European Journal of Radiology 64 (2007) 189–201

Review

The forgotten organ: Contrast enhanced sonography of the spleen

Christian Görg ∗
Medizinische Universitätsklinik, Baldingerstraße, 35043 Marburg/Lahn, Germany
Received 3 June 2007; received in revised form 5 June 2007; accepted 6 June 2007

Abstract
Objective: Ultrasound contrast agents in conjunction with contrast specific imaging techniques, are increasingly accepted in clinical use for
diagnostic imaging in several organs. Contrast enhanced sonography (CES) of second-generation contrast media have shown a spleen-specific
uptake of the microbubble contrast agent. The aim of this review is to illustrate indications for the use of CES in patients with suspected (peri-)splenic
pathology.
Methods: This review based on the experience of transcutaneous CES in 200 patients with (peri-)splenic pathology diagnosed by B-mode
sonography at an internal medicine center. CES studies were performed with a contrast-devoted unit (Acuson, Sequoia, Siemens medical solution)
that had contrast-specific, continuous-mode software. A low mechanical index was used. A sulfur hexafluoride-based microbubble contrast medium
(Sonovue® , Bracco SpA, Milan, Italy) was injected.
Results: On our experience, there are several clinical conditions which may show an diagnostic advantage of CES in comparison to B-mode US.
CES should be performed to investigate: (1) the perisplenic tumor to diagnose or exclude accessory spleen, (2) the small-sized spleen to diagnose
functional asplenia/hyposplenia, (3) the inhomogenous spleen of unknown cause to diagnose focal lesions within the spleen, (4) the incidentally
found hypoechoic splenic tumor to diagnose high vascular splenic hemangioma, (5) focal lesions suspect for splenic abscess, hematoma, infarction
to confirme diagnosis, and (6) patients with abdominal trauma to diagnose or exclude splenic injuriy.
Conclusion: CES is of diagnostic value in several clinical circumstances to diagnose accessory spleen, functional asplenia, small-sized splenic
involvement, high vascular splenic hemangioma, and vascular splenic pathology like splenic infarction, splenic abscess, and splenic laceration.
© 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Spleen; Contrast agent; Ultrasonography; Focal (peri-)splenic lesions

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
2. Ultrasound technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
3. General considerations of CES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
4. CES patterns of the (peri-)splenic region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4.1. The perisplenic tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4.2. CES in diffuse splenic abnormalities of splenic parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4.2.1. Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4.2.2. The small-sized spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
4.2.3. The inhomogenous spleen of unknown cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
4.3. CES in focal splenic abnormalities of splenic parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
4.3.1. Splenic lymphoma infiltration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
4.3.2. Splenic metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
4.3.3. Splenic incidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

∗ Correspondence address: Klinik für Hämatologie/Onkologie der, Phillipsuniversität, Baldingerstraße, D-35033 Marburg, Germany. Tel.: +49 6421 2866273;
fax: +49 6421 2866358.
E-mail address: goergc@med.uni-marburg.de.

0720-048X/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2007.06.036
190 C. Görg / European Journal of Radiology 64 (2007) 189–201

4.3.4. Splenic abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

4.3.5. Splenic infarct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
4.3.6. Splenic rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

1. Introduction diaphragma. A sector transducer for the B mode sonography

and a curved array transducer for CES are optimal for inter-
The spleen is regarded as the “silent and forgotten” organ of costal scanning as it avoids rib shadowing. As with all ultrasound
the abdomen. The main reason is that splenic diseases in compar- the highest frequency transducer that enables visualization
ison to the liver are rare. Nevertheless, the spleen is a frequent site should be used, usually a 3.5 or 5 MHz probe, however, some
of secondary manifestations. So various splenic abnormalities newer 7.5 MHz probes provide adequate depth penetration of
in haematological, immunological, infectious and oncological spleen.
diseases are described [1–9]. The poor correlation between B
mode sonographic appearances and specific pathology causes 3. General considerations of CES
difficulties in clinical diagnosis.
The development of ultrasound contrast agents in combi- Low-mechanical-index contrast sonography is a new tech-
nation with the development of ultrasound equipment have nique allowing real-time, gray-scale imaging during contrast
overcome the limitations of conventional B-mode sonography medium circulation. This “second-generation” contrast media
and enable the display of parenchymal microvasculature [10]. resonate even at low acoustic pressure levels. Second-generation
Second-generation contrast agents like SonoVue® has been contrast agents are made of stabilized microbubbles other than
shown a high spleen-specific enhancement that lasts longer air, having a good harmonic response even at low-mechanical-
than the blood pool and liver enhancement phases. This unique index as compared to first-generation contrast agents (containing
splenic specificity would therefore be useful for the detection of air), due to a higher elasticity and resistance to acoustic pressure.
splenic tissue and characterization of focal (peri-)splenic lesions Owing to the possibility of selectively detecting the harmonic
[11–17]. signals produced by contrast microbubbles, contrast-specific
In this review, we present our experience of CES performed techniques, when used at low mechanical index, provide real-
in 200 patients with (peri-)splenic lesions primarily diagnosed time sonography depending on the signal of microbubbles,
by B-mode ultrasound. The aim of this review is to challenge whereas the echo from the tissue is maintained very low. The
the diagnostic value of CES for final diagnosis of (peri-)splenic majority of microbubble agents were initially thought to be blood
abnormalities. pool agents. However, some contrast agents like SonoVue®
(Bracco SpA, Milan, Italy) have recently been shown to exhibit
2. Ultrasound technique specific hepatosplenic uptake after its disappearance from the
blood pool. The site of accumulation for this microbubble agent
Splenic examination is carried out with the patient in the is unknown, but it may be within the reticuloendothelial sys-
supine or decubitus position with the left arm raised in order tem or sinusoid. During the arterial phase splenic enhancement
to spread the intercostals spaces. The transducer is placed par- may be inhomogeneous and becomes homogeneous between
allel to the ribs in the 10th or 11th intercostals spaces in the 30 and 60 s. This ‘splenic contrast pattern’ is well known and
left mid-axillary line and a search for the best window car- has no clinical significance (Fig. 1). Pharmacokinetic studies of
ried out. In this manner, and at maximum inspiration, it is the second-generation contrast agent SonoVue® have shown a
often possible to demonstrate the entire spleen as far as the spleen-specific enhancement that lasts longer (5 min) than the

Fig. 1. Demonstration of splenic enhancement in a probant: (a) In the early arterial phase (14 s) an inhomogeneous enhancement of the spleen is seen. (b) In the
parenchymal phase (1 min) a homogeneous enhancement of the spleen is seen.
 C. Görg / European Journal of Radiology 64 (2007) 189–201
Fig. 2. Demonstration of liver and splenic enhancement in a probant. In the
late parenchymal phase (3 min) splenic enhancement (S) lasts longer than the
enhancement of the liver (L).
blood pool and liver enhancement phases (Fig. 2). This unique
splenic specifity would therefore be useful for the detection
of splenic tissue and characterization of focal splenic lesions
[12].
During clinical studies, safety parameters (such as vital signs,
electrocardiograph, oxygen saturation, neurologic examination,
and clinical laboratory parameters) were monitored and no clin-
ically meaningful change was noted [11].
The second-generation agent SonoVue® can be prepared in
a few seconds and can be administrated immediately after base-
line sonography. In our institution, the contrast agent is kept in
stock at all times so that this technique can be used any time. In
our series, the time for baseline sonography and CES was a max-
imum of 15 min. The producer prize for one CES examination
(4.8 ml SonoVue® ) in Europe is D 65.
CES studies reported here, were performed with a contrast-
devoted unit (Acuson, Sequoia, Siemens medical solution)
that had contrast-specific, continuous-mode software. A low
mechanical index was used. A sulfur hexafluoride-based
microbubble contrast medium (Sonovue® , Bracco SpA, Milan,
Italy) was injected intravenously in 2 s via a 20-gauge canula.
A volume of 2.4 ml was administered, followed by a 5 ml saline
flush immediately after contrast medium injection; the left upper
quadrant was continuously scanned sonographically for 3–5 min
until the enhancement effect began to decrease. Evidence of the
uptake of the contrast agent in the spleen was controlled over
5 min using uptake of the left kidney as an in vivo reference.
CES studies were analysed on the basis of review of sonographic
unit-stored clips.
The following CES patterns of focal lesions using the sur-
rounding splenic tissue enhancement as an “in vivo” reference
were considered: extent of enhancement during the arterial phase
between 5 and 30 s after injection and during the parenchy-
mal phase between 3 and 5 min after injection (anechoic versus
hypoechoic versus isoechoic versus hyperechoic versus mixed).
CES was performed in all patients immediately after baseline
sonography. The use of ultrasound contrast agent followed the
guidelines of the EFSUMB [18].
191
4. CES patterns of the (peri-)splenic region
In the first part, we will provide an overview of CES of the
perisplenic region especially for the diagnosis and exclusion of
accessory spleen. In the second part CES patterns of patients
with “diffuse” splenic pathology will be discussed including
patients with splenomegaly, a small-sized spleen, and an inho-
mogeneous spleen on B-mode sonography. The third and last
part is devoted to CES patterns of the most common focal splenic
lesions including splenic lymphoma infiltration, splenic metas-
tasis, splenic incidentaloma, splenic abscess, splenic infarct, and
splenic rupture.
4.1. The perisplenic tumor
Perisplenic masses causes difficulty in clinical diagno-
sis especially in patients with underlying malignant diseases.
Accessory spleens (AS) probably are the most common (peri-)
splenic anomaly with a frequency of 10–25% of normal individ-
uals [19]. The locations of AS is variable, but most are adjacent
to the medial border of the spleen. Most AS are less than 1 cm
in size, but they may occasionally be as large as 6 cm in diame-
ter. With the widespread use of abdominal ultrasound accessory
spleens are increased visualized and they may be mistaken
for lymphadenopathy or neoplastic masses. The poor correla-
tion between B-mode sonography, colour Doppler sonographic
appearance, and specific pathology of (peri-)splenic lesions is
well known [9]. So additional imaging procedures like colloid
scans with TC-99m-labeled microparticles [20], heat damaged
red blood cell scans [21] contrast enhanced computed tomogra-
phy [22], or magnetic resonance imaging [23], are necessary to
diagnose or exclude an accessory spleen.
As shown in recent studies AS do have a high specific CES
pattern characterized by marked contrast enhancement during
the arterial and parenchymal phase. It seems that the isoechoic
enhancement at the parenchymal phase is the most important
CES-pattern of accessory spleens [17] (Fig. 3). Especially in
cases of distant location from the spleen CES may characterize
splenic tissue (Fig. 4) Because of the specific enhancement of
splenic tissue one can assume that ectopic splenic tissue (spleno-
sis) may be indicated by CES. Lymphnodes of the splenic hilus,
adrenal lesions and tumors located in the tail of the pancreas have
a reduced enhancement in the parenchymal phase in comparison
to the contrast enhancement of the spleen.
In conclusion: in patients with a perisplenic tumor of
unknown cause CES enables to diagnose or exclude accessory
spleens.
4.2. CES in diffuse splenic abnormalities of splenic
parenchyma
4.2.1. Splenomegaly
Using CES the enlarged spleen like the normal sized spleen
usually shows a homogeneous and marked enhancement of its
texture by comparison with the renal cortex. An assessment of
splenic enhancement does not provide any differential diagnostic
clues.
192 C. Görg / European Journal of Radiology 64 (2007) 189–201

Fig. 3. 34-year-old female patient with an incidentally found perisplenic tumor. (a) On B-mode sonography a small-sized round isoechoic tumor in comparison to
the spleen is seen beneath the spleen (arrow). (b) Contrast enhanced sonography shows an isoechoic enhancement of the tumor in comparison to the spleen after 30 s
suggesting an accessory spleen.

4.2.2. The small-sized spleen
Functional hyposplenia or asplenia (FAS) in situ and the post-
splenectomy syndrome can both be associated with the onset
of potentially overwhelming fatal infections [24]. A diagnosis
of the postslenectomy syndrome is made on the basis of the
patient’s history and absence of the spleen on sectional image
procedures. Because FAS lacks characteristic symptoms, how-
ever, it is recognized only rarely. Imaging of the spleen with
Tc 99m colloid liver-spleen scintigraphy and the finding of
Howell–Jolly bodies within erythrocytes have been established
as gold standards for the diagnosis of FAS [25,26]. Two findings
might be relevant to the sonographic diagnosis of FAS. The first
is small-sized spleen [27,28]. In a retrospective study the spleen
was small in 83% of the patient with proven asplenia [29]. A
positive correlation of splenic size with splenic function has not
been described yet, but cases of postoperative splenosis with a
volume of 20–30 ml have been reported to have normal splenic
function [30]. In elderly subjects, small spleens may have no
pathologic significance, although no clear scintigraphic data in
this age group are available [31]. The second sonographic find-
ing is the absence or reduction of parenchymal flow by colour
Doppler sonography and CES. In a colour Doppler sonographic
study reduced vascularity was seen in 88% of patients with FAS
[29]. Although CES is sensitive for evaluation splenic vascular-
ity prospective studies will be necessary to confirm whether the
sonographic findings of a small spleen and reduced splenic vas-
cularity by CES are sensitive and specific enough to diagnose
FAS (Fig. 5).

Fig. 4. 62-year-old male patient with lung cancer and anamnestic splenectomy. (a) On B-mode sonography a round echoic tumor is seen in the left upper abdomen. (b)
Contrast enhanced sonography shows a marked homogeneous enhancement in the parenchymal phase (2 min) suggesting an accessory spleen. (c) Contrast enhanced
computed tomography shows the tumor (arrow).
 C. Görg / European Journal of Radiology 64 (2007) 189–201 193

Fig. 5. 53-year-old male patient with esophageal cancer. (a) B-mode sonography shows a small-sized spleen (S) (arrows). (b) Contrast enhanced sonography after
2 min shows a reduced enhancement of the spleen (arrows). Functional hypospleia/asplenia was confirmed by Tc 99 m colloid liver-spleen scintigraphy. (c) Contrast
enhanced computed tomography shows the small-sized spleen (arrow).

4.2.3. The inhomogenous spleen of unknown cause
In the sonographic diagnosis of hepatic pathology the
“inhomogeneous” liver is a well-known patterns of various
different causes. Less attention has been paid to the well-known
sonographic pattern of a slight inhomogeneity of the splenic
parenchyma without clearly definable focal lesions. In a
pilot study, CES enables to demarcate and characterize focal
lesions in patients with an inhomogeneous splenic texture
in about 50% [32]. The most common cause was splenic
infarction (Fig. 6). It is well known, that splenic infarction in
the acute phase is characterized by a nearly isoechoic pattern
which became increasingly hypoechoic after some days [1,2].
CES enables to show splenic involvement in some patients
with underlying diagnosis of malignant lymphoma and an

Fig. 6. 66-year-old male patient with endocarditis. (a) B-mode sonography shows an inhomogeneous spleen. (b) Contrast enhanced sonography after 1 min shows a
irregular demarcated unenhanced area suggesting splenic infarction (I). (c) Contrast enhanced computed tomography confirmed splenic infarction.
194 C. Görg / European Journal of Radiology 64 (2007) 189–201

Fig. 7. 35-year-old male patient with aggressive non-Hodgkin’s lymphoma. (a) B-mode sonography shows an inhomogeneous spleen. (b) Contrast enhanced
sonography after 3 min clearly shows reduced enhanced areas within the spleen suggesting splenic lymphoma involvement. (c) Contrast enhanced computed
tomography shows an inhomogeneous spleen.

inhomogeneous splenic texture (Fig. 7). On the other hand,
in patients with indolent non-Hodgkin’s lymphoma and very
small hypoechoic nodules on B-mode sonography [3], CES
may show a homogeneous enhancement (Fig. 8). In patients
with granulomatous splenic involvement (i.e. sarcoidosis,
Hodgkin’s disease, tuberculosis) CES may therefore increase
diagnostic sensitivity regarding splenic involvement in these
patients.
4.3. CES in focal splenic abnormalities of splenic
parenchyma
4.3.1. Splenic lymphoma infiltration
The B-mode sonomorphologic features of primary and sec-
ondary splenic lymphoma infiltrations have been described [3].
First reports about CES pattern have shown a hypoechoic inho-
mogeneous enhancement of the noduled lesions by comparison
with the enhancement of the surrounding splenic tissue [15,16].
To date, there are no studies which demonstrates a higher sen-
sitivity of CES versus B-mode US for the identification of focal
lymphoma lesions. So CES cannot be recommended as a staging
procedure in patients with malignant lymphoma.
4.3.2. Splenic metastases
The sonographic pattern of splenic metastases is variable.
Carcinoma infiltration to the spleen indicates an end stage can-
cer disease and is associated with an extreme short survival
time. First reports about CES patterns have shown a hypoechoic
inhomogeneous enhancement of the metastases by comparison
with the enhancement of the surrounding splenic tissue [14,16]
(Fig. 9). In cases of central necrosis this unenhanced area is better
seen by CES than by B-mode US. Like in the liver our first expe-
riences gives the impression, that one can see splenic metastases
more and better by CES than by B-mode US, but prospective
studies are warranted (Fig. 10). In cases of perisplenic tumor
involvement tumor infiltration of the spleen per continuitatem
is better seen by CES than by B-mode US (Figs. 11 and 12).
To date CES cannot be recommended as a staging procedure in
patients with cancer disease.
4.3.3. Splenic incidentaloma
A clinical problem occurs with the incidentally found focal
intrasplenic tumor on ultrasound. Sectional imaging procedures
are often non-specific. The first question is whether a lesion
is benign or malignant. In a recent series of 30 patients with

Fig. 8. 36-year-old male patient with chronic lymphatic leukemia. (a) B-mode sonography shows an inhomogeneous spleen. (b) Contrast enhanced sonography
after 2 min clearly shows a homogeneous splenic tissue enhancement without evidence of focal splenic lymphoma involvement. (c) Contrast enhanced computed
tomography shows a homogeneous spleen.
 C. Görg / European Journal of Radiology 64 (2007) 189–201 195

Fig. 9. 63-year-old male patient with malignant melanoma. (a) B-mode sonography shows an diffuse inhomogeneous spleen. (b) Contrast enhanced sonography
after 1 min clearly demarcates focal hypoechoic enhanced lesions within the spleen suggesting splenic metastases. (c) Contrast enhanced computed tomography
confirmed focal splenic involvement.

incidentalomas no increase of size was seen during a median
follow up from two years (unpublished). Primary malignant
lesions of the spleen were extremely rare and includes pri-
mary malignant non Hodgkin’s lymphoma of the spleen, primary
splenic Hodgkin’s disease, splenic hemangiosarcoma. To date,
there are no data about CES patterns of primary malignant
lesions of the spleen. One may suggest that the CES pattern
of primary splenic lymphoma is the same as that for secondary
splenic lymphoma. The rare primary benign splenic tumors of
the spleen are usually incidental findings. They include splenic
cysts, hemangiomas, hamartomas, and splenic lymphangiomas.
Lesions primary will be classified by there echotexture on B-
mode US. The echofree or echoic liquid tumor includes true
cysts and pseudocysts. Internal reflectivity of the cyst due to
hemorrhage, tissue sequestration, or sedimentation of cystic
content can be distinguished from vital tissue by CES [14]
(Fig. 13). Hydatid cysts demonstrate peripheral but not inter-
nal enhancement. Most splenic cysts will be diagnosed by
m-mode US. The differential diagnosis of incidentally found
hypoechoic/echoic benign splenic tumors includes hamartoma,
hemangioma, and littoral-cell angioma [33–36]. On B-mode US
both splenic hemangioma as well as splenic hamartoma may
present with a hypoechoic, isoechoic or a hyperechoic pattern.
Within the hypoechoic pattern on B-mode US two different CES
patterns could be observed. The first CES pattern is character-
ized by a marked increased enhancement during the early arterial
phase and a reduced enhancement during the parenchymal phase
(Fig. 14). With angiography hamartomas have a characteris-

Fig. 10. 72-year-old female patient with lung cancer. (a) B-mode sonography shows three isoechoic round lesions (arrows). (b) Contrast enhanced sonography after
1 min clearly demarcates the three focal hypoechoic enhanced lesions within the spleen suggesting splenic metastases. (c) Contrast enhanced computed tomography
confirmed focal splenic involvement.
196 C. Görg / European Journal of Radiology 64 (2007) 189–201

Fig. 11. 63-year-old female patient with a neuroendocrine tumor of the pancreatic tail. (a) B-mode sonography shows the pancreatic tumor (TU) and a isoechoic
splenic lesion (arrows). (b) Contrast enhanced sonography after 20 s shows a large hyperechoic enhanced area which includes the pancreatic tail, the splenic hilus
and the central part of the splenic tissue suggesting splenic tumor involvement per continuitatem. (c) Contrast enhanced sonography after 3 min shows a reduced
enhancement of the tumor tissue (TU) in comparison to the regular enhanced surrounding splenic tissue. (d) Contrast enhanced computed tomography confirmed
tumor involvement of the pancreatic tail and the spleen.

tic arteriographic pattern with irregular dilated tortuous vessels,
with or without aneurysmal dilatation, within a well-demarcated
mass, with occasional vascular lakes or arterio-venous shunting
[37–42]. With angiography (capillary) hemangiomas appear as
hypervascular nodules fed by dilated intrasplenic arteries with-
out tumor vessels and vascular lakes [43]. So it is most likely,
that the increased vascular pattern in the arterial phase indi-
cates hamartomas as well as capillary hemangiomas [14,44,45].
The second CES pattern within the hypoechoic incidentally
found splenic tumor shows a reduced enhancement of the lesion
during both phases. This pattern is also observed within the
hyperechoic incidentally found splenic tumor [16]. Depend-

Fig. 12. 74-year-old female patient colorectal cancer and peritoneal carcinomatosis. (a) B-mode sonography shows an inhomogeneous spleen with an irregular
surface (arrows). (b) Contrast enhanced sonography after 1 min clearly demarcates hypoechoic peritoneal tumor lesions (TU) from well-enhanced splenic tissue (S).
(c) Contrast enhanced computed tomography confirmed perisplenic tumor involvement.
 C. Görg / European Journal of Radiology 64 (2007) 189–201 197

Fig. 13. 25-year-old female patient with incidentally found splenic tumor. (a) B-mode sonography shows a large round hypoechoic splenic tumor with swirling
echoes within the lesion on real time examination suggesting a splenic cyst. (b) Contrast enhanced sonography after 3 min shows an unenhanced tumor. (c) Contrast
enhanced computed tomography confirmed diagnosis of a splenic cyst.

ing on internal fibrosis, calcification, and internal hemorrhage
larger (cavernous) hemangiomas may show a mildly hypoechoic
enhancement on CES. This second CES pattern may be seen in
hamartomas as well as in hemangiomas. It should be mentioned
that this CES pattern is also found in hypoechoic lesions due to
malignant lymphoma and hypoechoic splenic metastases. Com-
pared to other parenchymal organs diagnostic puncture or diag-
nostic splenectomy of the incidentally found splenic lesion is
seldom used. The benignity of the lesion is commonly confirmed
by sonographic follow-up investigations. Case reports with cor-
relations of B mode patterns and CES patterns of histologically
confirmed hemangiomas and hamartomas are warranted.
4.3.4. Splenic abscess
Within the spleen macro- and microabscesses could be distin-
guished. The B-mode sonographic features of macroabscesses
are extremely varied. This wide spectrum of ultrasound fea-
tures often makes it impossible to diagnose splenic abscesses
based on sonographic findings alone. CES enables to demar-
cate vital from avital tissue, so abscess are characterized by
an anechoic pattern during all phases and an enhanced rim of
the lesion may be seen (Fig. 15). In patients with subcapsu-
lar abscess formation, the anechoic collection can be clearly
distinguished from the enhanced spleen and enhanced abscess
border. Current therapy for malignant diseases increasingly
uses intensive chemotherapy including autologous and allogenic
bone marrow transplantation. Such treatment is associated with
profound and protracted immunosuppression and the risk of
serious bacterial and fungal infections with the development
of hepatosplenic microabscesses. This microabscesses are an-
/hypoechoic on B-mode US. This pattern can be mimicked
by lymphomatous masses. With CES microabscesses of the

Fig. 14. 48-year-old female patient with an incidentally found splenic tumor (a) B-mode sonography shows a solitary round hypoechoic splenic tumor (arrows). (b–e)
Contrast enhanced sonography shows a marked enhancement in the early arterial phase (b and c) and a hyperechoic enhancement after 1 min (d) and a hypoechoic
enhancement after 7 min (e). Lesion was controlled by sonographic follow up for 5 years without signs of tumor growth suggesting a benign vascular tumor. (c)
Contrast enhanced computed tomography confirmed diagnosis of a vascular tumor with an arterial rim enhancement.
198 C. Görg / European Journal of Radiology 64 (2007) 189–201

Fig. 15. 59-year-old female patient with fever and endocarditis. (a) B-mode sonography shows an inhomogeneous central located and well-delineated area with
swirling echoes on real time examination suggesting splenic abscess. (b) Contrast enhances sonography after 20 s demonstrates a clear demarcated unenhanced area
in the spleen. The diagnosis of abscess was confirmed by ultrasound guided abscess drainage. (c) Contrast enhanced computed tomography confirmed diagnosis of
an unenhanced splenic lesion.

spleen are clearly demarcated from the surrounded splenic tis-
sue and can therefore distinguished from lymphomatous lesions
(Fig. 16). An enhanced border may be seen in microabscesses
[14].
4.3.5. Splenic infarct
Splenic infarction is a relatively common splenic pathology
and may be demonstrated by B-mode US as altered texture.
It is well known, that splenic infarction in the acute phase
is characterized by a nearly isoechoic pattern which became
increasingly hypoechoic after some days [1,2]. The shape of the
infarct depends on the plane of section but always extends to
the surface of the spleen and may therefore produce pain. In the
acute phase splenic infarction may be overlooked by its isoe-
choic pattern on B-mode US. Areas of absent vascularization
like hematomas, abscesses, and infarcts are appropriate for CES
investigation [14,16]. It makes a great visual impact to identify
infarcted areas by using CES. In comparison to B-mode sonog-
raphy CES accurately demonstrates the morphology and extend
of infarcted areas (Fig. 17). Complete splenic infarction with is
characterized by an inhomogeneous splenic parenchyma on B-
mode US and shows no contrast enhancement by CES (Fig. 18).
On our experiences CES enables to see splenic infarctions more
and better than with B-mode US.

Fig. 16. 56-year-old female patient with acute myeloic leucemia in complete remission and incidentally found splenic lesions after high-dose chemotherapy. (a)
B-mode sonography shows multiple small-sized hypoechoic lesions. (b) Contrast enhances sonography after 1 min shows a clear demarcated unenhanced splenic
lesion suggesting splenic micoabscesses. Sonographic and clinical follow up confirmed splenic candidiasis. (c) Contrast enhanced computed tomography confirmed
diagnosis of multiple unenhanced splenic lesions.
 C. Görg / European Journal of Radiology 64 (2007) 189–201 199

Fig. 17. 73-year-old female patient with osteomyelofibrosis and pain in the left upper quadrant. (a) B-mode sonography shows an enlarged inhomogeneous spleen
without focal lesions. (b) Contrast enhances sonography after 4 min demonstrates a clear wedge shaped vascular area directed to the surface of the spleen proving
the diagnosis of splenic infarction. (c) Contrast enhanced computed tomography confirmed diagnosis of splenic infarction.

4.3.6. Splenic rupture
The commoner traumatic splenic blunt splenic rupture should
be differentiated from idiopathic or spontaneous splenic rup-
ture. In blunt abdominal trauma, the spleen is the organ most
frequently injured (up to 35%), because of its position, immo-
bility and soft consistency [46]. Signs of splenic injury that
may be sonographically seen include: (1) free abdominal fluid
which is predominantly located perisplenic, perihepatic, or in
the pouch of Douglas, (2) subcapsular splenic hematoma, (3)
splenic parenchymal organ injury, and (4) splenic posttraumatic
pseudoaneurysm [33]. There have been a number of reports eval-
uating the use of CES for the detection of solid organ injury
[47,48]. Compared with other imaging procedures B-mode US
is the method of choice for the detection of free abdominal
fluid [49]. Subcapsular hematoma is more sensitive seen by
CES than by B-mode sonography [47] (Fig. 19). One expla-
nation for this discrepancy in detection is that acute subcapsular
haemorrhage mostly presented echoic on B-mode sonography.
However, with CES these hematomas appeared anechoic com-
pared with the surrounding normal splenic parenchyma. The
appearance of parenchymal splenic injury on B-mode sonogra-
phy is extremely variable and may be hypoechoic, isoechoic,
mixed echoic, or hyperechoic. With CES this pattern changes
with a clear demarcation of areas of injury with a hypoechoic
or anechoic enhancement compared with the surrounding nor-
mal splenic parenchyma. So CES is much more sensitive than
B-mode sonography in the detection of parenchymal injury.
The value of CES in diagnosis of splenic parenchyma injury in

Fig. 18. 63-year-old male patient with diffuse metastases of pancreatic cancer. (a) B-mode sonography shows and an inhomogeneous splenic tissue and swirling
echoes within the spleen suggesting splenic liquidification due to complete splenic infarction. (b) Contrast enhances sonography after 2 min shows no splenic tissue
enhancement. Diagnosis of complete splenic infarction was confirmed by splenectomy. (c) Contrast enhanced computed tomography confirmed diagnosis of complete
splenic infarction.
200 C. Görg / European Journal of Radiology 64 (2007) 189–201

Fig. 19. 63-year-old male patient with blunt abdominal trauma. (a) B-mode sonography shows a homogeneous splenic parenchyma with a nearly isoechoic subcapsular
hemorrhage (arrows). (b) Contrast enhances sonography after 1 min clearly demarcates the subcapsular hematoma (H). (c) Contrast enhanced sonography in the
apical pol region of the spleen show two parenchymal lesions indicating the traumatic tissue injury (arrow).

Fig. 20. 70-year-old female patient with acute lymphoblastic leucemia and pain in the left upper quadrant. (a) B-mode sonography shows an inhomogeneous splenic
parenchyma with an anechoic lesion. (b) Contrast enhanced sonography after 14 s demarcates an arterial high flow lesion suggesting an intrasplenic pseudoaneurysm.
Splenectomy was indented, but patient developed acute delayed splenic rupture after 48 h. Emergency splenectomy was performed. (c) Contrast enhanced computed
tomography shows the intrasplenic pseudo-aneurysm.

comparison to CT as the gold standard method is discussed con- References

troversially. Catalano et al. [13] showed that avascular splenic
areas, which were not visualized on conventional B-mode sonog-
raphy were well seen on CES as well as on CT. In a CT controlled
study CES diagnosed only 80% of splenic parenchymal injuries
[50]. Their conclusion was that CES cannot be recommended
to replace CT in hemodynamically stable trauma patients. A
rare complication of splenic trauma is pseudoaneurysm. It has
been reported in up to 14% of patients with splenic trauma
[51]. This may be regarded as a special form of occult splenic
rupture [52]. Pseudoaneurysm may be a precursor of delayed
rupture into the abdominal cavity. It has been shown that pseu-
doaneurysm is clearly depicted by CES as a well-delineated
hypoechoic/anechoic lesion (Fig. 20). CES is therefore of value
to identify theses patients at risk for delayed splenic rupture.
The so-called primary or spontaneous splenic rupture is rare.
The signs and patterns of spontaneous splenic ruptures do
not differ from those found in traumatic splenic rupture. The
diagnostic impact is therefore as high as in traumatic splenic
pathology.
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