splenic pseudoaneurysms ( spa ) are a serious sequela of blunt traumatic injury to the spleen .
they are very rare with fewer than 200 cases reported in english literature in 2006 and their incidence is virtually unknown .
spa have a high risk of rupture and have been reported to be fatal if left untreated in adults . in the setting of trauma , spa can form 1 to 8 days after the blunt splenic injury and could be missed on the initial imaging .
however , the management in pediatric patients is poorly defined . with regards to spa ,
although the american pediatric surgical association does not recommend routine follow - up imaging in pediatric trauma patients regardless of grade of injury , several reviews have described the potential benefits of follow - up ct imaging for detection of pseudoaneurysm . here
, we share our experience at an urban level 1 trauma center of managing a hemodynamically stable pediatric patient who sustained a grade iii / iv splenic laceration following blunt trauma with follow - up imaging demonstrative of splenic pseudoaneurysm and proposed algorithm to manage such a case .
a 15 year - old male with no significant past medical history presented to the emergency room complaining of severe abdominal pain of acute onset after sustaining injury to his left side while playing football .
his vital signs were within normal limits on arrival to the emergency room with a gcs of 15 .
the patient s physical exam was significant for mild tenderness to palpation of his abdomen without peritonitis .
primary survey included a focused assessment with sonography for trauma ( fast ) , which was positive for free fluid in the abdomen .
a ct abdomen / pelvis was obtained , demonstrating a grade iii / iv left splenic laceration with moderate to large hemoperitoneum .
he was admitted to the surgical intensive care unit for further monitoring . over the next 24  h serial labs
were drawn with a hematocrit as follows : 34.5%  >  33.2%  >  30.1% .
serial abdominal exams and hemodynamic status remained stable throughout his admission . on hospital - day 3 , a follow - up cta abdomen / pelvis was obtained which demonstrated an approximately 6  mm ovoid hypervascular structure within the cleft of the splenic laceration suspicious for a small pseudoaneurysm ( fig .
interventional radiology was consulted and on hospital - day 5 ; they performed a splenic arteriogram which demonstrated multiple pseudoaneurysms arising from the second order splenic artery branches .
proximal coil embolization with 10  mm    20  cm boston scientific interlock coil was performed without complications .
he was observed for another 24  h post - procedure without event and was discharged the next day after receiving the pneumococcal and meningococcal vaccines .
the patient was seen for follow up in our trauma clinic 5 days post - discharge without complaints .
splenic artery pseudoaneurysms ( spa ) remain a rare but potentially fatal pathology following blunt trauma which is managed non - operatively .
studies have demonstrated the benefits of repeated follow - up imaging and early intervention upon diagnosis of spa .
management of spa can be operative entailing splenectomy with or without pancreatectomy or non - operative , using endovascular techniques .
in recent studies , utilization of angioembolization has been demonstrated to decrease non - operative management failure rate in adults with blunt splenic injuries . however in children , there are no strong evidence - based guidelines that exist to help guide management of spa
. pediatric splenic trauma may be more suitable for non - operative management than that of adult because the differences in pathophysiology of the injury .
the pediatric spleen has a fibrous capsule that is thicker than that of an adult , and lacerations in pediatric patients tend to occur in avascular planes .
one major controversy in management of pediatric blunt trauma patient is the utilization of predischarge or postdischarge follow - up imaging , usually 37 days after initial presentation [ 68 ] .
the recommendation from the american pediatric surgical association trauma committee against this practice is based on the fact that less than half of pediatric patient received follow - up imaging without reported complications . due to small cases presented in literature ,
. showed in a retrospective study that follow - up doppler ultrasound found spa in 7.7% of grade iii splenic injuries and 17% of grade iv .
the study showed that follow - up imaging may be useful in identifying spa in grade iii and iv splenic injury .
however , the study is limited by the size of the sample population . in 2008 , mayglothling et al .   described their experience of managing 97 adolescent patients with blunt splenic injury . in the study ,
mayglothling presented their algorithm with aggressive angiography and embolization as a useful adjunct to non - operative management of adolescents with blunt splenic injuries .
the trauma center performed splenic artery angiography screening for patients with grade iii , iv or v splenic injury , contrast blush or pseudoaneurysm on ct .
the authors also favored follow - up imaging 4896  h post - injury in their treatment algorithm .
when compared to the direct catheter angiography , our patient 's follow - up ct angiography of the abdomen demonstrated an underestimation of the size and severity of the pseudoaneurysms .
also , dsa may be better at showing the smaller pseudoaneurysms that can not be visualized on the ct scan .
direct catheter angiography of the splenic artery has been assumed to be the gold standard to diagnose splenic artery pseudoaneurysm . with the advancing technology of interventional radiology
, advanced blood vessel fluoroscopy techniques such as digital subtraction angiography ( dsa ) can provide high spatial resolution that allows the imaging of small vessels .
the use of doppler sonography has also been described in the diagnosis of splenic aneurysms . however
, this mode of imaging may be limited by its operators and its low spatial resolution . the use of magnetic resonance imaging ( mri ) has been reported .
multiple detector computer tomography ( mdct ) technology is the most utilized tool in critical care .
ct can obtain high resolution images of the whole body in a short amount of time when compared to dsa and to mri .
studies have shown that mdct is favorably comparable to catheter angiography in detecting stenosis and small blood vessels .
cta has also been shown to be safe and effective alternative to dsa for making decisions in cerebral aneurysm management .
, brenner et al .   of columbia university have estimated that the lifetime risk of fatal malignancy from both abdominal and head ct examination is roughly 500 out of 600,000 .
although the risk is present , benefit of ct scan may outweigh the small increase in cancer risk in acute situations .
given that many of above sample populations received ct scans over a decade ago , the advancement of ct technology may have significantly decreased the radiation burden to children .
even though there may be an association between incidence of spa and high grade splenic lacerations ( i.e. , grade iii and iv splenic laceration ) , there is no strong clinical evidence to show benefits of aggressive angiography of these patients .
we concur with safavi et al . in the necessity of follow - up imaging before planned discharge because there is a potential risk of delayed splenic rupture in this population .
the limited existing literature leaves us with a still unclear algorithm for the management of non - operative blunt splenic trauma in pediatric patients .
questions still remain regarding the timing of repeat imaging for diagnosis of spa following non - operative blunt splenic trauma , which patients should be imaged , and how to manage spa upon diagnosis .
more clinical study and basic science research is warranted to study the disease process of spa in pediatric patient .
we believe that our proposed management algorithm timely detect formation of delayed spa formation and addresses the possible fatal disease course of pediatric spa .
roger chen zhu  review of literature , preparation of case report , and writing of the paper .
 highlightssplenic pseudoaneurysms ( spa ) are a rare but serious sequela of blunt splenic trauma.natural course and management of spa are not well defined in children.we report a case of splenic pseudoaneurysm in pediatric blunt trauma.cta showed underestimate of severity of spa compared to direct catheter angiography.we propose an algorithm of management for pediatric splenic trauma . 
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