title: Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS).
abstract: BACKGROUND
  Pseudoaneurysm (PA) formation following blunt and penetrating abdominal trauma is a recognized complication in solid organ injury, usually diagnosed by contrast-enhanced CT (CECT) imaging. Delayed rupture is a potentially life-threatening event, although its frequency is not known in pediatric trauma. Contrast enhanced ultrasound (CEUS) is a novel radiation-free alternative to CECT with the potential to identify PA.
  
  
  METHODS
  A retrospective review of consecutive cases of significant liver and splenic injuries admitted to single institution (tertiary and quaternary referrals) over more than a 12year period was performed. From 2011, CEUS was performed routinely postinjury (5-10days) using SonoVue™ as contrast. Initially, CECT and CEUS were performed in tandem to ensure accurate correlation.
  
  
  RESULTS
  From January 2002-December 2014, 101 (73M) children [median age was 14.2 (1.3-18)years] with liver and splenic injuries were admitted. Injuries included: liver [n=57, grade 3 (1-5)], splenic [n=35, grade 3 (1-5)], and combined liver/spleen [n=8, (1-4)]. Median Injury Severity Score (ISS) was 13 (2-72). The predominant mechanisms of injury were blunt trauma n=73 (72%) and penetrating trauma n=28 (28%). Seventeen children (17%) developed PA. Six children became symptomatic (35%), and five went on to have embolization [at 7 (3-11)days]. These were detected by CECT (n=4) and CEUS (n=2). Eleven children remained asymptomatic [detected by CECT (n=8) and CEUS (n=3) at median 5 (4-8)days]. One underwent embolization owing to evidence of interval bleeding. Sensitivity of CEUS at detection of PA was 83%, with specificity of 92% (PPV=71%, NPV=96%). There was no association between grade of injury and presence of PA in either liver or splenic trauma (P=0.4), nor was there an association between size of PA and symptoms (P=0.68). Children sustaining splenic PA were significantly younger than those with hepatic PA (P=0.03). Follow-up imaging confirmed resolution of PA in 16 cases. One child was lost to follow-up.
  
  
  CONCLUSIONS
  The incidence of PA is higher than previously reported in the pediatric literature (<5%). Postinjury imaging appears mandatory, and CEUS appears to be highly sensitive and specific for diagnosis and follow-up.
authors.affiliation: Department of Paediatric Surgery, King's College Hospital, London, UK.
authors.forename: Natalie
authors.initials: N
authors.lastname: Durkin
authors.affiliation: Department of Radiology, King's College Hospital, London, UK.
authors.forename: Annamaria
authors.initials: A
authors.lastname: Deganello
authors.affiliation: Department of Radiology, King's College Hospital, London, UK.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Sellars
authors.affiliation: Department of Radiology, King's College Hospital, London, UK.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Sidhu
authors.affiliation: Department of Paediatric Surgery, King's College Hospital, London, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Davenport
authors.affiliation: Department of Paediatric Surgery, King's College Hospital, London, UK. Electronic address: erica.makin@ntlworld.com.
authors.forename: Erica
authors.initials: E
authors.lastname: Makin
mesh_terms: D000293:Adolescent; D017541:Aneurysm, False / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003287:Contrast Media; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D008099:Liver / Q000293:injuries*; D008297:Male; D011859:Radiography; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013154:Spleen / Q000293:injuries*; D014463:Ultrasonography; D014949:Wounds, Nonpenetrating / Q000150:complications; D014950:Wounds, Penetrating / Q000150:complications
chemical_list: D003287:Contrast Media
keywords: Abdominal trauma; Arterial pseudoaneurysm; Contrast-enhanced ultrasound