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1 Department of Radiology, University Hospital of Geneva, 24, rue
Micheli-du-Crest, 1211 Genève-14, Switzerland.
2 Clinic/Policlinic of Digestive Surgery, University Hospital of Geneva, Geneva,
Switzerland.
3 Emergency Center, University Hospital of Geneva, Geneva, Switzerland.
Received January 12, 2004;
accepted after revision March 22, 2004.
Address correspondence to P.-A. Poletti
(pierre-alexandre.poletti{at}hcuge.ch).
Abstract
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SUBJECTS AND METHODS. Two hundred ten consecutive hemodynamically stable trauma patients underwent both abdominal sonography and CT at admission. The presence of solid organ injuries and the quality of sonography examinations were recorded. Patients with false-negative sonography findings for solid organ injuries in comparison with CT results underwent control sonography. If a solid organ injury was still undetectable, contrast-enhanced sonography was performed. Findings of admission, control, and contrast-enhanced sonograms were compared with CT results for their ability to depict solid organ injuries. Contrast-enhanced sonography was also performed in patients in whom a vascular injury (pseudoaneurysm) was shown on admission or control CT.
RESULTS. CT findings were positive for 88 solid organ injuries in 71 (34%) of the 210 patients. Admission, control, and contrast-enhanced sonograms had a detection rate for solid organ injury of 40% (35/88), 57% (50/88), and 80% (70/88), respectively. The improvement in the detection rate between control and contrast-enhanced sonography was statistically significant (p = 0.001). After exclusion of low-quality examinations, contrast-enhanced sonography still missed 18% of solid organ injuries. Five vascular liver (n = 1) and spleen (n = 4) injuries (pseudoaneurysms) were detected on CT; all were visible on contrast-enhanced sonography.
CONCLUSION. Contrast-enhanced sonography misses a large percentage of solid organ injuries and cannot be recommended to replace CT in the triage of hemodynamically stable trauma patients. However, contrast-enhanced sonography could play a role in the detection of pseudoaneurysms.
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To enhance the sensitivity of sonography for the detection of intraperitoneal injuries, some investigators advocate that a complete abdominal sonography study should be performed by a well-trained operator to depict both free fluid and organ injuries [3, 5, 6]. Two series reported that direct depiction of organ injuries by parenchymal analysis is limited on sonography and concluded that normal sonography findings cannot be relied on as the sole criterion to exclude a major intraabdominal injury [13, 14].
Because of the potential of severe bleeding or delayed complications, or both, of the liver, spleen, and kidneys, the emergency physician is usually reluctant to immediately discharge a patient with a history of abdominal trauma on the basis of normal abdominal sonography as the sole imaging assessment technique. For these patients, some authors recommend clinical observation, delayed control sonography, or abdominal CT [4, 5, 9].
The advent of second-generation sonography contrast agents and the recent improvement in sonography equipment require that the place of sonography in the abdominal evaluation of patients with blunt trauma be reconsidered. Second-generation sonography contrast agents consist of stabilized microbubbles filled by an inert innocuous gas [15-18] and are characterized by outstanding stability and resistance to pressure that allow prolonged examination time after a single IV bolus [19].
The goal of this study was to determine how the conspicuity of solid organ injuries can be improved by using a second-generation contrast medium (SonoVue [an aqueous suspension of phospholipid-stabilized microbubbles filled with sulfur hexafluoride], Bracco) for sonography in hemodynamically stable patients with blunt abdominal trauma.
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Admission sonography examinations were performed using a multiview unit (SSD 2000, Aloka) and a 12-inch (30-cm) monitor. A 3.5-MHz convex sector probe was used. The frequency could be changed to 2.5- and 5-MHz for thick and thin patients, respectively. Film copies were obtained for each patient. Sonography was completed in 10-15 min. The presence of free intraperitoneal fluid was assessed in the perihepatic area, Morison's pouch, perisplenic region, paracolic gutters, and pouch of Douglas. The retroperitoneum was also assessed for the presence of fluid. The liver, spleen, kidneys, adrenals, mesenteric root, and bladder were evaluated specifically for evidence of organ injury. The urinary catheter was clamped until sonography was performed. The results of sonography were recorded on a form, and the form was inserted into an attending physician's mailbox before CT of the abdomen and pelvis was performed. The quality of the sonography examination was rated as low, medium, or good according to the patient's habitus and the environmental conditions.
Patients admitted after blunt trauma with a Glasgow Coma Scale score higher than 13, no clear history of abdominal involvement, normal findings on clinical abdominal examination (e.g., no pain at palpation, no guarding), no rib fracture, a blood glutamic oxaloacetic transaminase level in the normal range, and no extraabdominal reason to undergo a CT were not selected for further abdominal CT if admission sonography findings were normal (no free fluid or organ injury). This mode of triage is based on a recent survey that reported a major intraabdominal injury can be ruled out in patients who meet those criteria [20]. If there was no other reason for hospitalization, patients were immediately discharged from the emergency department after they were instructed to return if their condition deteriorated. All other trauma patients underwent abdominal CT.
In the current study, we defined a solid organ injury as an injury of the liver; spleen; or kidneys, including the adrenal glands. A solid organ injury was reported on sonography if an intraparenchymal hyper- or hypoechogenicity or a distortion of the normal anatomy was present. A collection of fluid in contact with a solid organ in the absence of the latter sonography findings was not reported as solid organ injury but was considered free intraabdominal fluid.
CT and Control Sonography Examinations
Typically within 30 min after sonography, CT was performed using a 4-MDCT
unit (MX-8000 Quad Slice, Philips Medical System) before May 2003 and a
16-MDCT unit (MX-8000 16 Slice, Philips Medical System) since May 2003. CT was
routinely performed with IV contrast enhancement using a bolus of 140 mL of
240 mg I/mL of contrast material power-injected at a rate of 3 mL/sec. A
uniphasic IV contrast injection with a scanning delay of 60 sec was used. When
clinical circumstances allowed the use of oral contrast material, 300 mL of
megluminioxitalamate (4% Telebrix Gastro, Guerbet) was administered 15 min
before scanning and an additional 100 mL immediately before scanning. CT was
performed from the lung bases to the pelvis with 5-mm contiguous sections and
a table speed of 5 mm/sec (pitch = 1).
CT images were initially interpreted by the in-house radiology resident and were reviewed a second time by the attending radiology staff. Organ injuries were evaluated with regard to severity. Scoring of injuries was performed on CT, using the American Association for the Surgery of Trauma (AAST) classification for spleen and kidney injuries, and an AAST-adapted CT-based classification for liver injuries [21-24]. Major organ injuries were defined as serious and potentially life-threatening injuries, lesions requiring surgery or embolization and grade 2 or higher spleen injury and grade 3 or higher liver injury because of their potential for massive delayed bleeding, even if the clinical follow-up was uneventful. Grade 3 and higher kidney injuries were also considered major injuries because grades 1 and 2 kidney injuries are managed nonoperatively with excellent results [25]. Bone injuries were not considered in the current study.
All patients with a false-negative sonography result for liver, spleen, and
kidney (including adrenal glands) injury underwent a control sonography
examination performed within 6 hr after CT by an attending radiologist. The
control sonography examinations were performed on a diagnostic sonography
system (HDI 5000, ATL Ultrasound) and a 14-inch (36-cm) monitor. A C5-C2
curved array probe was used. The control sonography examination was performed
in the best possible conditions in an isolated dimmed examination room with no
time limitation (usually 
10 min) in the emergency department or ICU. A
hard-copy image was obtained to illustrate the presence or absence of new
sonography findings. The purpose of the control sonography was to assess
whether the lesion was conspicuous or was still undetectable on sonography in
optimal conditions. A color Doppler analysis was not systematically performed
at the control sonography examination because color Doppler sonography has
been shown not to depict additional parenchymal lesions at either admission or
control examination of patients with blunt abdominal trauma
[13].
If a solid organ injury was not depicted at the control sonography examination, the patient was asked to undergo contrast-enhanced sonography. This examination was performed with the same sonography system as used for control sonography, equipped with a contrast optimization system (ATL 5000, version 10.3), switched on the pulse inversion harmonic mode, with a reduced mechanical index of 0.18. Five milliliters of a second-generation contrast agent (SonoVue) consisting of phospholipid-stabilized microbubble filled with the inert gas sulfur hexafluoride was injected IV by a second operator using a 20-gauge catheter placed into an antecubital vein and was immediately followed by a 10-mL flush of saline water (0.9% NaCl). Serial images of the injured organ were obtained every 3 sec from the beginning of the injection, for a total duration of 3 min. Only one injection was used to analyze one organ. The additional time required to perform a contrast-enhanced sonography was estimated to be 10-15 min. When a patient had two noncontiguous injuries to be controlled at contrast-enhanced sonography (i.e., spleen and right kidney injuries), two injections were performed. In these situations, both injections were separated by a delay of at least 10 min and the total examination time (including the control sonogram) was approximately 35-40 min. A contrast-enhanced sonogram was considered positive for a CT-proven organ injury when an obvious hypoechoic area or rent contrasting with hyperechoic enhanced surrounding parenchyma could be clearly seen.
If focal pooling of contrast medium was depicted on admission or control CT, a pseudoaneurysmal vascular injury was suspected, according to the CT criteria reported in the literature [26-28]; an additional contrast-enhanced sonography examination was performed immediately after CT even if the parenchymal injury was depicted on admission or control sonography. We wanted to evaluate whether a pseudoaneurysm could be specifically shown on contrast-enhanced sonography. In this situation, a color Doppler examination was also performed after contrast-enhanced sonography was completed.
The protocol of this study was approved by the ethics review board of our hospital. Because the sulfur hexafluoride-based microbubble contrast medium (SonoVue) was not yet commercialized in our country at the time of the study, authorization from the National Agency for Therapeutic Products was also required to use this contrast medium for the current study. Written informed consent was obtained from every patient in whom contrast-enhanced sonography was performed. No informed consent was required to perform the control sonography examination because the routine care was not altered in these patients. Patients who refused to undergo a contrast-enhanced sonography were excluded from the study.
Follow-Up and Data Analysis
Results of clinical and surgical follow-up, as recorded in medical and
surgical records, were obtained for each patient up to the time of discharge
from our hospital. Admission sonography results were compared with CT
results—the standard of reference—to determine the sensitivity of
admission sonography in revealing a solid or non-solid organ injury. A solid
organ injury was defined as a liver, spleen, or kidney (including the adrenal
glands) injury. A non-solid organ injury was defined as a diaphragmatic injury
or an injury of the mesentery, small or large bowel, or bladder. If an injury
(i.e., a bowel injury) was missed on admission CT and detected on follow-up
CT, the second CT result was also considered the standard of reference. If the
control sonography examination revealed injury that was not seen on admission
sonography, the admission sonography result was reclassified as true-positive,
rather than false-negative, to calculate the detection rate of control
sonography. The detection rate corresponded to the sum of the number of the
positive cases on admission sonography and the new number of positive cases
detected on control sonography divided by the total number of positive cases
on CT (gold standard). Similarly, if the contrast-enhanced sonography
examination revealed injury that was not seen on both admission and control
sonography, this injury was also reclassified as a true-positive result. The
detection rate of contrast-enhanced sonography corresponded to the sum of the
positive cases on admission, control, and contrast-enhanced sonograms divided
by the total number of positive cases on the gold standard examination (CT).
Because the sonologist was aware of the CT results when the control and
contrast-enhanced sonography examinations were performed, the detection rates
corresponded to the best possible results that could be obtained in optimal
conditions of use. It was not possible to calculate specificity and positive
predictive value in these settings.
The presence or absence of peritoneal or retroperitoneal fluid or collections and of injuries involving structures other than the three solid organs analyzed was recorded and separately analyzed. The presence of perihepatic, perisplenic, or perirenal fluid in the absence of parenchymal injury shown on sonography was considered a negative result for a solid organ injury.
Statistical Analysis
Statistical analysis was performed using statistical software (QuickCalcs
GraphPadR software [29]). The
Fisher's exact test, two-tailed, was used, when appropriate, to evaluate the
univariate association between the tested parameters. A p value of
less than 0.05 was considered to be indicative of a statistically significant
difference between two sample populations. Detection rates of control and
contrast-enhanced sonograms were compared with each other to calculate a
p value but were not compared with the sensitivity on admission
sonograms because the methodologies were different. The 95% confidence
interval (CI) of proportions was computed using the modified Wald method.
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Of the 237 remaining patients, 27 were excluded from our series. Twenty patients who were hemodynamically unstable at admission and underwent surgery immediately after the initial sonography examination or CT examination were excluded. The seven remaining excluded patients had normal findings on admission and control sonography and a solid organ injury depicted on CT, but these patients were unconscious, thus unable to give informed consent, or refused to participate in the study.
The remaining 210 patients formed the population enrolled in our study. The study group consisted of 145 men and 65 women who ranged in age from 18 to 88 years (mean age, 41 years). Blunt abdominal trauma was caused by motor vehicle crash in 135 (64%) of the 210 patients; fall, 52 patients (25%); a sports accident, six patients (3%); interpersonal violence, four patients (2%); and miscellaneous other causes, 13 patients (6%).
CT Findings
Eighty patients had at least one intraabdominal (solid or nonsolid) injury
depicted on CT, 71 (89%) of whom had at least one solid organ injury. Thirteen
(18%) of these 71 patients had two concomitant solid organ injuries and two
had three. Therefore, 88 solid organ injuries were found in these 71 patients.
The injuries consisted of 38 liver, 28 spleen, and 22 kidney or adrenal
injuries.
Fifty-seven (65%) of these 88 injuries were considered major injuries, and 18 (20%) required either surgical repair or angiographic procedure.
Non-solid organ abdominal injuries were found in 11 patients, two of them had a concomitant solid organ injury. Four (36%) of the 11 patients with non-solid organ injuries required surgery.
Peritoneal or retroperitoneal fluid was depicted on CT in 68 (32%) of the 210 patients. Intraabdominal injuries were shown on CT in 47 (69%) of these 68 patients. Thirty-six (77%) of these 47 patients were considered to have major injuries, 15 (32%) of whom underwent surgery or an angiographic procedure.
Of the 142 patients without peritoneal or retroperitoneal fluid on CT, 33 (23%) had at least one intraabdominal injury. Forty injuries were shown on CT in these 33 patients. They consisted of 36 solid organ injuries (90%) and the following four other injuries (10%): three isolated bowel or mesenteric injuries and one diaphragm rent (associated with a grade 3 splenic injury). Thirteen (39%) of the 33 patients were considered to have a major injury, four (12%) of whom required surgery or an angiographic procedure.
Admission, Control, and Contrast-Enhanced Sonography Findings
Detection of free fluid.—Free fluid was detected on
admission sonography in 61 (90%) of the 68 patients found to have free
peritoneal or retroperitoneal fluid on CT.
Control sonography depicted free fluid in 65 (96%) of these 68 patients; the quality of the three false-negative sonography examinations was reported as low.
Detection of intraabdominal injuries (free fluid excluded).—An organ (solid or nonsolid) injury was detected on admission sonography in 33 of 80 patients with a CT-proven abdominal organ injury, leading to a sensitivity of 41% (95% CI, 31-52%). Control sonography was performed in 47 patients with a false-negative finding on admission sonography. A solid organ injury was detected on control sonography in 16 more patients; the detection rate was 60% (95% CI, 49-70%). After injection of SonoVue (Figs. 1A, 1B, 1C, 2A, 2B, 2C, 2D, 3A, 3B, 3C), the detection rate was improved to 76% (95% CI, 66-84%). The difference between the two latter examinations was statistically significant (p = 0.029).
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Admission sonography achieved a 45% sensitivity (95% CI, 34-57%) for the detection of patients with solid organ injuries. On control sonography, the detection rate was 60% (95% CI, 53-75%). Twenty-five patients were still considered to have a false-negative result for the presence of a solid organ injury on control sonography. These 25 patients underwent an injection of contrast medium for sonography, eight of whom received two injections because they had more than one solid organ injury. In 12 patients with 18 solid organ injuries, contrast-enhanced control sonography findings were still considered negative for solid organ injury. In these optimal conditions of use, the detection rate of contrast-enhanced sonography to reveal solid organ injuries was 83% (95% CI, 73-90%).
The 18 solid organ injuries that were still considered negative after contrast-enhanced control sonography consisted of eight liver injuries (grade 1, n = 1; grade 2, n = 4; grade 3, n = 3), seven splenic injuries (grade 1, n = 2; grade 2, n = 5), and three kidney or adrenal injuries (grade 2 kidney injuries, n = 2; adrenal injury, n = 1).
Of 11 intraabdominal non-solid organ injuries found on CT, only one (a duodenal contusion) was directly shown on admission sonography. A second duodenal contusion was found on control sonography. The detection rate of control sonography for non-solid organ injuries was 18% (95% CI, 0-40%).
Table 1 illustrates the comparative values of the admission, control, and contrast-enhanced sonograms to depict free fluid and solid organ lesions with regard to CT results.
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Depiction of grade and severity of solid organ injuries.—Admission sonography depicted 11 (39%) of 28 CT-proven splenic injuries. Control sonography and contrast-enhanced sonography revealed 14 and 20 of the 28 splenic injuries, respectively. The detection rate of the latter two examinations were 50% and 71%, respectively.
Admission sonography depicted 16 (42%) of 38 CT-proven liver injuries. Control sonography and contrast-enhanced sonography revealed 23 and 32 of the 38 liver injuries, respectively. The detection rate of the latter two examinations were 61% and 84%, respectively.
Admission sonography depicted eight (36%) of 22 CT-proven kidney or adrenal injuries. Control sonography and control contrast-enhanced sonography showed 13 and 18 of the 22 kidney or adrenal injuries, respectively (Figs. 1A, 1B, 1C). The detection rate of the latter two examinations were 59% and 82%, respectively.
Table 2 illustrates the improvement of the sensitivity of admission sonography and the detection rate of control and contrast-enhanced sonography to reveal liver, spleen, and kidney or adrenal traumatic lesions with regard to the grade of the injuries.
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Quality of examinations.—Irrelative to the quality of the examination, admission sonography depicted 35 of 88 solid organ injuries shown on CT, leading to a sensitivity of 40% (95% CI, 30-50%). At control sonography, the detection rate of solid organ injuries was 57% (95% CI, 46-67%). After injection of contrast medium, the detection rate was improved to 80% (95% CI, 70-87%). The difference between the detection rates of control sonography and contrast-enhanced sonography was statistically significant (p = 0.0013).
The quality of the sonography examinations was reported as good or medium in 185 (88%) of the 210 patients included in the study and low in 25 patients (12%).
Seventy-eight solid organ injuries were depicted on CT in the 185 patients with good- or medium-quality sonography examinations; 49 (63%) of those solid organ injuries were major injuries. Unenhanced and contrast-enhanced control sonography depicted 33 (67%) and 45 (92%) of these 49 major injuries, respectively. The four organ injuries that were missed on contrast-enhanced sonography when image quality was good or medium were two grade 3 liver injuries and two grade 2 spleen injuries; none required surgery or an angiographic procedure.
Table 3 shows the sensitivities of admission sonography and the detection rate of un-enhanced and contrast-enhanced sonography to depict organ injuries by the quality of sonography examination and presence of major injuries.
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Pseudoaneurysms.—In five patients, a focal extravasation of contrast medium suggestive of a pseudoaneurysmal vascular injury was depicted on CT. In two patients, this finding was present on admission CT (Figs. 2A, 2B, 2C, 2D). In three patients, it was detected on control CT performed within the first 5 days after trauma (Figs. 4A, 4B, 4C, 4D). Four of these five vascular injuries involved the spleen, one the liver. Their size ranged from 5 to 25 mm.
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All these vascular injuries were easily depicted on contrast-enhanced sonography; they appeared as isolated hyperechoic foci within the first minute after the contrast injection. Only one (20%) of these five vascular injuries was also clearly shown on color Doppler sonography. Two of these patients underwent an emergent splenectomy; two were managed by angiographic procedure; and the last one, with a 5-mm liver vascular injury, underwent a successful conservative management.
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Sonography at admission achieved an overall sensitivity of 41% (33/80) to identify an intraabdominal injury in blunt abdominal trauma patients. The detection rate improved to 60% (48/80) at control sonography after CT. These results are close to those obtained in a prior study, which reported a 41% and 55% sensitivity of sonography to detect intraabdominal injuries [13].
On contrast-enhanced sonography, the detection rate of organ injuries was improved to 76% (61/80). This result reveals that in spite of this significant improvement in detection rate with regard to control sonography, contrast-enhanced sonography still carries an important amount (24%) of false-negative results. A detailed analysis is necessary to determine the actual limitation of this method. When focused on the retrospective detection of solid organ injuries only, in the best conditions of use, contrast-enhanced sonography would have missed 20% of injuries including major injuries.
The false-negative rate for splenic lacerations on unenhanced and enhanced control sonography was higher than those for liver and kidney lacerations. The categorization by the severity of the injuries showed that contrast-enhanced sonography had a detection rate of 100% for spleen and kidney lacerations of grade 3 and higher and also 100% to show grade 4 liver lacerations, independent of the quality of the examination. These observations suggest that contrast-enhanced sonography could achieve a detection rate close to CT for high-AAST-grade solid injuries, which has never been achieved with conventional (unenhanced) sonography.
Because only AAST grade 3 and 4 kidney lacerations are usually considered major injuries [25], the potential of lower grade kidney injuries or adrenal lesions to be overlooked on contrast-enhanced sonography is probably of minor (if any) clinical interest. Therefore, contrast-enhanced sonography could obviate CT to rule out a major kidney injury.
However, the observation that contrast-enhanced sonography might miss major liver and spleen injuries is concerning. Twelve percent of grade 3 liver and 38% of grade 2 spleen injuries were overlooked on contrast-enhanced sonography. Our results suggest that a low-quality examination (obese patient, plasters, or massive subcutaneous emphysema) is responsible for only a negligible percentage (2%) of these bad results (Table 3). When only sonography examinations of medium or good quality were considered in the comparative analysis with CT, contrast-enhanced sonography still missed 8% of the major injuries.
In spite of a satisfactory quality examination (medium or good), 18% (14/78) of solid organ injuries shown on CT were false-negative findings on contrast-enhanced sonography. Four were considered major injuries in four patients.
Using contrast-enhanced sonography without knowledge of the CT findings would have certainly led to a sensitivity lower than the detection rate found in the current study for the depiction of solid organ injuries. Therefore, our results should be considered the optimal results that could be achieved using contrast-enhanced sonography.
None of the 12 patients with 18 solid organ injuries in whom contrast-enhanced sonography failed to depict intraabdominal injuries, including those considered to have a major injury, underwent surgery or required an angiographic procedure. It cannot be excluded that some minor intraabdominal solid injuries consist mainly of edema (contusions), whereas other more severe injuries consist of rents (lacerations) within the parenchyma. If contrast-enhanced sonography could show only parenchymal rents, this would help explain why some injuries with a large extension on CT cannot be shown with sonography. If this hypothesis were confirmed by larger series, contrast-enhanced sonography could be an interesting complement to CT in the characterization of an injury by differentiating a clinically relevant laceration (i.e., with extension to the suprahepatic veins or the splenic hilum), clearly shown as a hypoechoic area, from a benign edema, not visible on contrast-enhanced sonography. This might help to better understand the uncertain correlation between CT grade of solid organ injuries and patient outcome [31, 32]. However, these hypotheses cannot be asserted by the current data because the number of patients with false-negative findings on contrast-enhanced sonography (n = 12) is too small to allow a rigorous statistical analysis.
Another limitation of the use of contrast-enhanced sonography is that this method will not allow any improvement of the poor result of sonography to detect intestinal or mesenteric injuries. These injuries are often not associated with free peritoneal fluid [33, 34].
In the current study, we also analyzed the potential of contrast-enhanced sonography to reveal intraparenchymal vascular injuries. All five focal hepatic or splenic intraparenchymal hyperdensities suggestive of pseudoaneurysms on CT were also clearly depicted on contrast-enhanced sonography. The ability of contrast-enhanced sonography to reveal contrast medium pooling as seen on CT has also recently been reported by Catalano et al. [35]. In the current study, the operators who performed contrast-enhanced sonography examinations were aware of the presence of the pooling of contrast material on CT; the prospective sensitivity of contrast-enhanced sonography for the depiction of such lesions can therefore not be inferred from our data. Furthermore, the small number of vascular injuries reported in our series (n = 5) does not allow statistical analysis. However, our observations and those reported by Catalano et al. suggest that contrast-enhanced sonography could be an interesting alternative to control CT for the detection of delayed pseudoaneurysms in patients with splenic trauma when a control CT examination cannot be performed for technical reasons. Indeed, up to 75% of these vascular injuries have been reported to appear within 3 days after admission for a splenic laceration [26]. Performing a control CT examination, as recommended by some authors [26, 36], is not always feasible such as when the patient is unconscious, has multiple associated injuries, or both. In these cases, a contrast-enhanced sonography examination could be an optimal and efficient tool to check splenic injuries for pseudoaneurysms without recruiting too many medical resources.
In conclusion, this preliminary experience shows that even under optimal conditions major solid organ injuries may be missed with contrast-enhanced sonography. Therefore, contrast-enhanced sonography cannot be recommended to replace CT in the triage of hemodynamically stable trauma patients with negative findings on abdominal (unenhanced) sonography at admission. However, our data suggest that contrast-enhanced sonography could be a useful alternative to control CT for the depiction of a delayed splenic pseudoaneurysm from trauma. This needs to be confirmed by further prospective series.
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