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Description of the Anatomical and histological structural characteristics of the spleen at the vascular and perivascular level, Explaining Its lesional presentation and evolution during blunt trauma.

Student: Alexia Bichon and Anne Allarousse
Advisor: Alexandre Bellier

28/01/2022

01. Introduction

02. Goals

04. Results

05. Discussion

06. Conclusion

08. Thanks

07. Bilbiography

Index

03. Methods

Introduction

.01

1.1 General anatomical and vascularisation description



Hc : common hepatic artery, Gg : left gastric artery, Gc : short gastric arteries , S: splenic artery, PD : dorsal pancreatic artery, AMS: superior mesenteric artery

1 - phrenico-splenic ligament(lgt), 2 - phrenico-colic lgt, 3 - spleno-colic lgt, 4 - spleno-gastric lgt, 5 - reno-splenic lgt, 6 - pancreatico-splenic lgt
E : stomach, Rt : spleen, Rn : kidney, P : pancreas,
C : colon

Spleen vascularization, fixation and relationships with the other abdominal organs

- lymphoid organ, left hypochondrium
- friable texture easily torned
- held in the abdominal cavity by different ligament
- red and white pulp with different functions : hemolytic and immune


- splenic artery : terminal branch of the coeliac trunk
- colleteral branches : it end with two branches creating two lobes
- lobar artery -> segmental artery in the hilum
- Drained by trabecular veins -> splenic vein
- ONLY efferent lymphatic vessels

Introduction

.01

1.2 Spleen scanography, what is a “blush” ?

Focal hyperattenuation isodense to the main arterial vessels :


-> Active arterial extravasation within a haematoma
-> called "BLUSH"
-> embolisation if needed

Introduction

.01

1.4 Synchrotron Imaging

1- Utility


- resolution and sensitivity down to te cellular level
- high tissue contrast
- imaging whole human body in detail

2- Mecanism

- source of Xrays producted by electrons of high energy
- based on detection of attenuation or phase shift of Xrays
- lower then higher resolution
- Sequential acquisition
- Two dimensionnal -> three dimansional model

Introduction

.01

1.5 Spleen trauma

- Most frequent trauma-related injury
-> intense hemorrage

- Classification according to AAST Spleen trauma

- Hemodynamic stability + blunt splenic trauma -> nonoperative management
--> surveillance +/- Angiography (AG) and angioembolization (AE)

- Splenic blush : predictor of failure of NOM ?

- Unstable patients : operative management

THERAPEUTIC DILEMMA

Introduction

.01

NOM strategy

  • Improving CT imaging quality + time intervall between techniques
--> blush cannot be found on AG

  • Absence of blush on initial CT scan, AE ?

  • Unclear recommendations for AG of minor and moderate lesions with blush on CT
--> simple monitoring ?

Complications

  • of Angioembolization
  • of NOM failure
  • of splenectomy

Other Factors

  • Intensive monitoring available
  • age, ISS score, hemodynamic status, anatomic derangement, associated injuries.....

1.6 Therapeutic dilemma

Introduction

.01

1.6 Hemerheology and hemostasis

HEMOSTASIS

HEMERHEOLOGY

MAJOR STEPS

- Vascular spasm
- Plug
-Coagulation factors
- Retraction of the clot
- Vascular repair
- Fibrinolysis

= Mechanical rules of fluids applied to blood

Goals

.02

Anatomical and histological structural characteristics of the spleen
-> vascular and perivascular ++

Lesional presentation and evolution during blunt trauma

Comparison with an ex vivo reconstruction of a blunt spleen trauma with contrast blush using reperfusion of the organ.

Methods

.03

Normal spleen

  • Bibliography
  • Histological sections
  • Synchrotron imaging

Traumatized spleen

  • Trauma reproduction on fresh body
  • Histological sections

Descriptive study

TRAUMA EXPERIENCE

Bag of perfusion fluid

image intensifier

pressure transducer

2-way system

contrast fluid

manometer

jar with circulation liquid
at 37°

traumatized spleen

cannula

Set up of the splenic traumatism experience

TRAUMA EXPERIENCE

100 mmHg

Variations of the intra splenic pressure before the trauma

120 mmHg

Variations of the intra splenic pressure during the trauma

Results

.04

4.2 Nomal spleen : Bibliography
and histology sections

.04

Results

4.1 Nomal spleen : Synchrotron imaging

Results

.04

4.3 Traumatized spleen : Histology sections

.04

Results

4.4 Traumatized spleen : Imaging

Canula

Extravasation of contrast liquid : blush ?

Results

.04

4.5 Hemorheology and Hemostasis

Primary haemostasis






  • depends on frequency of collisions between platelets and the vascular breach--> platelet concentration ,hematocrit,shear forces.

  • Blood : maximum velocity at the centre, laminar flow

  • shear force : relative speed between the blood layers

  • Shear forces : ++ arterioles
and vasoconstriction : Sympathetic nerves with the arteries


  • Circulatory slowing : primary hemostasis + vasoconstriction + resistance of tissues
(mesh structure ?)

  • Veinous splenic sinusoid : two sphincters on each -> regulate the splenic circulation

Coagulation





Hematoma


  • Expansion of a haematoma : resistance adjacent tissues

  • Pressure on bleeding vessel > haemorrhage = self limitation

Discussion

.05

  • Various means of analysis :
- synchrotron imaging advantages :
- histology advantages:

  • traumatized spleen experiment

Strenghts

Flaws

  • No synchrotron imaging post trauma

  • traumatized spleen experiment
- Liver reference study --> reproducibility
- Pressure + Trauma
- Inclusion criteria
- Leakage
- Single spleen

.06

Conclusion

  • Histology/synchrotron + hemerheology, what we learned ?

- 2 types of circulation


- high density of small caliber vessels (shear forces) + opened circulation : efficiency of the primary hemostasis

- sphincters + sympathetic innervation → low blood velocity → fast primary haemostasis

- control of the hematoma : resistance of the tissues + shear forces + myocytes in the capsule

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.07

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Bilbiography

INFO

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Thanks for your attention