Imaging Pearls ❯ Spleen ❯ Vascular Pathology Including Aneurysms
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- “Practice Recommendation: Splenic artery aneurysms ≥2 cm, or any aneurysm with features suspicious for a pseudoaneurysm should be referred to interventional radiology (or other endovascular specialist) for consideration of treatment. Aneurysms <2 cm can be followed for growth annually with CT or MR angiography, with discontinuation of follow-up made in consultation with a vascular specialist after a period of ongoing stability.”
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025) - “Practice Recommendation: A single measurement of >13 cm in maximal diameter is recommended to screen for splenomegaly in adults, recognizing that the positive predictive value for disease has not been determined. Volume calculations can be reserved for when more accuracy is required.”
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025) - Although medical calculators can diagnose splenomegaly by correcting for body size, they are cumbersome, requiring knowledge of the patient’s height, weight, and gender.6 Although the literature suggests that splenic volume calculation may represent the future of spleen measurement, other studies showing a close correlation between a single largest measurement and total spleen volume favour continuing with the current status quo of providing a single value to represent spleen size. Volume calculations can be referenced to body size when more accuracy is required, particularly to avoid overdiagnosing splenomegaly in larger patients.
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025) - “Lymphoma is the most common malignancy of the spleen, either primary or part of diffuse systemic disease.12,15 Splenic involvement occurs in approximately 33% of patients with Hodgkins and 30% to 40% in patients with non-Hodgkins Lymphoma.16 Lymphoma can present in many forms including splenomegaly, diffuse nodules (either in a miliary pattern or larger nodules), or a solitary mass.12 Primary splenic lymphoma confined only to the spleen ± perisplenic nodes is very rare, comprising less than 1% of cases, and most patients will present with constitutional symptoms.”
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025) - Splenic incidental findings are defined as lesions detected on imaging in the spleen not related to the clinical history. Incidental splenic lesions are less common than in other organs such as liver or kidneys, but increased demand for imaging means that their frequency is rising. Incidental focal splenic lesions have a wide range of etiologies, ranging from common benign diagnoses (cysts, granulomas, and hemangiomas) to lymphoma or metastases to exceedingly rare primary malignancies such as angiosarcoma. In one study, 1.5% of trauma patients with CT had an incidental splenic lesion and the vast majority are benign. Benign lesions are almost always asymptomatic, whereas malignant lesions are very rarely entirely incidental or a solitary isolated finding.
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025) - Practice Recommendation: If an incidental isolated indeterminate splenic mass is found on CT or MR in a patient with no history of malignancy or symptoms, it is unlikely to be clinically significant, and no further evaluation or follow-up is necessary.
Practice Recommendation: In patients with constitutional symptoms (fever, weight loss, night sweats), epigastric or left upper quadrant pain, or a history of prior malignancy, the risk of malignancy is low but not negligible. An incidental indeterminate splenic lesion should be further evaluated with MRI, PET/CT, or biopsy, especially if it may affect patient management.
CAR Recommendations for the Management of Incidental Findings of the Spleen and Nodes in Adults
Jeffery R. Bird, Gary L. Brahm, Christopher I. Fung et al.
Canadian Association of Radiologists Journal1–10 (2025)
- “Splenic artery aneurysms are the most frequent of visceral artery aneurysms. Splenic artery aneurysms may be intra or extra-splenic and most of the cases are calcified. If it measures more than 2.0 cm, there is high risk of rupture (76% fatal), and are often treated.Women with more than two pregnancies have high predisposition to aneurysm rupture and are often treated more aggressively.”
MDCT Findings of Splenic Pathology
Sangster GP et al.
Current Problems in Diagnostic Radiology 2021 (in press)
- Interruption of the inferior vena cava: facts
- Interruption of the inferior vena cava (IVC) with azygos continuation is a rare congenital anomaly, in which the IVC is interrupted below the hepatic vein and venous return beyond this point is restored by the dilated azygos and hemiazygos veins draining into the superior vena cava.
- this congenital anomaly could be isolated, but often it is part of more complex syndrome including for example cardiac malformations, asplenia, and polysplenia syndrome. Interruption of the IVC with azygos continuation is the second most common abnormality associated with polysplenia syndrome - “The polysplenic syndrome is defined by the presence of multiple spleens, usually numbering between two and six. In contrast to accessory spleens, the spleens are of uniform size. Accessory spleens usually measure between 1 and 2 cm and are not considered as a form of the polysplenic syndrome. Splenosis, an acquired rather than congenital condition that arises in the context of traumatic splenic rupture, can be ruled out by patient history.”
Polysplenia syndrome
B. De La Villeon et al.
Journal of Visceral Surgery,Volume 148, Issue 5,2011, Pages e395-e396,
- Splenic Artery Aneurysm: Facts
- 3rd most common intra-abdominal aneurysm
- Frequency of 0.2% to 10.4%
- 4x more common in woman
- 3x more likely to rupture in men - Splenic Artery Aneurysm: Associated Conditions
- Atherosclerosis
- Hypertension
- Portal hypertension
- Cirrhosis
- Pregnancy
- Liver transplantation - Splenic Artery Pseudoaneurysms: Associated With
- Pancreatitis
- Trauma
- Post operative complication
- Peptic ulcer disease - Splenic Artery Pseudoaneurysms: Presentation
- abdominal pain
- melana or hematochezia
- hematemasis
- fact: pseudoaneurysms rupture in up to 37% of cases with mortality then approaching 90%
- Splenic Artery Pseudoaneurysms: Presentation
- abdominal pain
- melana or hematochezia
- hematemasis
- fact: pseudoaneurysms rupture in up to 37% of cases with mortality then approaching 90% - Splenic Artery Pseudoaneurysms: Associated With
- Pancreatitis
- Trauma
- Post operative complication
- Peptic ulcer disease - Splenic Artery Aneurysm: Associated Conditions
- Atherosclerosis
- Hypertension
- Portal hypertension
- Cirrhosis
- Pregnancy
- Liver transplantation - Splenic Artery Aneurysm: Facts
- 3rd most common intra-abdominal aneurysm
- Frequency of 0.2% to 10.4%
- 4x more common in woman
- 3x more likely to rupture in men - Splenic Vascular Pathology
- Aneurysm
- Pseudoaneurysm
- Fact: Aneurysms usually are incidental findings while pseudoaneurysms usually present with symptoms - "Although splanchnic artery aneurysms are relatively rare, they are being diagnosed with increased frequency given the widespread availability of MDCT and 3D imaging capabilities."
MDCT and 3D CT Angiography of Splanchnic Artery Aneurysms
Horton KM, Smith C, Fishman EK
AJR 2007;189:641-647 - "Although splanchnic artery aneurysms are relatively rare, they are being diagnosed with increased frequency given the widespread availability of MDCT and 3D imaging capabilities. It is important that these aneurysms be diagnosed accurately because they can carry a high morbidity and mortality, even in asymptomatic patients."
MDCT and 3D CT Angiography of Splanchnic Artery Aneurysms
Horton KM, Smith C, Fishman EK
AJR 2007;189:641-647 - Splanchnic Artery Aneurysms: Facts
- Incidence of 0.01-0.2% in autopsy series
- Most common is splenic artery aneurysm (60%), with hepatic artery aneurysm being second most popular (20%)
- Aneurysm rupture is associated with high morbidity and mortality - Splanchnic Artery Aneurysms: Frequency
- Splenic artery (60%)
- Hepatic artery (20%)
- SMA (5.5%)
- Celiac artery (4%)
- Pancreatic arteries (2%)
- Gastroduodenal artery (GDA) 1.5% - Splenic Artery Aneurysms: Facts
- 4x more common in woman than men
- In woman association with pregnancy and multiparity
- Although more common in woman more likely to rupture in men
- Risk of rupture (2-3%) increases with pregnancy, portal hypertension, and after liver tralntation - "The most common finding was upper abdominal pain. Angiosarcoma of the spleen could be suggested in the majority of cases (83%) by using the imaging features of splenic mass with metastatic disease."
Angiosarcoma of the Spleen: Imaging Characteristics in 12 Patients
Thompson WM et al.
Radiology 2005; 235:106-115 - Splenic Artery Aneurysm: Facts:
- 3rd most common intra-abdominal aneurysm
- Frequency of 0.2% to 10.4%
- 4x more common in woman
- 3x more likely to rupture in men - Splenic Artery Aneurysm: Associated Conditions
- Atherosclerosis
- Hypertension
- Portal hypertension
- Cirrhosis
- Pregnancy
- Liver transplantation - Splenic Artery Pseudoaneurysms: Associated With:
- Pancreatitis
- Trauma
- Post operative complication
- Peptic ulcer disease - Splenic Artery Pseudoaneurysms: Presentation:
- abdominal pain
- melana or hematochezia
- hematemasis
- fact: pseudoaneurysms rupture in up to 37% of cases with mortality then approaching 90% - "Ultrasound and CT have made the diagnosis of splenic artery aneurysm or false aneurysm more frequent. Endovascular treatment, the morbidity of which is low, is effective and spares the spleen."
Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients.
Guillon R et al.
Cardiovasc Intervent Radiol. 2003 May-Jun;26(3):256-60. - Vascular Splenic Lesions: Differential Dx
- Hemangioma
- Hamartoma
- Lymphangioma
- Littoral Cell Angioma
- Peliosis
- Hemangiopericytoma
- Angiosarcoma