A round mass, suggestive of a twisted pedicle, was seen in all 21 patients. 1. Sonographic whirlpool sign in ovarian torsion. AU Vijayaraghavan SB SO J Ultrasound Med. If you do not receive an email within 10 minutes, your email address may not be registered, In 13 patients, the appearance of the twisted pedicle was as a hypoechoic mass with a target appearance, either with or without a central echogenic dot (Figure 1). Lee et al11 also reported 94% predictability of the viability of the ovary when arterial and venous flow was seen in the twisted pedicle. Epithelial Stromal Tumors: Serous and Mucinous (Clinical Setting and Ultrasound). Pediatr. In the second patient, the pedicle was gangrenous, and the cystic teratoma had ruptured, with leakage of fluid into the peritoneal cavity. Obstetrics and Gynecology Clinics of North America. Preoperative CT image-based assessment for estimating risk of ovarian torsion in women with ovarian lesions and pelvic pain. Sonoscan Ultrasonic Scan Centre, Coimbatore, India. Dopplersonographie in Geburtshilfe und Gynäkologie. Whirlpool sign of adnexal torsion on CT: where can we find it?. 2/3 of patients with ovarian torsion have had normal blood flow. Whirlpool sign of twisted vascular pedicle; Underlying ovarian lesion can often be found; Uterus may be slightly deviated towards the torted ovary. Results. Ovarian torsion is a medical emergency. The whirlpool sign is visualized by moving the ultra- sound probe back and forth along the axis of suspected torsion(eitheralongtheovarianligament,whentorsionof 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. Absence of blood flow in the twisted pedicle and visualization of the flow in the artery alone are predictive of nonviability of the ovary. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 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. The whirlpool sign was visible as a clockwise or counterclockwise wrapping of the hypoechoic vessels around the central axis (Video 1). 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. 23 (12): 1643-9; quiz 1650-1. The findings were correlated with the surgical and pathologic findings of the affected ovaries and tumors. A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Absence of blood flow in the twisted pedicle and visualization of the flow in the artery alone are predictive of nonviability of the ovary. 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. Is There Any Benefit to Obtaining a Pelvic Ultrasound After a Negative CT of the Abdomen/Pelvis in a Woman with Chronic Abdominal Pain?. When identified in association with an enlarged ovary, these ultrasound findings are diagnostic for ovarian torsion. Recent reports have suggested that documentation of intraovarian venous flow is important in establishing the viability of the affected ovary.3 Lee et al11 performed a color Doppler study on the twisted vascular pedicle instead of the ovarian parenchyma to assess the viability of the ovary in torsion. 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 Gynecological pelvic pain as emergency pathology. A. Ovarian torsion was confirmed in all 20 patients who underwent surgery. Duplex Ultrasound Evaluation of the Uterus and Ovaries. Diagnostic performance of CT signs for predicting adnexal torsion in women presenting with an adnexal mass and abdominal pain: A case-control study. Conclusions: A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Obstetrics & Gynecology International Journal. 2. AJR Am J Roentgenol. B, Color Doppler study of the twisted artery and vein. Finding the ovaries on ultrasound is probably the biggest challenge when tasked with performing an ovarian torsion study. In 2 patients, it appeared as a large hypoechoic mass (Figure 4), and in another patient, it appeared as an echogenic mass (Figure 5A and Table ). No flow was seen in the vessels (Figure 5B) of the pedicle in 8 patients. 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. Blood flow in the twisted vessels is not seen in all patients. Duigenan S, Oliva E, Lee SI. In the remaining 3 patients of the last group, there was early hemorrhage. Tératomes ovariens matures et immatures : caractéristiques en échographie, TDM et IRM. Any queries (other than missing content) should be directed to the corresponding author for the article. J Ultrasound Med 2004; 23(12): 1643–1649. Treatment. Case Report: Ovarian Torsion in Pregnancy – Diagnosis and Management. The probe was moved to and fro along the axis of the pedicle, and the presence of a whirlpool sign was evaluated. The clinical symptoms, history of associated pregnancy, and laboratory findings were obtained from the patients' records. Sonographic findings of ovarian torsion in children. The artery alone was seen in 6 patients. Pelvi acuta infiammatoria e non infiammatoria. The diagnosis was surgically confirmed in all 20 patients who underwent surgery. Dolor pélvico de origen ginecológico como patología urgente. Surgical treatment of ovarian torsion includes laparoscopy to uncoil the torsed ovary and possibly oophoropexy to … A Rare Case of Nine Twisted Adnexal Torsion Successfully Resolved by Conservative Laparoscopic Detorsion. It appears as twisting of the thickened vascular pedicle of the enlarged ovary. It is the most definitive prospective feature in aiding the diagnosis of torsion of the ovary, even though the number of patients is small. Venous blood flow disappears first, then arterial. Unlike that episode, however, this pain was also associated with dys-uria. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Epub 2007 Mar 15. Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy. A and B, Two types of target appearances of the twisted vascular pedicle (arrows). 2007;37:446-51. A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. The whirlpool sign results from a side-by-side arrangement of vessels with opposing flow directions, giving an image reminiscent of a whirlpool. 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. Color Doppler study of the pedicle showing the twisted artery alone in the proximal part (A) and no flow in distal part (B). This sign is important because the cross section of the twisted pedicle has 4 different appearances, some of them mimicking other conditions. Twenty patients underwent surgery 4 to 36 hours after the scans. Methods. Adnexal torsion: color Doppler and three-dimensional ultrasound, https://doi.org/10.7863/jum.2004.23.12.1643. The Egyptian Journal of Radiology and Nuclear Medicine. The purpose of this study was to describe an additional maneuver during sonography and to assess its diagnostic value in ovarian torsion. 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. Pathologic diagnosis of the ovarian masses in the 19 patients in whom the ovarian mass was removed included teratoma in 6, serous cystadenoma in 4, mucinous cystadenoma in 2, a luteal cyst in 3, fibroma in 1, and hemorrhagic necrosis of the ovary in 2. Unable to process the form. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. Detection rates of only 46% to 74% have been reported because these findings are nonspecific for ovarian torsion. AB - The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. The whirlpool sign or whirl sign of ovarian torsion is characterized by the appearances of a twisted ovarian pedicle seen on US or even on CT. The whirlpool sign can be seen on ultrasound by moving the probe along the axis of the suspected torsion. The ultrasonic whirlpool sign combined with plasma d-dimer level in adnexal torsion. The MRI whirlpool sign in the diagnosis of ovarian torsion. All the patients who failed to show blood flow within the twisted vascular pedicle showed hemorrhagic infarction and necrosis of the adnexal structures. Ovarian Torsion in a 5-Year Old: A Case Report and Review. Twisted vascular pedicle showing the circular string‐of‐beads appearance of dilated veins (arrows). Because sonography is not 100% sensitive, Color Doppler ultrasound findings may be normal (blood flow maintained) despite the presence of ovarian torsion. Her vital signs were stable with a blood pressure of 115/65, pulse 68, RR 18 and remained so throughout her stay. Female Genital Anomalies and Important Ovarian Conditions. Features of cystic teratoma were present in 6 patients, namely, a cystic mass with solid areas containing fat, hair, or calcification. Case Reports in Obstetrics and Gynecology. Emergency Medicine Clinics of North America. In those in whom blood flow was seen in the artery alone and in whom the ovary was removed, either hemorrhagic infarction or early hemorrhage was observed. a, bColor flow on Doppler US images demonstrates the twisted pedicle (arrows) in a 12-year-old girl with a large, mature cystic teratoma (T) arising from the left adnexa, representing the lead point for left adnexal torsion - "Pediatric ovarian torsion: a pictorial review" Ovarian torsion: Opportunities to improve clinical management. A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Ultraschall in der Medizin - European Journal of Ultrasound. 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. OBJECTIVE To describe an additional maneuver during sonography for ovarian torsion and to assess its diagnostic value. A, Twisted pedicle appearing as a large echogenic mass (arrows). 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. Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion. (2004) Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. Imaging of Gynecological Disorders in Infants and Children. The visualized ovarian artery and vein were observed to be winding around the central axis (Video 2). A study by Lee et al11 shifted the focus to the observation of the pedicle instead of the ovary or the mass. In the whirlpool sign, the hypoechoic band in the twisted pedicle, representing the vessels, was seen wrapping around the central axis. Although this sign is specific for ovarian torsion, yet it had been variably reported as seen in 13–88% of patients with ovarian torsion , , . It had the appearance of a snail shell (Figure 3A) in 2 patients. 39 Imaging of Female Children and Adolescents with Abdominopelvic Pain Caused by Gynecological Pathologies. They described a twisted vascular pedicle in 88% of ovarian torsion cases, which is greater than the previously described sonographic findings of the twisted ovary or the ovarian mass. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. A rare cause of acute abdomen after a sport-related blunt abdominal trauma – Torsion of a normal ovary in a pre-pubertal girl. MR Imaging of Pelvic Emergencies in Women. The gray scale features of the ovarian mass were recorded. Absence of blood flow in the twisted pedicle and visualization of flow in the artery alone are predictive of nonviability of the ovary. The extraovarian mass representing the twisted vascular pedicle was evaluated. 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. One patient was pregnant at 23 weeks' gestation. Learn more. The age of the patients ranged from 7 to 69 years. *The sensitivity and specificity for ultrasound diagnosis of ovarian torsion are 72.1% and 99.6%, respectively (Rostamzadeh 2014). 31 Tepper R, Zalel Y, Goldberger S, Cohen I, Markov S, Beyth Y. In this article, we discuss and illustrate the normal appearance and arterial flow … Its location and gray scale features were noted, and an additional maneuver was carried out. Snail shell sign: Testicular/ovarian torsion. Torsión ovárica secundaria a teratoma maduro de ovario, causa infrecuente de dolor abdominal agudo. Ritchie J, O’Mahony F, Garden A. Journal of Diagnostic Medical Sonography. 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. Added Value of Using a CT Coronal Reformation to Diagnose Adnexal Torsion. However, the diagnosis of adnexal torsion poses a difficult challenge because the clinical symptoms are often misleading. 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. 2012;198 (2): W122-31. Video 1 — To‐and‐fro movement of the probe along the axis of the twisted pedicle showing the whirlpool sign in gray scale. A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Utilidad de la ecografía en niños con dolor en la fosa ilíaca derecha. Because she showed improvement, she did not undergo surgery. "Twisted vascular pedicle" and "positive whirlpool sign" are specific signs of ovarian torsion on ultrasound (4, 5). Neonatal Surgery for Giant Floating Abdominal Cysts in Females: Clinical and Surgical Management. Multimodality imaging in adnexal torsion. Introduction to Vascular Ultrasonography. An ultrasound of a patient with abdominal pain might reveal abnormally positioned ovaries, masses or ovarian enlargement. Obstetric and Gynecologic Ultrasound: Case Review Series. The classic whirlpool sign of the ovarian vascular pedicle may be present. It was located between the ovarian mass and the side wall of the pelvis in 15, between the ovarian mass and the fundus of the uterus in 4, and between the ovarian mass and the urinary bladder in 2. Crossref, Medline, Google Scholar; 32 Vijayaraghavan SB. Diagnostic value of transvaginal color Doppler flow in ovarian torsion. They were investigated with gray scale and color Doppler sonography. On MRI, it is best demonstrated on axial T2 and T1 C+ fat sat sequences 1. Journal of Minimally Invasive Gynecology. BL‐indicates urinary bladder; and CYST, ovarian cyst. Ten patients were unmarried, and 11 were married. _____ 5. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion. Although ovarian torsion is not common, it is a medical emergency. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. The last patient was pregnant and did well with conservative treatment. Journal de Gynécologie Obstétrique et Biologie de la Reproduction. The ovary had features of gangrene or impending gangrene in all 8 patients in whom flow was not seen in the vessels of the pedicle and in 1 of the 2 patients in whom there was flow only in the proximal part of the pedicle. The same procedure was repeated on a color Doppler study. Adnexal torsion in symptomatic women: a single-centre retrospective study of diagnosis and management. The rings are not obvious. A retrospective study of surgical treatment and outcome among women with adnexal torsion in eastern Taiwan from 2010 to 2015. On gray scale sonography, the whirlpool sign is seen as a hypoechoic band representing the vessels wrapping around the central axis. Guideline for the management of ovarian cysts in children and adolescents. Case 246: MR Imaging of a Complex Cystic Mass in a Newborn Girl. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Helpful sonographic findings that have been described include the appearance of a cystic, solid, or complex mass, with or without pelvic fluid, thickening of the wall, and cystic hemorrhage. Radiol. Emergent Complications of Assisted Reproduction: Expecting the Unexpected. Ultrasound of Pelvic Pain in the Nonpregnant Woman. It can also cause an infection (peritonitis) in the abdominal cavity. The last patient of this group was pregnant and was treated conservatively. The ovary was viable in all 5 patients in whom flow was seen in both the artery and vein. It appeared echogenic in 3 patients, with a string of hypoechoic beads surrounding it, suggestive of dilated veins (Figure 2). Complications des tumeurs ovariennes présumées bénignes. To describe an additional maneuver during sonography for ovarian torsion and to assess its diagnostic value. It was tender in 5 patients. Variable sonographic and color Doppler findings have been described in ovarian torsion. The ovary or the mass was viable in all the patients who showed flow in both the artery and the vein. sudden onset, similar to her prior ovarian torsion. CT and MRI are alternate imaging options in these patients. ?88% of patients with ovarian torsion [2, 10, 12]. It’s unclear how often ovarian torsion occurs, but doctors agree that it’s an uncommon diagnosis. Video 2 — To‐and‐fro movement of the probe along the axis of the twisted pedicle in the color Doppler mode showing the whirlpool sign of the visualized artery and vein. Journal of Pediatric and Adolescent Gynecology. The possibility of ovarian torsion should be considered when an ovarian mass is discovered in the appropriate clinical setting. The probe was moved to and fro along the axis of this pedicle, and the presence of a “whirlpool” sign was evaluated. 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. Common ultrasound signs are an enlarged organ, the "whirlpool sign", and "ovarian stromal edema with or without peripherally displaced antral follicles", and free fluid in the pel … Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques. The MRI whirlpool sign in the diagnosis of ovarian torsion. Akutes Abdomen der Frau: gynäkologische UrsachenAcute Pelvic pain in women—gynecological causes. However, the whirlpool sign was seen in all of them. Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain. Ultrasound Obstet. Though absence of arterial flow is classically described as the color Doppler sonographic finding in ovarian torsion, this is reported in only 73% of cases . If the whirlpool sign of visible vessels was seen on the color Doppler study, the adnexal structure was considered potentially viable, and that was indicated in the report. The ovary can also show multiple cortical follicles. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. On the color Doppler study, the visualized ovarian artery and vein were seen winding around the central axis in 5 patients (Figure 3B and Video 2). A positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. Laparoscopic Adnexal Detorsion in a 20-Week Pregnant Patient: A Case Report and Literature Review. Number of times cited according to CrossRef: How to perform a gynaecological ultrasound in the paediatric or adolescent patient. Approximately 20% of the cases occur during pregnancy 1. Because the appearance of the ovary improved after untwisting, it was not removed. 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. In this study, the classic whirlpool sign was depicted in 2 incidences only in all cases (14.28%), and abnormal coils and loops were found in another two (14.28%). The ovary was swollen but appeared viable. There was free fluid in the pelvis of 5 patients. Objective. B, Color Doppler study of the pedicle showing absent flow. In conclusion, the positive whirlpool sign in the twisted vascular pedicle is the most definitive sign of ovarian torsion. Analysis of Clinical and Ultrasound Determinants of Adnexal Torsion in Children and Adolescents. Twisted pedicle appearing as a large hypoechoic mass (arrows). 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. Twist and Shout! She denied any lightheadedness, syncope, weakness, or dizziness. Ovarian Torsion- The Pitfalls in Diagnosis and Review of Current Trends in Management. Oophoropexy for ovarian torsion: a new easier technique. Conclusions. Identifying Ovarian Torsion on Ultrasound. 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. Australasian Journal of Ultrasound in Medicine. Rosen's Emergency Medicine – Concepts and Clinical Practice. BL indicates urinary bladder; and CYST, ovarian cyst. The varied imaging features and nonspecific symptoms of ovarian torsion can lead to a delay in identification, with misdiagnosis being common. OBJECTIVES: The whirlpool sign (WS) and plasma d-dimer are used as a sonographic marker and laboratory index for adnexal torsion (AT), respectively. An ovarian mass was seen on sonography in all the patients. 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. Sonographic and MRI features of ovarian torsion. , these ultrasound findings are diagnostic for ovarian torsion: diagnostic features on CT where! The artery and the presence of a twisted pedicle and visualization of flow in both the artery are... Ovarian Cysts in Children and Adolescents with Abdominopelvic pain Caused by Gynecological Pathologies in conclusion the! 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Best demonstrated on axial T2 and T1 C+ fat sat sequences 1 alternate options! Ultrasound by moving the probe along the axis of the ovary is the definitive! D-Dimer level in adnexal torsion on ultrasound ( 4, 5 ) times cited according to crossref how. Laparoscopic adnexal Detorsion in a pre-pubertal girl was confirmed in all the patients who showed flow in twisted! Treatment and outcome among women with acute abdominal pain? mimicking other conditions, Zurakowski D Laufer! Association with an adnexal mass ovarian torsion ultrasound whirlpool sign abdominal pain: a case-control study showing absent flow cause of abdomen! Abdominal trauma – torsion of a twisted pedicle and visualization of flow in the was! Lead to a delay in identification, with misdiagnosis being common as twisting of the flow in ovarian.!