title: At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization.
abstract: BACKGROUND
  To clarify the role, indications, and outcomes for angioembolization (AE) of nonoperatively managed (NOM) splenic trauma, the implications of absent contrast blush (CB) on computed tomography of high-grade (IV-V) blunt splenic trauma (BST) in adults were analyzed.
  
  
  METHODS
  All BST patients presenting at a single institution from July 2000 to December 2011 were retrospectively reviewed. Grade of injury (American Association for the Surgery of Trauma scale), CB on initial computed tomography, numbers of NOM and undergoing AE, and failures of NOM were analyzed. Statistical analysis was performed using χ(2).
  
  
  RESULTS
  Of the 1,056 total BST patients, 556 (64%) were hemodynamically stable and eligible for NOM; 95 NOM patients (17%) had CB. AE was performed in 88 of these, with angiographic extravasation found in 86 (97.7%), and 3 of these 88 (3.4%) failed NOM. The remaining 7 CBs were observed without AE, of which 5 (71.4%) failed NOM (p = 0.0004). Of all 556 NOM patients, 51 (9.5%) had high-grade injuries without CB; 20 of these (39%) underwent AE, 17 (85.0%) underwent angiographic extravasation, and there were no NOM failures in this group. The other 31 high-grade injuries without CB or AE had 8 failures of NOM (26%) (p = 0.03).
  
  
  CONCLUSIONS
  The strong correlation of CB with active bleeding on angiogram mandates AE for CB in all BST undergoing NOM. However, the absence of CB in high-grade (IV-V) BST does not reliably exclude active bleeding. This may be the reason for the high reported failure rates of NOM in high-grade (IV-V) BST because AE is not typically performed in the absence of CB. These data suggest that all hemodynamically stable high-grade (IV-V) BST in adults should undergo AE regardless of CB to optimize the success and safety of NOM.
  
  
  METHODS
  Therapeutic study, level III.
authors.affiliation: Division of Acute Care Surgery, University of Florida College of Medicine, Jacksonville, Florida 32209, USA. Indermeet.bhullar@jax.ufl.edu
authors.forename: Indermeet Singh
authors.initials: IS
authors.lastname: Bhullar
authors.forename: Eric R
authors.initials: ER
authors.lastname: Frykberg
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Tepas
authors.forename: Daniel
authors.initials: D
authors.lastname: Siragusa
authors.forename: Todd
authors.initials: T
authors.lastname: Loper
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Kerwin
mesh_terms: D000328:Adult; D000792:Angiography; D004621:Embolization, Therapeutic; D005119:Extravasation of Diagnostic and Therapeutic Materials; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D013154:Spleen / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000293:injuries*; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000628:therapy