Splenik arter trombozu ve dalak hipoperfüzyonu

Özet

Atriyal fibrilasyon, emboli eğilimi veya vasküler hastalığı olan kişide ani sol üst kadran ağrısı, splenik arter tıkanması ve buna bağlı segmental ya da yaygın infarktı düşündürür. Kontrastlı BT, dalak infarktını gösterebilir; BT anjiyografide splenik arter trombozu ve buna eşlik eden dalak infarktı saptanabilir. Arteriyel faz tıkayıcı odağı, portal venöz faz ise infarktlı parankimi ve komplikasyonlarını ortaya koyar. Yaygın devaskülarizasyon, enfekte infarkt veya kanama fark edilmezse klinik kötüleşmenin nedeni açıklanamayabilir.

Faz ve pencere

Arteriyel tanısal

Splenik arter boyunca lümen içi dolum kusuru veya ani kalibrasyon kesilmesi; distal dallarda azalmış opaklaşma aranır. MIP/koronal rekonstrüksiyonlar hilustan distale uzanan damarı takip etmeyi kolaylaştırır.

Portal tanısal

İnfarkt, periferden hilusa yönelen kama biçimli veya yaygın coğrafi hipodens kontrastlanmayan alan olarak görülür; kapsüler kollateral akım ince bir çevresel kontrastlanmayı koruyabilir. Dalak infarktının BT ile değerlendirilmesinde kontrastlı inceleme kullanılır.

Önerilen pencereler: Anjiyo (G 600 / M 150), Batın (G 400 / M 50).

BT bulguları

• Splenik arter lümeninde trombüs — arteriyel fazda damar içi kontrast sütununu kesen dolum defekti veya hilus yakınında ani sonlanma.
• Segmental infarkt — kapsüler yüzeye dayanan, tabanı periferde ve ucu hilusa yönelen kama biçimli kontrastlanmayan parankim alanı.
• Yaygın infarkt — dalak parankiminin büyük bölümünde kontrastlanma kaybı; kısa gastrik arterlerden gelen kapsüler çevresel kontrast korunabilir.
• Segmental dalak infarktı — kapsül altına uzanan kama biçimli kontrastlanmayan parankim alanı olarak görülebilir.
• Kollateral dolaşım — kronik tıkanmada kısa gastrik ve gastroepiploik damarların belirginleşmesi; akut embolide bu gelişmiş ağ beklenmeyebilir.
• İnfarkt komplikasyonu — sıvılaşma, gaz, çevresel duvar kontrastlanması veya çevre yağ dokuda inflamasyon gelişirse apseleşme düşünülür.
• Eşlik eden embolik odak — renal veya mezenterik arter dallarında benzer dolum kusuru ve kardiyak emboli kaynağına işaret edebilecek bulgular aranır.

Normalde

Normal dalakta portal fazda parankim homojen kontrastlanır; segmental kama biçimli perfüzyon kaybı bulunmaz. Splenik arter çölyak trunkustan hilusa kadar kesintisiz opaklaşır ve distal dallara ayrılır; aynı düzeyde arter lümeninin devamlılığı ile dalak parankiminin bölgesel kontrastlanmasını birlikte kıyaslayın.

Ayırıcı tanı

Dalak apsesi

merkezde sıvı dansitesi, çevresel kontrastlanan duvar ve bazen gaz görülür; basit infarkt genellikle kama biçimli, duvarsız perfüzyon defektidir.

Dalak kisti

düzgün sınırlı, su dansitesinde ve kontrastlanmayan yuvarlak odaktır; arter dalı tıkanmasına uyan kama dağılımı göstermez.

Dalak lenfoması

çok odaklı nodüller veya yaygın infiltrasyon yapabilir; damar lümeninde akut trombüs ve arter dağılımına uyan kama biçimi beklenmez.

Dalak ven trombozu

dolum kusuru splenik vende veya portal venöz sistemde izlenebilir; BT'de arteriyel ve venöz damarları ayrı değerlendirin.

Geçici dalak kontrastlanma heterojenliği

erken arteriyel fazda yamalı görünüm portal fazda homojenleşir; gerçek infarkt takip fazında kontrastlanmaz.

Tuzaklar

• Erken arteriyel fazdaki fizyolojik dalak heterojenliğini infarkt sanma; portal venöz fazda parankim kontrastlanmasının homojenleşip homojenleşmediğini kontrol et.
• Kontrastsız BT'de parankim silik veya normal görünebildiği için akut infarktı dışlama; tanısal değerlendirme kontrastlı fazlara dayanır.
• Kapsüler ince kontrast halkası, yaygın arter tıkanmasında kısa gastrik kollaterallerden kaynaklanabilir; bunu canlı parankim diye yorumlama.

Kendini dene

1. Atriyal fibrilasyonu olan bir hastanın kontrastlı BT'sinde dalakta periferik, kama biçimli kontrastlanmayan bir lezyon görülüyor. Bu lezyon için en olası tanı nedir?

   • Dalak infarktı
   • Böbrek infarktı
   • Karaciğer infarktı
   • Splenik ven trombozu
   Cevabı göster

   Dalak infarktı. Dalakta kontrastlanmayan lezyon, klinik bağlamla birlikte dalak infarktıyla uyumludur.

2. Arteriyel fazda dalak yamalı kontrastlanıyor; portal fazda parankim homojenleşiyor ve arter dalları açık. Bu görünüm en çok neyi temsil eder?

   • Geçici arteriyel heterojenlik
   • Yaygın dalak infarktı
   • Splenik ven trombozu
   • Dalak apsesi
   Cevabı göster

   Geçici arteriyel heterojenlik. Dalak erken arteriyel fazda geçici yamalı kontrastlanabilir ve portal fazda homojenleşir. İnfarkt portal fazda da kontrastlanmayan alan bırakır; ven trombozunda dolum kusuru vende aranır; apse tipik olarak koleksiyon ve çevresel duvar gösterir.

Kaynaklar

Bu sayfadaki 37 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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