiple cystic masses
• Slightly hypodense on NECT & isodense on CECT
• Central punctate or peripheral curvilinear Ca++
• Malignant tumor
o Angiosarcoma
• Heterogeneous density; variable enhancement
• Solitary or multiple, nodular, irregular margins
• ± Multiple liver or distant metastases
Splenic infarction
• Wedge-shaped peripheral defect
Splenic infection
• Pyogenic (bacterial): Abscess
 SPLENIC METASTASES AND LYMPHOMA
o Low density lesion with thick, irregular dense rim
o ± Gas within fluid collection, left pleural effusion
• Fungal (e.g., Candida, Aspergillus, Cryptococcus)
o Solitary/multiple; small/large; low density lesions
o May show minimal peripheral enhancement
o Candida microabscesses
• Well-defined nonenhancing I attenuation lesions
• Typically 5-10 mm in size (smaller than 2 cm)
• Wheel within wheel pattern: 1 HU central focus
• AIDS: Pneumocystis carinii infection
o Focal low-attenuation splenic lesions
o Large lesions: Calcification, rim-like or punctate type
Granulomatous
• Tuberculosis
o Splenomegaly (SMG)
o Micro & macronodular lesions of low-attenuation
o ± Abdominal adenopathy, high density ascites
• Sarcoidosis
o SMG, low density nodules ranging from 0.3-2.0 cm
o Periaortic & retrocrural adenopathy (small, discrete)
o Associated mediastinal, hilar nodes & lung lesions
Artifact
• Early phase of of LV. bolus contrast injection
o Heterogeneous enhancement, mimic splenic tumor
I PATHOLOGY
General Features
• General path comments
o Splenic metastases
• Usually seen in widespread tumor dissemination
6 • Isolated splenic metastases are rarely seen
• Etiology
o Splenic metastases: Breast (21 %), lung (18%), ovary
32
(8%), stomach (7%), melanoma (6%), prostate (6%)
o Splenic lymphoma
• Hodgkin (HD) & non-Hodgkin lymphoma (NHL)
• Primary lymphoma; secondary (more common)
• Primary: Usually non-Hodgkin lymphoma (NHL)
• Secondary: Extension from generalized lymphoma
• Epidemiology
o Splenic metastases
• 7.1% of patients with malignancy at autopsy
o Splenic lymphoma
• Primary splenic lymphoma: 1% of all cases of NHL
• Hodgkin (23-34%); non-Hodgkin (30-40%)
• Associated abnormalities
o Primary carcinoma in splenic metastases
o Generalized adenopathy in secondary lymphoma
Gross Pathologic & Surgical Features
• Splenic metastases: Solitary or multiple
• Splenic lymphoma
o Solitary, multifocal, diffuse infiltration (> common)
o Homogeneously enlarged spleen, no discrete mass
Microscopic Features
• Splenic metastases: Varies based on primary carcinoma
• Splenic lymphoma: Hodgkin type
o Nodular sclerosing; mixed cellular
o Lymphocyte predominance; lymphocyte depletion
Staging, Grading or Classification Criteria
• Ann Arbor staging: Anatomic extent of HD & NHL
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Splenic metastases
• Asymptomatic; LUQ pain, mass, splenomegaly
• Acute pain: Splenic infarct due to tumor emboli
o Splenic lymphoma
• Fever, weight loss, night sweats, malaise
• LUQ pain, palpable mass, splenomegaly
• Diagnosis: Imaging + clinical; guided splenic biopsy
Demographics
• Age
o Primary splenic lymphoma: Older age group
o Splenic metastases: Any age group
• Gender
o HD: Young age, M:F = 4:1; older age, M:F = 2:1
o NHL: M:F = 1.4:1
Natural History & Prognosis
• Complications
o Splenic metastases: Splenic vein thrombosis, rupture
• Prognosis
o Splenic metastases: Poor prognosis
o Splenic lymphoma: Early stage (good); late (poor)
Treatment
• Chemotherapy, radiation or surgery in isolated lesion
I DIAGNOSTIC CHECKLIST
Consider
• To look for primary cancer, generalized adenopathy
Image Interpretation Pearls
• HD (45-66%); NHL (70%) show diffuse infiltration
making difficult to detect by US, CT & MR
• Splenic size is not a reliable clinical & imaging
indicator of presence or absence of disease
• Imaging important to suggest & stage malignancy,
evaluate tumor volume/monitor response to therapy
I SELECTED REFERENCES
1. Urban BAet al: Helical CT of the spleen. AJRAm J
Roentgenol. 170(4):997-1003, 1998
2. Rabushka 15 et al: Imaging of the spleen: CT with
supplemental MR examination. Radiographies.
14(2):307-32, 1994
3. Freeman J1 et al: CT of congenital and acquired
abnormalities of the spleen. Radiographies. 13(3):597-610,
1993
4. Taylor AJ et al: CT of acquired abnormalities of the spleen.
AJRAm J Roentgenol. 157(6):1213-9, 1991
5. Hahn PF et al: MR imaging of focal splenic tumors. AJRAm
J Roentgenol. 150(4):823-7, 1988
 SPLENIC METASTASES AND LYMPHOMA

I IMAGE GALLERY

(Left) Axial CECT shows

splenic metastases from
melanoma. (Right) Axial
CECT shows splenic, liver
and adrenal metastases from
primary sinus carcinoma.

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

Definitions Radiographic Findings

• Splenomegaly: Enlarged spleen; volume> 500 cm3
• Hypersplenism: Syndrome consisting of splenomegaly
& pancytopenia in which bone marrow is either
normal or hyperreactive
6 o Calcification within or adjacent to spleen
I IMAGING FINDINGS
34
General Features
• Best diagnostic clue: Increased volume of spleen with
convex medial border
• Location: Spleen occupies LUQ with tip extending
inferiorly below 12th rib
• Size
o Normal spleen in adult measures up to 13 cm;
enlarged if it is 14 cm or longer
o Splenic index: Normally 120-480 cm3 (product of
length, breadth & width of spleen)
o Splenic weight: Splenic index x 0.55
• Normal weight: 100-250g
o SMG: Anteroposterior (AP) diameter> two-thirds
distance of AP diameter of abdominal cavity
• Radiography
o Splenic tip below 12th rib
o Marked SMG may displace stomach medially
o Displacement of splenic flexure of colon (splenic
flexure usually anterior to spleen)
CT Findings
• SMG: Medial margin of spleen is convex on CT
• Congestive SMG
o Portal hypertension: SMG with varices, nodular
shrunken liver, ascites
o Splenic vein occlusion or thrombosis (often
secondary to pancreatitis or pancreatic tumors)
o Sickle-cell disease: Splenic sequestration
• Peripheral j HU areas + areas 1 attenuation
• Represent areas of infarct & hemorrhage
• Storage disorders
o Gaucher disease
• Spleen may have abnormal low attenuation
• Marked SMG, often extending into pelvis
o Amyloidosis .
• NECT & CECT: Generalized or focal j densIty

DDx: Splenic or left Upper Quadrant Mass

Gastric Tumor Candida Abscesses Melanoma Metastases Splenic MAl, AIDS

 SPLENOMEGALY AND HYPERSPLENISM
Key Facts
Terminology
• Splenomegaly (SMG); hypersplenism (HS)
• Splenomegaly: Enlarged spleen; volume> 500 cm3
• Hypersplenism: Syndrome consisting of
splenomegaly & pancytopenia in which bone marrow
is either normal or hyperreactive
Imaging Findings
• Best diagnostic clue: Increased volume of spleen with
convex medial border
• Normal spleen in adult measures up to 13 cm;
enlarged if it is 14 cm or longer
• Splenic tip below 12th rib
• Marked SMG may displace stomach medially
• Displacement of splenic flexure of colon (splenic
flexure usually anterior to spleen)
o Primary hemochromatosis
• Density of spleen is normal (unlike that of liver)
o Secondary hemochromatosis
• Increased attenuation values in liver & spleen
• Space occupying lesions: Cysts, abscess, tumor
• Splenic infarction (veno-occlusion caused by sickling)
o SMG with focal infarcts; peripheral areas of low
attenuation & hemorrhage associated with SMG
• Hemosiderosis
o 1 Attenuation of spleen (hemosiderin deposition)
o Consequence of multiple blood transfusions
(thalassemia, hemophilia)
• Splenic trauma
o Splenic laceration or subcapsular hematoma
o Surrounding perisplenic hematoma (> 30 HU)
• Extramedullary hematopoiesis
o Spleen may be diffusely enlarged
o CECT: Focal masses of hematopoietic tissue that are
isoattenuating relative to normal splenic tissue
MR Findings
• Congestive SMG
o Portal hypertension
• Multiple tiny (3-8 mm) foci of decreased signal
• Hemosiderin deposits; organized hemorrhage
(Gamna-Gandy bodies or siderotic nodules)
o Sickle cell disease (splenic sequestration)
• Areas of abnormal signal intensity
• Hyperintense with dark rim on Tl WI (subacute
hemorrhage)
o Hemochromatosis
• Primary: Normal signal & size of spleen
• Secondary: Marked signal loss; enlarged spleen
o Gaucher disease: Increased signal intensity on Tl WI
o Infarction
• Peripheral, wedge-shaped areas of abnormal signal
• Low signal resulting from iron deposition
o Hemosiderosis
• ! Signal intensity of spleen on both Tl & T2WI
o Extramedullary hematopoiesis
• Focal hypointense nodules
Top Differential Diagnoses
• Other LUQ masses
• Lymphoma & metastases
• Primary splenic tumor
Diagnostic Checklist
• SMG, most common cause of left upper quadrant
mass
• SMG, usually a systemic cause rather than primary
• US can confirm presence of enlarged spleen or space
occupying lesions
• CT & MR can further clarify abnormalities in size,
shape & define parenchymal pathology
• Radioisotope scanning can diagnose HS & provide
functional status of spleen
Ultrasonographic Findings
• Real Time
o SMG with normal echogenicity
• Infection, congestion (portal HT), early sickle cell
• H. spherocytosis, hemolysis, Felty syndrome
• Wilson disease, polycythemia, myelofibrosis,
leukemia
o SMG with hyperechoic pattern
• Leukemia, post chemo & radiation therapy
• Malaria, TB, sarcoidosis, polycythemia
• Hereditary spherocytosis, portal vein thrombosis,
hematoma, metastases
o SMG with hypo echoic pattern
• Lymphoma, multiple myeloma, chronic
6
lymphocytic leukemia
35
• Congestion from portal HT, noncaseating
granulomatous infection
o Sickle cell disease: Immediately after sequestration,
peripheral hypoechoic areas seen
o Gaucher disease: Multiple, well-defined, discrete
hypoechoic lesions; fibrosis or infarction
Nuclear Medicine Findings
• Chromium 51-labeled RBCs or platelets
o HS is diagnosed if injected RBCs exhibit shortened
half-life (average half-life of 25-35 days)
• Tc99m sulfur colloid scan: Detect splenic function
Imaging Recommendations
• Best imaging tool: Helical CT
I DIFFERENTIAL DIAGNOSIS
Other lUQ masses
• E.g., gastric, renal, adrenal tumor
lymphoma & metastases
• Lymphoma: Various patterns of splenic involvement
o Homogeneous enlargement without discrete mass
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.