Imaging Pearls ❯ Spleen ❯ Imaging Techniques
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- ”Spontaneous or atraumatic rupture of the spleen is an uncommon but potentially fatal abdominal emergency, often overshadowed by trauma-related etiologies. However, a wide range of infectious, neoplastic, vascular, autoimmune, and iatrogenic conditions can predispose the spleen to rupture without direct trauma. Multidetector computed tomography (MDCT) is the preferred modality for evaluating these cases, offering rapid, high-resolution assessment of hemorrhage—with or without active bleeding—and associated parenchymal abnormalities. This pictorial review highlights the diverse spectrum of underlying causes and characteristic imaging findings through 13 cases. It also outlines CT acquisition protocols, postprocessing techniques, and key clinical features that radiologists must be aware of to reach timely diagnoses and guide management. Early recognition and identification of the underlying pathology are critical in improving patient outcomes and directing appropriate interventions. ”
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Epidemiologically, only 7% of atraumatic splenic ruptures are idiopathic, while the rest are due to one or more underlying etiological factors that include neoplastic processes, inflammatory or autoimmune disorders, viral infections, and hematological conditions. Patients typically present with vague to sharp abdominal pain and tenderness, nausea and vomiting, referred left shoulder pain (Kehr’s sign) that is seen in up to half of all patients, drop in hemoglobin, and sudden hemodynamic instability and shock in cases of more severe bleeding. The presence of splenomegaly, which has been seen in up to 55% of patients with atraumatic splenic rupture, and age above 40 are significantly associated with a higher mortality rate.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Infectious disorders are the second most common cause of pathologic atraumatic splenic rupture, following neoplastic processes that we will discuss below. Infectious mononucleosis is a common cause of splenomegaly, occurring nearly all cases of infectious mononucleosis, typically caused by Ebstein Barr Virus (EBV) and cytomegalovirus (CMV). The incidence of splenic rupture in infectious mononucleosis ranges between 0.1%−0.5%, and over 85% of ruptures occur in the absence of any explicit trauma or injury . Other infections that rarely result in splenic hemorrhage or rupture include varicella zoster virus (VZV), CMV, dengue virus, malaria, babesia, and bacterial infections like tuberculosis, brucellosis, salmonella typhi, and tularemia.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Aneurysms and pseudoaneurysms of the splenic artery make up nearly 70% of all visceral aneurysms. True aneurysms are most commonly idiopathic, but associated causes include portal hypertension, chronic liver disease, atherosclerosis, and acute or chronic pancreatitis. Atypical intraparenchymal pseudoaneurysms, which tend to be more saccular in morphology, are less frequent and almost always secondary to an underlying cause, commonly pancreatitis, iatrogenic injury, or infection. They pose a particularly high risk of rupture (up to 37%) and are nearly always fatal when untreated.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Malignant hematologic disorders are the most common cause of spontaneous splenic rupture, including acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), lymphoma (discussed in the next section), myeloproliferative disorders such as polycythemia vera or myelofibrosis, and myelodysplastic syndromes. The presence of splenomegaly and age above 40 are significantly associated with increased mortality when ruptured . While the pathophysiology remains unclear, infiltrative processes and infarction are thought to be responsible for spontaneous splenic rupture. Apart from an enlarged spleen, sites of splenic infarcts and perisplenic fluid collections can be appreciated in cases of spontaneous splenic rupture.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Malignant masses can be primary or metastatic lesions. Lymphoid neoplasms are the most common primary malignant splenic neoplasms, including Hodgkin and non-Hodgkin lymphoma subtypes. They often present as part of systemic disease commonly with associated adenopathy, and rarely as primary site of disease (less than 2% of all lymphomas). CT findings range from homogenous splenomegaly to solitary or multiple nodules or masses. Splenomegaly is present in two-thirds of patients and the lesions are frequently hypoenhancing. Another major primary splenic malignancy is angiosarcoma. Primary angiosarcomas of the spleen are rare (less than 5% of all angiosarcomas) and present as single or multiple complex masses or nodules with irregular borders in the background of splenomegaly.
CT of spontaneous atraumatic splenic rupture: etiologies and imaging findings.
Yasrab M, Rahmatullah ZF, Chu LC, Kawamoto S, Fishman EK
Emerg Radiol. 2025 Sep 30. doi: 10.1007/s10140-025-02383-w. Epub ahead of print. - Splenic Rupture: Background
Splenic rupture, a rare but life-threatening condition, leads to internal bleeding and acute abdominal distress.
Pathologic Ruptures: Arise from underlying splenic disease. (93%)
Infections
Inflammatory or autoimmune disorders
Vascular abnormalities
Hematological abnormalities and thromboembolism
Benign lesions
Neoplastic processes
Idiopathic Ruptures: No identifiable cause. (7%) - Background
Clinical Signs and Symptoms:
Abdominal Pain and Tenderness: Vague or sharp.
Kehr's Sign: Referred left shoulder pain (present in ~50% of patients).
Nausea and vomiting.
Hemodynamic instability and shock (in severe bleeding).
Drop in hemoglobin.
Associated Risk Factors:
Presence of splenomegaly (55% of cases).
Age > 40 years, linked to higher mortality rates. - Splenic Rupture :Utility of CT Imaging
Contrast enhanced CT imaging gold standard for diagnosis:
Provides detailed evaluation of:
- Splenic parenchyma (e.g., hematomas, infarcts, hyperdensity).
- Active bleeding and extravasation of contrast.
- Associated complications (e.g., hemoperitoneum, splenomegaly).
Rapid acquisition for emergency presentations
Widely accessible
High spatial resolution
Arterial, venous, delayed phase acquisition
Ability for post-processing (e.g. 3D cinematic rendering) - Splenic Rupture : Infectious Causes
Epstein–Barr virus (EBV) or cytomegalovirus (CMV) most common.
Other Viral: Varicella zoster virus (VZV), dengue virus.
Parasitic: Malaria, babesia.
Bacterial: Tuberculosis, brucellosis, salmonella typhi, tularemia.
Pathophysiology:
Involves splenic sequestration, splenomegaly, hemorrhage, ± abscess or hematoma formation.
Abscesses may appear as centrally low-density lesions with possible peripheral enhancement (if encapsulated). - Splenic Rupture: Other Inflammatory Causes
Acute or chronic pancreatitis-associated rupture. Direct extension of peripancreatic inflammation to the spleen.
Vasculitis-associated rupture (polyarteritis nodosa, granulomatosis with polyangiitis). Involve splenic vessels, increasing hemorrhage risk.
Autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, and Behçet disease). - Splenic Rupture Vascular Causes
True Aneurysms of Splenic Artery:
Most commonly idiopathic.
Associated causes: portal hypertension, chronic liver disease, atherosclerosis, acute/chronic pancreatitis.
Pseudoaneurysms of Splenic Artery:
Less common and typically saccular in morphology.
Nearly always secondary to underlying causes: pancreatitis, iatrogenic injury, or infection.
Significantly higher risk of rupture (up to 37%) and often fatal without treatment. - Splenic Rupture: Vascular Causes
Connective Tissue Disorders: Ehlers-Danlos, Marfan syndrome → Increased rupture risk; rare fibromuscular dysplasia cases.
Hypercoagulability: From malignancy/pancreatitis → Vessel occlusion, infarction, rupture.
Emboli: Endocarditis or atrial fibrillation → Infarcts, hemorrhaging, mycotic pseudoaneurysms.
Medications: Anticoagulants (e.g., apixaban, rivaroxaban) → Higher risk of atraumatic bleeding. - Splenic Rupture: Benign Masses
Hemangiomas: Most common benign splenic neoplasm (seen in up to 14% of autopsies). Risk of rupture in up to 25%. Imaging: Persistent homogeneous enhancement, or early peripheral enhancement with delayed fill-in.
Splenic Hamartomas: Contour abnormalities, fat deposition, calcifications, cystic changes.
Epidermoid and Mesothelial Cysts: Hypoattenuating, fluid-filled, well-circumscribed lesions with possible calcifications and no enhancement. - Splenic Rupture: Malignant Causes
Hematologic Malignancies:
Acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), lymphoma, polycythemia vera, myelofibrosis, and myelodysplastic syndromes.
Primary Malignant Splenic Neoplasms:
Lymphoid Neoplasms (e.g., Hodgkin and non-Hodgkin lymphoma). Presents with homogenous splenomegaly, solitary/multiple nodules or masses, hypoenhancing lesions.
Angiosarcoma: presents as heterogeneously enhancing masses with necrotic or hemorrhagic areas; highly aggressive. - Splenic Rupture: Metastatic Lesions
Common Primary Cancers
- Lung
- Melanoma
- Breast
- Ovarian
- GI malignancies.
Features: Solitary or multiple hypoenhancing lesions, cystic or necrotic components.
Complications: Bleeding, rupture, vessel occlusion, infarcts.
- MDCT of the Spleen: Technique
Routine scanning
- Single phase acquisition
- 60-70 second delay
Suspected splenic artery aneurysm or bleed
- Dual phase acquisition
- 25 and 60-70 second delay - Laparoscopic Splenectomy: Why?
- Decreased pain
- Lower morbidity and transfusion rate
- Less postoperative ileus
- Shorter hospital stay
- Faster return to work
- Improved cosmesis when compared to open splenectomy - Laparoscopic Splenectomy: Indications
- Autoimmune disorders (ITP)
- Hereditary hemolytic anemias
- Hematologic malignancies
- Other causes of splenic dysfunction - Laparoscopic Splenectomy: Contraindications
- Portal hypertension
- Severe coagulopathy