Contrast-enhanced sonography was conducted in 17 confirmed focal splenic lesions (five malignant, 12 benign). Relative echogenicity changes were used for subjective interpretation of lesion perfusion. A rapid influx of contrast agent, resulting in an increased relative echogenicity of the lesion, followed by a rapid clearance of contrast agent was referred to as early washin/early washout. There were 6/12 benign, and 3/5 malignant lesions characterized by early washin/early washout. Therefore, sensitivity, specificity, and accuracy for this parameter in differentiating malignant from benign lesions was 60%, 50%, and 53%, respectively. There were 2/12 benign, and 2/5 malignant lesions with persistent hypoperfusion throughout all phases. Therefore, sensitivity, specificity, and accuracy for malignancy using this criterion were 40%, 83%, and 71%, respectively. However, none of the benign and all malignant lesions were characterized by tortuous and persistently visible feeding vessels. This suggests that interpretation of splenic lesions cannot be performed accurately on the basis of echogenicity or persistent hypoperfusion, but that assessment of vascular tortuosity may be helpful in discriminating between a malignant vs. benign focal splenic lesion.