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A Pattern-oriented Approach to Splenic Imaging in Infants and Children¹

¹ From the Department of Radiology, Division of Pediatric Radiology, Duke University Medical Center, Durham, NC 27710. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received February 16, 1999; revision requested March 16 and received April 1; accepted April 1. Address reprint requests to D.P.F.

View larger version (141K): [in a new window]   Figure 1.   Arciform splenic enhancement artifact in a 10-year-old girl with undifferentiated sarcoma. Contrast material-enhanced CT scan shows alternating bands of high and low attenuation. The artifact occurs during the early phase of contrast enhancement—in this case, only 20 seconds after the initiation of contrast material injection.

View larger version (149K): [in a new window]   Figure 2.   Focal artifact in a 10-year-old boy with a history of lymphoproliferative disorder who had undergone liver transplantation. Contrast-enhanced CT scan shows focal low-attenuation artifact mimicking a splenic mass (arrow).

View larger version (134K): [in a new window]   Figure 3.   Normal spleen in a 4-day-old male infant. T2-weighted (repetition time msec/echo time msec = 1,800/80) MR image demonstrates hypointensity of the spleen (arrow) relative to the liver. The nonthrombotic blood in the splenic sinusoids contributes to this finding, which should not be confused with a pathologic condition such as hemochromatosis.

View larger version (152K): [in a new window]   Figure 4.    Normal spleen in a 5-year-old child. T2-weighted (1,800/80) MR image demonstrates hyperintensity of the spleen (arrow) relative to the liver. The high water content of the lymphoid tissue of the white pulp contributes to this finding.

View larger version (87K): [in a new window]   Figure 5a.   Abnormal splenic location in an infant girl with cyanotic congenital heart disease. The spleen could not be visualized at US. (a) On an anterior technetium-99m sulfur colloid scintigram, only the liver is clearly identified; the radiotracer is normally taken up by both the liver and spleen. (b) Anterior Tc-99m denatured red cell scintigram clearly depicts only the spleen (arrow), which lies beneath the right lobe of the liver.

View larger version (60K): [in a new window]   Figure 5b.   Abnormal splenic location in an infant girl with cyanotic congenital heart disease. The spleen could not be visualized at US. (a) On an anterior technetium-99m sulfur colloid scintigram, only the liver is clearly identified; the radiotracer is normally taken up by both the liver and spleen. (b) Anterior Tc-99m denatured red cell scintigram clearly depicts only the spleen (arrow), which lies beneath the right lobe of the liver.

View larger version (154K): [in a new window]   Figure 6.   Hypertrophic accessory spleen in a young girl with hereditary spherocytosis who had undergone splenectomy 30 days earlier. The surgeon had removed all visible splenic tissue. A mass was palpated in the left upper quadrant at follow-up. Contrast-enhanced CT scan shows regeneration of the accessory spleen (arrow).

View larger version (122K): [in a new window]   Figure 7a.   Wandering spleen without evidence of torsion in a 7-year-old girl. (a) Contrast-enhanced CT scan reveals an anterior mass at the level of the cecal pole (solid arrows) with vessels entering posteromedially (open arrow). (b) Anterior Tc-99m sulfur colloid scintigram shows the mass to be an abnormally located spleen (arrow). The liver also demonstrates radiotracer uptake (top).

View larger version (131K): [in a new window]   Figure 7b.   Wandering spleen without evidence of torsion in a 7-year-old girl. (a) Contrast-enhanced CT scan reveals an anterior mass at the level of the cecal pole (solid arrows) with vessels entering posteromedially (open arrow). (b) Anterior Tc-99m sulfur colloid scintigram shows the mass to be an abnormally located spleen (arrow). The liver also demonstrates radiotracer uptake (top).

View larger version (140K): [in a new window]   Figure 8.   Heterotaxia syndrome in a 2-year-old girl. Axial T1-weighted (600/11) MR image shows polysplenia (solid arrows) with azygous continuation of the inferior vena cava (open arrow). The intrahepatic portion of the inferior vena cava is absent. The accessory spleens are isointense relative to the adjacent spleen.

View larger version (161K): [in a new window]   Figure 9.   Heterotaxia syndrome in a 5-month-old infant with congenital heart disease. Axial T1-weighted (600/20) MR image shows polysplenia (arrows). The accessory spleens are all isointense relative to normal splenic tissue.

View larger version (148K): [in a new window]   Figure 10.   Heterotaxia syndrome in a male neonate with biliary atresia. Axial T1-weighted (600/10) MR image shows the liver and midline polysplenia (solid arrow) with a right-sided stomach (open arrow). A preduodenal portal vein (not shown) was also present.

View larger version (152K): [in a new window]   Figure 11.   Splenomegaly in a 15-year-old boy with cystic fibrosis, cirrhosis, and portal hypertension. Contrast-enhanced CT scan obtained at the level of the superior mesenteric artery shows a portosystemic shunt (arrow).

View larger version (137K): [in a new window]   Figure 12a.   Cavernous transformation of the portal vein in a 16-year-old girl with idiopathic portal hypertension who presented with hypersplenism. Coronal T1-weighted (500/10) (a) and axial gradient-echo (33/12, 30° flip angle) (b) MR images show massive splenomegaly. Multiple low-signal-intensity lesions are seen within the spleen in b. These lesions are due to susceptibility artifact from hemosiderin-laden siderotic nodules, which developed secondary to repeated hemorrhage.

View larger version (107K): [in a new window]   Figure 12b.   Cavernous transformation of the portal vein in a 16-year-old girl with idiopathic portal hypertension who presented with hypersplenism. Coronal T1-weighted (500/10) (a) and axial gradient-echo (33/12, 30° flip angle) (b) MR images show massive splenomegaly. Multiple low-signal-intensity lesions are seen within the spleen in b. These lesions are due to susceptibility artifact from hemosiderin-laden siderotic nodules, which developed secondary to repeated hemorrhage.

View larger version (129K): [in a new window]   Figure 13.   Shift in colloid distribution in an adolescent girl with portal hypertension secondary to hepatic veno-occlusive disease who had undergone bone marrow transplantation. Posterior Tc-99m sulfur colloid scintigram shows radiotracer uptake predominantly in the spleen (arrowhead) but also in the liver (open arrow) and faintly in the bone marrow (solid arrow). These findings resolved completely after successful anticoagulation therapy.

View larger version (132K): [in a new window]   Figure 14.   Splenomegaly secondary to acute sequestration crisis in a 20-month-old girl with sickle cell anemia. An enlarged spleen was palpated at physical examination. Abdominal radiograph shows a large, soft-tissue structure in the left upper quadrant.

View larger version (110K): [in a new window]   Figure 15.   Splenic epidermoid cyst in a 5-year-old boy. Transverse US scan through the spleen shows an anechoic lesion with internal septations (arrow). The cyst was discovered incidentally.

View larger version (141K): [in a new window]   Figure 16.    Epidermoid cyst in a 7-year-old boy. Contrast-enhanced CT scan demonstrates a splenic epidermoid cyst (arrow). The lesion was initially discovered at US for urinary tract infection. The diagnosis was confirmed at histopathologic analysis.

View larger version (167K): [in a new window]   Figure 17.   Hemangiomatosis in a 1-month-old boy. Axial fat-saturated T2-weighted fast spin-echo (4,000/102) MR image shows multiple areas of increased signal intensity within an enlarged and distorted liver and small foci of increased signal intensity within the spleen (arrows).

View larger version (147K): [in a new window]   Figure 18a.   Splenic trauma in a 3-year-old boy. (a) Contrast-enhanced CT scan shows a ruptured spleen with free intraperitoneal fluid. The patient also had an associated liver laceration (not shown). (b) Contrast-enhanced CT scan obtained 6 weeks later after conservative management shows a posttraumatic cyst (arrow).

View larger version (126K): [in a new window]   Figure 18b.   Splenic trauma in a 3-year-old boy. (a) Contrast-enhanced CT scan shows a ruptured spleen with free intraperitoneal fluid. The patient also had an associated liver laceration (not shown). (b) Contrast-enhanced CT scan obtained 6 weeks later after conservative management shows a posttraumatic cyst (arrow).

View larger version (157K): [in a new window]   Figure 19.    Splenic trauma in an adolescent girl who was involved in a motor vehicle accident. CT scan shows active extravasation of intravenously administered contrast material (arrows). This finding is considered to require surgical intervention.

View larger version (139K): [in a new window]   Figure 20.   Spontaneous splenic rupture in a 15-year-old boy with splenomegaly who had undergone bone marrow transplantation for leukemia. US showed nonspecific heterogeneity of the splenic echotexture. On a contrast-enhanced CT scan, the splenic fragments are readily appreciated (arrows).

View larger version (158K): [in a new window]   Figure 21a.   Calcified granulomas due to congenital cytomegalovirus infection in a 2-day-old girl. (a) Abdominal radiograph shows calcifications within the liver (open arrow) and spleen (solid arrow). (b) Unenhanced CT scan (bone window) shows the extent of the calcifications more clearly (arrowhead).

View larger version (126K): [in a new window]   Figure 21b.   Calcified granulomas due to congenital cytomegalovirus infection in a 2-day-old girl. (a) Abdominal radiograph shows calcifications within the liver (open arrow) and spleen (solid arrow). (b) Unenhanced CT scan (bone window) shows the extent of the calcifications more clearly (arrowhead).

View larger version (132K): [in a new window]   Figure 22.   Pyogenic splenic abscess in a 2-year-old girl with aplastic anemia. Contrast-enhanced CT scan shows a well-defined, low-attenuation lesion in the tip of the spleen (arrow). The abscess was drained, and culture was positive for E coli and mixed gram-positive organisms. (Courtesy of B. Spector, MD, University of North Carolina Memorial Hospital, Chapel Hill, NC.)

View larger version (116K): [in a new window]   Figure 23.   Splenic candidal microabscesses in a 4-year-old girl with leukemia. US scan shows multiple hypoechoic lesions in an enlarged spleen (arrows).

View larger version (139K): [in a new window]   Figure 24.   Cat-scratch fever in a 6-year-old boy who presented with a fever of unknown origin. Contrast-enhanced CT scan shows multiple low-attenuation lesions within a normal-size spleen. These lesions can be occult without the use of intravenously administered contrast material.

View larger version (183K): [in a new window]   Figure 25.   Leukemic involvement of the spleen in a 13-year-old girl with sickle cell disease. Transverse US scan through the splenic hilum shows multiple hypoechoic nodules (arrows). The spleen was not enlarged, and there was no evidence of recurrent disease elsewhere within the abdomen.

View larger version (158K): [in a new window]   Figure 26.   Multifocal splenic lymphoma in a 17-year-old girl with Hodgkin disease. Contrast-enhanced CT scan obtained just inferior to the level of the splenic hilum shows multiple low-attenuation nodules of varying size within an enlarged spleen. Moderate hepatomegaly and intraabdominal lymphadenopathy (not shown) were also found.

View larger version (154K): [in a new window]   Figure 27.   Multifocal masses from lymphoproliferative disease in a male infant who had undergone liver transplantation. Contrast-enhanced CT scan shows multifocal low-attenuation masses in the spleen (arrows).

View larger version (125K): [in a new window]   Figure 28a.   Gaucher disease in an adolescent girl. Axial T1-weighted (600/12) (a) and T2-weighted fast spin-echo (4,000/104) (b) MR images obtained at routine follow-up show massive splenomegaly with areas of low signal intensity (arrows). These findings are consistent with fibrosis after splenic infarction, which is typical with Gaucher disease. The liver also appears somewhat enlarged.

View larger version (140K): [in a new window]   Figure 28b.   Gaucher disease in an adolescent girl. Axial T1-weighted (600/12) (a) and T2-weighted fast spin-echo (4,000/104) (b) MR images obtained at routine follow-up show massive splenomegaly with areas of low signal intensity (arrows). These findings are consistent with fibrosis after splenic infarction, which is typical with Gaucher disease. The liver also appears somewhat enlarged.

View larger version (153K): [in a new window]   Figure 29.   Disseminated mycobacterial infection in an 11-year-old boy. Transverse US scan through the upper pole of the spleen shows heterogeneity of the splenic echotexture. No focal lesion is seen. There was no associated splenomegaly.

View larger version (179K): [in a new window]   Figure 30.   Splenic infarction secondary to severe fungal infection in an immunocompromised 4-year-old boy. Contrast-enhanced CT scan shows several large, wedge-shaped areas of nonenhancing splenic tissue. The liver and kidneys are enlarged.

View larger version (105K): [in a new window]   Figure 31a.   Wandering spleen with infarction in a 3-year-old boy. (a) Transverse US scan shows the spleen in the right lower quadrant (arrow). There are no discernible abnormalities in echotexture. (b) Anterior Tc-99m sulfur colloid scintigram shows the liver in its normal location in the right upper quadrant (arrow). There is no evidence of splenic uptake of radiotracer. These findings helped confirm the clinical suspicion for splenic infarction secondary to torsion about the elongated vascular pedicle.

View larger version (72K): [in a new window]   Figure 31b.   Wandering spleen with infarction in a 3-year-old boy. (a) Transverse US scan shows the spleen in the right lower quadrant (arrow). There are no discernible abnormalities in echotexture. (b) Anterior Tc-99m sulfur colloid scintigram shows the liver in its normal location in the right upper quadrant (arrow). There is no evidence of splenic uptake of radiotracer. These findings helped confirm the clinical suspicion for splenic infarction secondary to torsion about the elongated vascular pedicle.

View larger version (151K): [in a new window]   Figure 32.   Splenic infarction secondary to idiopathic pancreatitis and splenic vein thrombosis in an adolescent girl. Contrast-enhanced CT scan obtained at the level of the pancreatic tail shows a nonenhancing spleen. The pancreatic tail is inflamed, and there is subjacent stranding in the peripancreatic and splenic fat (arrow).

View larger version (147K): [in a new window]   Figure 33.   Splenic infarction in a 7-year-old boy with sickle cell disease. Contrast-enhanced CT scan shows a predominantly low-attenuation enlarged spleen with capsular enhancement (arrow). This finding is due to a separate arterial supply to the splenic capsule.

View larger version (96K): [in a new window]   Figure 34.   Splenic hemosiderosis due to iron overload secondary to transfusions for sickle cell anemia. Axial T1-weighted (600/15) MR image shows low signal intensity secondary to reduced T1 and T2 in both the liver and spleen. This finding is due to a combination of hemosiderin deposition, calcification, and fibrosis.

View larger version (159K): [in a new window]   Figure 35.   Splenic hemangioma in a 1-month-old boy. Axial T2-weighted (1,800/80) MR image shows large areas of signal void corresponding to slow flow within the intrasplenic vessels. Splenomegaly is also present.

View larger version (135K): [in a new window]   Figure 36a.   Diffuse splenic disease due to peliosis from androgen therapy for Fanconi anemia in an 18-year-old girl. Axial T1-weighted (600/20) (a) and gradient-echo (25/13, 30° flip angle) (b) MR images show multiple low-signal-intensity lesions within both the liver and spleen. The lesions represent magnetic susceptibility artifact in siderotic nodules. These nodules occur after hemorrhage and are more readily apparent in b. Signal void due to renal excretion of gadolinium-enhanced contrast material is seen within the renal collecting system (arrow).

View larger version (137K): [in a new window]   Figure 36b.   Diffuse splenic disease due to peliosis from androgen therapy for Fanconi anemia in an 18-year-old girl. Axial T1-weighted (600/20) (a) and gradient-echo (25/13, 30° flip angle) (b) MR images show multiple low-signal-intensity lesions within both the liver and spleen. The lesions represent magnetic susceptibility artifact in siderotic nodules. These nodules occur after hemorrhage and are more readily apparent in b. Signal void due to renal excretion of gadolinium-enhanced contrast material is seen within the renal collecting system (arrow).