Emerg Radiol (2014) 21:657–658 DOI 10.1007/s10140-014-1275-4
CASE REPORT
Core curriculum illustration: ovarian torsion Jennifer True & David Nickels
Received: 23 September 2014 / Accepted: 29 September 2014 / Published online: 21 October 2014 # American Society of Emergency Radiology 2014
Abstract This is the tenth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources.
multiple peripheral displaced follicles without evidence of internal vascularity. These findings are highly concerning for underlying ovarian torsion (Figs. 2 and 3).
Keywords Ovarian . Torsion
Discussion
This is the tenth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.aseronline.org/ curriculum/toc.htm.
History A 36-year-old female presented with an 18-h history of severe lower abdominal pain, nausea, vomiting, and fever.
Findings CT of the abdomen/pelvis with contrast demonstrates a large 9×8×5-cm heterogeneous right adnexal mass lesion with numerous peripheral low attenuation foci. Underlying ovarian torsion cannot be excluded (Fig. 1). Transvaginal ultrasound with color Doppler reveals a 8.2× 3.9×6.7-cm large right adnexal mass which demonstrates J. True : D. Nickels (*) Department of Radiology, University of Kentucky, 800 Rose Street, Room HX 313E, Lexington, KY 40356-0293, USA e-mail: [email protected]
Ovarian torsion is a rare gynecologic emergency most commonly diagnosed on ultrasound. Patients can often present with nonspecific symptoms such as nausea, vomiting, fever, and nonspecific pelvic pain. If these symptoms occur in younger patients, it is not uncommon for them to initially receive a CT scan of the abdomen/pelvis because their presenting symptoms are so similar to the presentation of appendicitis, diverticulitis, ovarian cyst rupture, or PID (much more common entities) [1, 2]. Therefore, it is important to be able to recognize ovarian torsion on CT as well as on ultrasound. Ultrasound is the imaging modality of choice for ovarian torsion and has a >74 % accuracy rate [3]. The most common finding on ultrasound is an asymmetrically enlarged ovary, usually with multiple peripheral follicles [1, 3]. A small amount of free fluid is often visible adjacent to the torsed ovary [3]. The torsed ovary commonly does not demonstrate venous or arterial flow on color Doppler imaging; however, occasionally, a torsed ovary may continue to demonstrate arterial flow as venous flow is the first to be compromised [1, 2]. The “whirlpool sign” or the swirling of bloodflow within the twisted pedicle is considered to be the most definitive sign of ovarian torsion [1, 2]. The findings of ovarian torsion on CT are similar in many respects to those on ultrasound. Commonly, there is a unilateral, enlarged ovary with multiple peripheral follicles. CT may also demonstrate decreased contrast enhancement of the torsed ovary, twisting of the uterus toward the side of torsion, hematoma formation within the ovary, and occasionally, the actual twisted pedicle can be seen [1].
658
Fig. 1 Axial image from CT abdomen and pelvis with contrast demonstrates an enlarged right ovary (yellow arrow) which is located posteriorly to the uterus and contains multiple peripheral follicles
Ovarian torsion occurs when the ovary and the ovarian pedicle twist along their suspensory ligament [1]. Venous flow is the first to be compromised, leading to swelling and enlargement of the ovary. Next, arterial flow to the ovary is compromised, often causing thrombosis and subsequent is-
Emerg Radiol (2014) 21:657–658
Fig. 3 Sagittal transvaginal ultrasound imaging of the right adnexa with color Doppler reveals no identifiable internal vascular flow within the enlarged right ovary consistent with ovarian torsion
chemia and infarction and increasing the chances of nonviability of the ovary. Ovarian torsion is often associated with an underlying ovarian lesion, most commonly, a benign lesion such as a cyst or dermoid [1]. Ovarian malignancies can also increase the risk of torsion [1]. Definitive treatment of ovarian torsion is usually by laparoscopy performed by gynecologic surgery [1]. Conflict of interest The authors declare that they have no conflict of interest.
References
Fig. 2 Sagittal transvaginal ultrasound of the right adnexa reveals an enlarged right ovary with multiple peripheral follicles (yellow arrows)
1. Dulgenan S, Oliva E, Lee S (2012) Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. Am J Roentgenol 198: W122–W131 2. Pope T, Harris JH, Harris’ radiology of emergency medicine. 5th edition (2013) 717–720 3. Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Meizner I (2011) Sonographic diagnosis of ovarian torsion accuracy and predictive factors. J Ultrasound Med 30:1205–1210
CASE REPORT
Core curriculum illustration: ovarian torsion Jennifer True & David Nickels
Received: 23 September 2014 / Accepted: 29 September 2014 / Published online: 21 October 2014 # American Society of Emergency Radiology 2014
Abstract This is the tenth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources.
multiple peripheral displaced follicles without evidence of internal vascularity. These findings are highly concerning for underlying ovarian torsion (Figs. 2 and 3).
Keywords Ovarian . Torsion
Discussion
This is the tenth installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.aseronline.org/ curriculum/toc.htm.
History A 36-year-old female presented with an 18-h history of severe lower abdominal pain, nausea, vomiting, and fever.
Findings CT of the abdomen/pelvis with contrast demonstrates a large 9×8×5-cm heterogeneous right adnexal mass lesion with numerous peripheral low attenuation foci. Underlying ovarian torsion cannot be excluded (Fig. 1). Transvaginal ultrasound with color Doppler reveals a 8.2× 3.9×6.7-cm large right adnexal mass which demonstrates J. True : D. Nickels (*) Department of Radiology, University of Kentucky, 800 Rose Street, Room HX 313E, Lexington, KY 40356-0293, USA e-mail: [email protected]
Ovarian torsion is a rare gynecologic emergency most commonly diagnosed on ultrasound. Patients can often present with nonspecific symptoms such as nausea, vomiting, fever, and nonspecific pelvic pain. If these symptoms occur in younger patients, it is not uncommon for them to initially receive a CT scan of the abdomen/pelvis because their presenting symptoms are so similar to the presentation of appendicitis, diverticulitis, ovarian cyst rupture, or PID (much more common entities) [1, 2]. Therefore, it is important to be able to recognize ovarian torsion on CT as well as on ultrasound. Ultrasound is the imaging modality of choice for ovarian torsion and has a >74 % accuracy rate [3]. The most common finding on ultrasound is an asymmetrically enlarged ovary, usually with multiple peripheral follicles [1, 3]. A small amount of free fluid is often visible adjacent to the torsed ovary [3]. The torsed ovary commonly does not demonstrate venous or arterial flow on color Doppler imaging; however, occasionally, a torsed ovary may continue to demonstrate arterial flow as venous flow is the first to be compromised [1, 2]. The “whirlpool sign” or the swirling of bloodflow within the twisted pedicle is considered to be the most definitive sign of ovarian torsion [1, 2]. The findings of ovarian torsion on CT are similar in many respects to those on ultrasound. Commonly, there is a unilateral, enlarged ovary with multiple peripheral follicles. CT may also demonstrate decreased contrast enhancement of the torsed ovary, twisting of the uterus toward the side of torsion, hematoma formation within the ovary, and occasionally, the actual twisted pedicle can be seen [1].
658
Fig. 1 Axial image from CT abdomen and pelvis with contrast demonstrates an enlarged right ovary (yellow arrow) which is located posteriorly to the uterus and contains multiple peripheral follicles
Ovarian torsion occurs when the ovary and the ovarian pedicle twist along their suspensory ligament [1]. Venous flow is the first to be compromised, leading to swelling and enlargement of the ovary. Next, arterial flow to the ovary is compromised, often causing thrombosis and subsequent is-
Emerg Radiol (2014) 21:657–658
Fig. 3 Sagittal transvaginal ultrasound imaging of the right adnexa with color Doppler reveals no identifiable internal vascular flow within the enlarged right ovary consistent with ovarian torsion
chemia and infarction and increasing the chances of nonviability of the ovary. Ovarian torsion is often associated with an underlying ovarian lesion, most commonly, a benign lesion such as a cyst or dermoid [1]. Ovarian malignancies can also increase the risk of torsion [1]. Definitive treatment of ovarian torsion is usually by laparoscopy performed by gynecologic surgery [1]. Conflict of interest The authors declare that they have no conflict of interest.
References
Fig. 2 Sagittal transvaginal ultrasound of the right adnexa reveals an enlarged right ovary with multiple peripheral follicles (yellow arrows)
1. Dulgenan S, Oliva E, Lee S (2012) Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. Am J Roentgenol 198: W122–W131 2. Pope T, Harris JH, Harris’ radiology of emergency medicine. 5th edition (2013) 717–720 3. Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Meizner I (2011) Sonographic diagnosis of ovarian torsion accuracy and predictive factors. J Ultrasound Med 30:1205–1210
