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Sonographic Diagnosis of Ovarian Torsion. Acute abdominal distension in early pregnancy from torted ovarian serous cystadenoma. Rarely is the “whirlpool sign” seen – twisted vessels in the ovarian pedicle. The possibility of ovarian torsion should be considered when an ovarian mass is discovered in the appropriate clinical setting. It can be detected on ultrasound confirming the diagnosis along with the other suggestive imaging features and clinical presentation 2. Pediatric synchronous bilateral ovarian torsion: a case report and review of the literature. Ultrasound Evaluation of Gynecologic Causes of Pelvic Pain. Guideline for the management of ovarian cysts in children and adolescents. Finding the ovaries on ultrasound is probably the biggest challenge when tasked with performing an ovarian torsion study. A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. In 4 of 5 patients in whom blood flow was observed in the artery and vein in the pedicle, a tumor was also present replacing the ovary, and they were removed. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, By continuing to browse this site, you agree to its use of cookies as described in our, I have read and accept the Wiley Online Library Terms and Conditions of Use. Approximately 20% of the cases occur during pregnancy 1. Sonographic findings of ovarian torsion in children. A study by Lee et al11 shifted the focus to the observation of the pedicle instead of the ovary or the mass. Point-of-Care Pelvic Ultrasonography in Emergency Medicine. The extraovarian mass representing the twisted vascular pedicle was evaluated. Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction. Ghonge NP, Lall C, Aggarwal B, Bhargava P. Clinical symptoms and signs of ovarian torsion are often nonspecific, and imaging studies have a crucial role in making an accurate timely diagnosis. It appears as twisting of the thickened vascular pedicle of the enlarged ovary. If there is evidence of blood flow, especially if blood flow is present in the interior of the ovary, it does not exclude torsion but may suggest that a viable ovary exists. Whirlpool sign of twisted vascular pedicle; Underlying ovarian lesion can often be found; Uterus may be slightly deviated towards the torted ovary. The ovary can also show multiple cortical follicles. Because she showed improvement, she did not undergo surgery. Medial or Lateral Location of the Whirlpool Sign in Adnexal Torsion. Diagnostic performance of CT signs for predicting adnexal torsion in women presenting with an adnexal mass and abdominal pain: A case-control study. The MRI whirlpool sign in the diagnosis of ovarian torsion. Miscellaneous tumour-like lesions of the ovary: cross-sectional imaging review. CT and MRI are alternate imaging options in these patients. On MRI, it is best demonstrated on axial T2 and T1 C+ fat sat sequences 1. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion. Use the link below to share a full-text version of this article with your friends and colleagues. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The whirlpool sign in a twisted vascular pedicle has been variably reported as seen in 13?? MR Imaging of Pelvic Emergencies in Women. 2012;198 (2): W122-31. The presence of a twisted vascular pedicle was evaluated. Journal of Minimally Invasive Gynecology. There was free fluid in the pelvis of 5 patients. It can also cause an infection (peritonitis) in the abdominal cavity. During a period of about 2 years 6 months, 21 patients with acute or intermittent lower abdominal pain who had an ovarian mass and an extraovarian mass suggestive of a twisted vascular pedicle on sonography were studied. The MRI whirlpool sign in the diagnosis of ovarian torsion. An ovarian mass was seen on sonography in all the patients. A retrospective study of surgical treatment and outcome among women with adnexal torsion in eastern Taiwan from 2010 to 2015. Imaging of Common Solid Organ and Bowel Torsion in the Emergency Department. Here, we have described an additional maneuver, wherein during sonography the probe is moved to and fro along the central axis of the twisted pedicle. The movement of the probe during the color Doppler study also highlighted the whirlpool sign of wrapping of the visualized vessels around the central axis. Radiol. 23 (12): 1643-9; quiz 1650-1. The findings were correlated with the surgical and pathologic findings of the affected ovaries and tumors. Administering opiate analgesics B. Laparotomy C. Serial abdominal exams The ovarian mass in others appeared as a unilocular cyst in 3 patients, a multiseptated cyst in 3, solid and cystic in 2, and solid in 2. Unlike that episode, however, this pain was also associated with dys-uria. The twisted vascular pedicle corresponds to the broad ligament, fallopian tube, and adnexal and ovarian branches of the uterine artery and vein.11 Lee et al11 reported that a false‐positive diagnosis could be made in cases of ovarian tumor‐associated salpingitis, endometriosis, or hemorrhagic cyst–associated edema because these conditions could have findings similar to those of a twisted vascular pedicle. Duplex Ultrasound Evaluation of the Uterus and Ovaries. {"url":"/signup-modal-props.json?lang=us\u0026email="}. The purpose of this study was to describe an additional maneuver during sonography and to assess its diagnostic value in ovarian torsion. Journal of Medical Imaging and Radiation Oncology. If the whirlpool sign was present on gray scale sonography, torsion of the ovary was diagnosed; torsion was excluded if the whirlpool sign was not seen. Prise en charge en urgence d’une torsion d’annexe. Features of cystic teratoma were present in 6 patients, namely, a cystic mass with solid areas containing fat, hair, or calcification. During a period of about 2 years 6 months, there were 21 patients with lower abdominal pain who had an ovarian mass and an extraovarian mass suggestive of a twisted vascular pedicle on sonography. Is There Any Benefit to Obtaining a Pelvic Ultrasound After a Negative CT of the Abdomen/Pelvis in a Woman with Chronic Abdominal Pain?. Ovarian torsion was confirmed in all 20 patients who underwent surgery. Hemorrhagic infarction of the ovary or a mass was present in all the patients in whom no blood flow was seen in the pedicle. Ultrasound Obstet. sudden onset, similar to her prior ovarian torsion. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Ovarian torsion usually occurs on just one side and can cause sudden, intense pain and vomiting. Ultrasonography findings suggestive of ovarian torsion include unilateral ovarian enlargement, ovarian edema characterized by the presence of a hyperechogenic ovary with peripherally displaced follicles and echogenic stroma, free fluid, and a coiled vascular pedicle (referred to as the “whirlpool sign”) 17 Figure 2. Please check your email for instructions on resetting your password. Adnexal torsion is reported to be the fifth most common gynecologic emergency condition encountered, with a prevalence of 2.7%.1 Prompt diagnosis and surgery may prevent irreversible adnexal damage. Australasian Journal of Ultrasound in Medicine. Tératomes ovariens matures et immatures : caractéristiques en échographie, TDM et IRM. In 2 patients with cystic masses, the wall was thick, suggestive of torsion. Objective. Pelvi acuta infiammatoria e non infiammatoria. The varied imaging features and nonspecific symptoms of ovarian torsion can lead to a delay in identification, with misdiagnosis being common. It is the most definitive prospective feature in aiding the diagnosis of torsion of the ovary, even though the number of patients is small. • Ovarian torsion 4. The aim of this study was to evaluate whether their combination improved diagnostic efficiency of AT in patients presenting with a benign ovarian mass and abdominal pain and clinically suspected AT. The whirlpool sign is visualized by moving the ultra- sound probe back and forth along the axis of suspected torsion(eitheralongtheovarianligament,whentorsionof Transabdominal scans were performed with HDI 5000 equipment (Philips Medical Systems, Bothell, WA) using convex 2‐ to 5‐ and 4‐ to 7‐MHz probes and linear 5‐ to 12‐MHz probes. It is difficult to distinguish these findings from those of other diseases, such as hemorrhagic cysts, endometriosis, ovarian masses, pelvic inflammatory disease, and ectopic pregnancy.145 Previous reports suggested that the presence of a unilateral enlarged ovary with multiple peripherally located follicles might be a specific finding for ovarian torsion, with a detection rate of 64%, but this feature was not always observed.57 In this series, 1 of these gray scale features of torsion was seen in only 7 patients. Torsion may be intermittent and recurrent, with spontaneous detorsion, allowing arterial and venous flow to the ovary to be observed on ultrasonography. Ten patients were unmarried, and 11 were married. Her vital signs were stable with a blood pressure of 115/65, pulse 68, RR 18 and remained so throughout her stay. Magnetic Resonance Imaging Clinics of North America. Case Reports in Obstetrics and Gynecology. Journal de Gynécologie Obstétrique et Biologie de la Reproduction. In the second patient, the pedicle was gangrenous, and the cystic teratoma had ruptured, with leakage of fluid into the peritoneal cavity. Akutes Abdomen der Frau: gynäkologische UrsachenAcute Pelvic pain in women—gynecological causes. The whirlpool sign is a more definitive indicator of torsion. _____ 5. In conclusion, the positive whirlpool sign in the twisted vascular pedicle is the most definitive sign of ovarian torsion. Any queries (other than missing content) should be directed to the corresponding author for the article. Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion. The Egyptian Journal of Radiology and Nuclear Medicine. ?88% of patients with ovarian torsion [2, 10, 12]. 2010;36:630-4. To describe an additional maneuver during sonography for ovarian torsion and to assess its diagnostic value. Introduction to Vascular Ultrasonography. However, heightened awareness and suspicion of this condition are needed for timely intervention. Ovarian Torsion: Diagnostic Features on CT and MRI With Pathologic Correlation. Epub 2007 Mar 15. Detection rates of only 46% to 74% have been reported because these findings are nonspecific for ovarian torsion. and you may need to create a new Wiley Online Library account. The last patient of this group was pregnant and was treated conservatively. Isolated torsion of the fallopian tube in a 16-year-old girl: A case report and review of the literature. Hemorrhagic infarction or early hemorrhage of the ovary or ovarian mass was seen in all 8 patients who did not show flow in the twisted pedicle on the color Doppler study and in 2 patients who showed flow in the artery in the proximal part of the pedicle. Of the 6 patients who showed flow in the artery alone, the ovary was removed in 4, and all had hemorrhagic infarction or early hemorrhage. Multimodality imaging in adnexal torsion. There have been few reports of an enlarged ovary with absent or markedly diminished ovarian blood flow on transvaginal and color Doppler sonography as a specific finding for the early diagnosis of ovarian torsion.89 Other studies showed the presence of normal arterial flow in 3 confirmed cases of ovarian torsion, which suggested venous thrombosis without arterial occlusion and a dual blood supply to the ovary as possible explanations for the occurrence.210 These different results indicated that, in partial or early torsion, both arterial and venous flow could be maintained with viable ovarian tissue. One patient was pregnant at 23 weeks' gestation. On gray scale sonography, the whirlpool sign is seen as a hypoechoic band representing the vessels wrapping around the central axis. The whirlpool sign was visible as a clockwise or counterclockwise wrapping of the hypoechoic vessels around the central axis (Video 1). The probe was moved to and fro along the axis of this pedicle, and the presence of a “whirlpool” sign was evaluated. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 BL indicates urinary bladder; and C, ovarian cyst. Adnexal torsion — A multimodality imaging review. Gynaecological Ultrasound in Emergency Medicine. An ultrasound of a patient with abdominal pain might reveal abnormally positioned ovaries, masses or ovarian enlargement. The ovary or the mass was viable in all the patients who showed flow in both the artery and the vein. This is similar to the whirlpool sign described with caudal movement of the probe in malrotation of the midgut with volvulus.1213 The diagnosis of ovarian torsion is made only when this whirlpool sign is seen. It appears as twisting of the thickened vascular pedicle of the enlarged ovary. Ovarian torsion is a medical emergency. Although this sign is specific for ovarian torsion, yet it had been variably reported as seen in 13–88% of patients with ovarian torsion , , . The same procedure was repeated on a color Doppler study. Rosen's Emergency Medicine – Concepts and Clinical Practice. Check for errors and try again. Preoperative CT image-based assessment for estimating risk of ovarian torsion in women with ovarian lesions and pelvic pain. B, Color Doppler study of the pedicle showing absent flow. Ovarian torsion is caused by rotation of the ovary or adnexa with the vascular pedicle on its axis, resulting in arterial, venous, or lymphatic obstruction. 1. The immediate duration of the pain ranged from 8 to 72 hours. Snail shell sign: Testicular/ovarian torsion. A, Snail shell appearance of the twisted pedicle (arrows). Unable to process the form. Color Doppler study of the pedicle showing the twisted artery alone in the proximal part (A) and no flow in distal part (B). Venous blood flow disappears first, then arterial. If you do not receive an email within 10 minutes, your email address may not be registered, Usefulness of ultrasonography in children with right iliac fossa pain. OBJECTIVE To describe an additional maneuver during sonography for ovarian torsion and to assess its diagnostic value. What is the most common confirmatory physical finding for peritonitis? 39 Imaging of Female Children and Adolescents with Abdominopelvic Pain Caused by Gynecological Pathologies. AU Vijayaraghavan SB SO J Ultrasound Med. Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques. Case 246: MR Imaging of a Complex Cystic Mass in a Newborn Girl. Imaging Diagnosis of Right Lower Quadrant Pain in Children. Treatment. Significant elevation in serum CA 125 and CA 19-9 levels with torsion of the hydrosalpinx in a postmenopausal woman. There was hemorrhagic infarction in all 8 patients in whom there was no flow within the twisted vascular pedicle, in the 2 patients in whom blood flow was seen only in the proximal part of the pedicle, and in 1 of the 4 patients in whom only the artery but not the vein was visualized. The ovary was viable in all 5 patients in whom flow was seen in both the artery and vein. Utilidad de la ecografía en niños con dolor en la fosa ilíaca derecha. Its location and gray scale features were noted, and an additional maneuver was carried out. Seeing past the appendix: the role of ultrasound in right iliac fossa pain. The majority of ovarian torsion cases affect women of reproductive age, but girls can have the condition as well. Twist and Shout! Crossref, Medline, Google Scholar; 32 Vijayaraghavan SB. Added Value of Using a CT Coronal Reformation to Diagnose Adnexal Torsion. In ovarian torsion, if the viability of the ovary can be predicted preoperatively, an attempt can be made to untwist the pedicle and retain the ovary to conserve ovarian function and fertility. Sonographic Appearance of Adnexal Torsion, Correlation With Other Imaging Modalities, and Clinical History. *The sensitivity and specificity for ultrasound diagnosis of ovarian torsion are 72.1% and 99.6%, respectively (Rostamzadeh 2014). The sonographic appearances of ovarian torsion vary according to the duration and degree of torsion (complete or incomplete) and the presence or absence of an ovarian mass.23 Twisted adnexal masses are often midline, positioned cranial to the uterine fundus. Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy. Underlying ovarian lesion can often be found ; Uterus may be slightly deviated the... Is discovered in the artery alone are predictive of nonviability of the showing! 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Literature analysis medicine – Concepts and Clinical history crossref: how to perform a ultrasound...: official Journal of the thickened vascular pedicle ; Underlying ovarian lesion can often found! In young women ( 15-30 years ) and post-menopausal women ovary with peripheral suggestive... Of Female Children and Infants: Evidence-Based Emergency imaging a cystic teratoma rates of 46. American Institute of ultrasound in medicine with adnexal torsion classic whirlpool sign of cysts. Be found ; Uterus may be slightly deviated towards the torted ovary miscellaneous tumour-like lesions of the flow in twisted. Because these findings are nonspecific for ovarian torsion cases: Lessons Learnt pedicle is the most sign., a color Doppler is often the initial investigation both the artery alone are predictive of of.: Expecting the Unexpected be slightly deviated towards the torted ovary ovarian Torsion- the Pitfalls in diagnosis and Management infarction... 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