British Journal of Radiology (2004) 77, 333-334
© 2004 British Institute of Radiology
doi: 10.1259/bjr/73325367
A novel application of ultrasound contrast: demonstration of splenic arterial bleeding
P Glen, MRCS
1
J MacQuarrie, BSc
1
C W Imrie, FRCS
1 and
E Leen, MD
2
Lister Department of 1 Surgery and 2 Department of Radiology, Queen Elizabeth Building, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
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Abstract
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Recent research in the use of ultrasound contrast agents has found they are able to increase the diagnostic power of ultrasound, to a level that may exceed other imaging modalities, in the diagnosis of liver lesions. Their application in the assessment of haemorrhage following angiographic embolisation has not previously been described. We report on a case where metal coil embolisation of a bleeding splenic artery aneurysm was completed to angiographic satisfaction, but on injection of ultrasound contrast medium, the aneurysm, distal to the embolisation, showed the presence of ultrasound contrast medium within it. We suggest that contrast enhanced ultrasound may be more sensitive than conventional angiography in the assessment of blood flow through intra-abdominal small vessel aneurysms or solid organs.
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Introduction
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Ultrasound has recently benefited from the introduction of contrast agents. These agents consist of microspheres that enhance the reflection of the ultrasound signal and modify the acoustic properties of areas of interest [1, 2]. They are safer than non-ionic contrast media and have the benefit of not requiring ionizing radiation to image [3]. Reported applications of ultrasound contrast include demonstrating the blood–endocardial barrier in the heart and heart valves [4], demonstration of patency of fallopian tubes [5], demonstration of vesicoureteric reflux [6] and imaging and assessment of perfusion of the tissues of solid abdominal organs or lesions therein [7]. We report on a case where SonoVue (Bracco SpA, Milan, Italy) contrast was found to be of value in the assessment of embolisation in a patient bleeding from a splenic artery aneurysm.
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Case report
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A patient with previous acute pancreatitis and a splenic haematoma, who was being treated conservatively, was kept under CT surveillance. When the CT showed gas around the haematoma the patient was taken to theatre for a splenectomy and evacuation of the suspected infected haematoma. The splenic artery was embedded within an inflammatory mass and could not be safely completely explored. Post-splenectomy the patient became hypotensive and as CT angiography (Figure 1
), demonstrated a splenic artery aneurysm, embolisation was performed. Standard metal coils were placed until no bleeding could be identified by angiography (Figure 2). As the splenic artery aneurysm was visible on transabdominal ultrasound, a contrast enhanced ultrasound was performed at the same time as angiography. 2 ml of ultrasound contrast medium (SonoVue; Bracco SpA, Milan, Italy) was injected into a peripheral intravenous cannula followed by 5 ml of saline flush and scanning performed using an Acuson Sequioa scanner (now Siemans, Mountain View, CA; non-linear CCI mode, with continuous low mechanical index (MI) imaging (0.12)). This demonstrated contrast flowing into the splenic artery aneurysm (Figure 3), consequently further coils were immediately placed in. Following this no contrast could be demonstrated distal to the embolisation (Figure 4). The patient had a further urgent laparotomy to evacuate a second haematoma and haemostasis post-embolisation was confirmed at surgery approximately 2 h after the embolisation.
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Discussion
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Angiographic embolisation is a useful tool in the management of bleeding, where it can be difficult to identify haemorrhage amongst an inflammatory or necrotic mass at surgery. Unfortunately angiography does not always demonstrate blood loss, unless the rate of haemorrhage is sufficient, as is often the case in the investigation of occult gastrointestinal bleeding. Previous studies have estimated the threshold for the demonstration of bleeding as 0.5 to 1.3 ml min–1 [8–10]. It therefore follows that successful embolisation may occasionally not have caused complete occlusion of the bleeding vessel. The use of ultrasound contrast may enable the detection of haemorrhage at a lower threshold than angiography.
The use of ultrasound contrast in the assessment of intra-abdominal haemorrhage has been investigated in canine models and found to improve the detection of bleeding sites in the kidney, spleen, and gastrointestinal tract [11, 12]. We have not found any specific reports of ultrasound contrast agents being used to assess bleeding in humans. Although further studies are required, it is possible that as in this case contrast enhanced ultrasound may prove to have a useful role in the immediate assessment of embolisation in the liver and spleen.
Received for publication February 26, 2003.
Revision received March 27, 2003.
Accepted for publication July 3, 2003.
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References
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