Imaging Pearls ❯ Spleen ❯ Infection and Infarction
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- While splenic rupture or hemorrhage is most often associated with trauma, a variety of non-traumatic conditions can also cause life-threatening rupture or hemorrhage that require urgent evaluation and management, yet these may not always be considered high on the differential diagnosis in the absence of trauma. Other nomenclatures associated with non-traumatic splenic ruptures include ‘spontaneous, ‘idiopathic’, or even ‘occult’ rupture. In many cases, the spleen harbors an underlying disease process that predisposes it to rupture without direct trauma, hence why it is commonly referred to as ‘atraumatic’ or ‘non-traumatic’ rupture of the spleen. These are further subcategorized as pathologic and non-pathologic (idiopathic).
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. Management can involve interventional radiological procedures such as splenic artery embolization or surgical intervention via laparotomy and splenectomy, in addition to addressing the underlying etiology.
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. - Spontaneous Splenic Rupture
Infectious and inflammatory etiologies
Vasculopathy and thromboembolism
Benign masses and malignancies - 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. Certain connective tissue disorders such as Ehlers- Danlos syndrome and Marfan syndrome can cause noninflammatory vasculopathy and involve the splenic vasculature, increasing the risk of rupture and bleeding. Rare instances of splenic involvement due to fibromuscular dysplasia have also been reported.
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 (Fig. 9). 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. They are heterogeneously enhancing due to areas of necrosis and hemorrhage, and distant metastases may already be present at diagnosis due to the aggressive nature of this disease.
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.
- “Sarcoidosis is a systemic inflammatory condition characterized by noncaseating granulomas. Its annual incidence ranges from 1 to 15 per 100,000 individuals and is more common in women. While pulmonary and mediastinal lymph node involvement is common, affecting 90% of patients, splenic involvement is reported in close to 24% of cases. Splenic sarcoidosis at CT scans reveals multiple solid hypodense nodules of varying sizes, typically hypoenhancing after contrast administration, often coexisting with hepatic nodules and abdominal lymphadenopathies . Traditionally, these splenic lesions exhibit characteristic MRI features based on disease activity. Inflammatory lesions show high signals on T2 and DWI sequences, whereas fibrous lesions present with low signals on both T1 and T2 sequences.”
Spleen anomalies and lesions in CT and MRI: essentials for radiologists and clinicians—a pictorial review
Andres Felipe Herrera‑Ortiz et al.
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04405-6 - Splenic metastases are rare and often associated with advanced stages of widespread metastatic disease in melanoma,breast, ovarian, lung, and colon cancers . Splenic metastases are generally multiple, although isolated metastasis has also been reported as an even rarer occurrence. At CT, splenic metastases commonly present as hypodense lesions; nevertheless, their appearance can vary based on the primary tumor, occasionally manifesting as cystic lesions with diverse enhancement patterns. At MRI, splenic metastases present low signal intensity on T1 and high signal intensity on T2 sequences, with a variable degree of contrast enhancement, making their diagnosis challenging.
Spleen anomalies and lesions in CT and MRI: essentials for radiologists and clinicians—a pictorial review
Andres Felipe Herrera‑Ortiz et al.
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04405-6 - Primary splenic angiosarcoma predominantly affects patients in the 6th–7th decade of life, with an annual incidence of one case per 4 million individuals. This aggressive neoplasm displays a predilection for males and has a poor prognosis, marked by a high mortality rate and significant risk of rupture in up to 30% of cases. At CT imaging, splenic angiosarcoma often presents as solitary or multiple poorly defined nodular masses distorting the normal anatomy of the spleen and producing enlargement. The contrast enhancement pattern on CT varies depending on the extent of necrosis within the lesion. Its enhancement is usually centripetal and heterogeneous, and 69–100% of the cases tend to present with metastases, most commonly disseminating to the liver, lungs, adrenals, bones, and lymphatics .
Spleen anomalies and lesions in CT and MRI: essentials for radiologists and clinicians—a pictorial review
Andres Felipe Herrera‑Ortiz et al.
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04405-6
Diagnosis and treatment of focal splenic lesions
B. Malgras, H. Najah, A. Dohan et al.,
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2021.11.010- “ Pyogenic Splenic abscess is most often due to hematogenous spread of infection with risk factors of diabetes, immunosuppression, corticosteroid therapy and sickle cell disease. It usually manifests as a high fever with chills and pain in the left hypochondrium. Splenic abscess can be single, multiple, or multiloculated.”
Diagnosis and treatment of focal splenic lesions
B. Malgras, H. Najah, A. Dohan et al.,
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2021.11.010 - "On imaging, splenic candidiasis presents as multiple focal lesions that are small (< 1 cm) and rounded. They are hypoechoic on US, and minimally enhanced on CT and MRI. They are best visualized as hyper-intense on T2-weighted sequences and on diffusion sequences. Splenic candidiasis is most often associated with hepatic candidiasis, with hepatic lesions that show the same characteristics as the splenic lesions on imaging. MRI is suggestive when it reveals the ‘‘bull’s eye’’ sign (echogenic center sur- rounded by a hypo-echoic zone).”
Diagnosis and treatment of focal splenic lesions
B. Malgras, H. Najah, A. Dohan et al.,
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2021.11.010 - “Sarcoidosis can affect all organs of the body; its manifesta- tions are non-specific, with clinical repercussions involving mainly the lungs, abdomen (pain) or systemic symptoms (fever, fatigue, weight loss). Imaging reveals splenic involve- ment in 6 to 33% of patients with sarcoidosis, although the prevalence of splenic involvement is between 24 and 59% when systematic histological analysis is performed, or even 38 to 77% in autopsy series. Splenic sarcoidosis is generally manifested by homogeneous splenomegaly that is present in approximately 40% of patients and much more rarely by focal splenic lesions.”
Diagnosis and treatment of focal splenic lesions
B. Malgras, H. Najah, A. Dohan et al.,
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2021.11.010 - “When focal splenic lesions exist, they are often multi- ple, small in size (between 1 mm and 3 cm). They are rarely visible on US, and when they are, they are mildly hyperechoic. On CT, these lesions are mostly hypodense and contain small calcifications in 16% of cases. After IV contrast injection, the lesions are hypodense compared to the splenic parenchyma without peripheral enhancement. On MRI, the focal splenic lesions of sarcoidosis are hypo-intense with weak and late enhancement. They are better visible in T2-weighting with fat saturation, or in the early phase after injection. The lesional architecture is similar to that of lymphomas or splenic metastases.”
Diagnosis and treatment of focal splenic lesions
B. Malgras, H. Najah, A. Dohan et al.,
Journal of Visceral Surgery, https://doi.org/10.1016/j.jviscsurg.2021.11.010