Magnetic resonance imaging findings in adnexial torsion

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1 cse report Mgnetic resonnce imging findings in dnexil torsion Achdos d ressonânci mgnétic n torção nexil Ronld Meir Cstro Trindde 1, Ronldo Hue Broni 2, Michelle Rosemerg 3, Mrinne Siqur de Qudros 4, Mrcelo de Cstro Jorge Rcy 5, Adrino Tchin 6, Mrcelo Burque de Gusmão Funri 7 ABSTRACT Adnexil torsion is n unusul event, ut mjor cuse of dominl pin in women. It is often ssocited with ovrin tumor or cyst, ut cn occur in norml ovries, especilly in children. The twisting of dnexil structures my involve the ovry or tue, ut frequently ffects oth. In most cses, it is unilterl, with slight predilection for the right side. In imging findings, incresed ovrin volume nd dnexil msses re oserved, with reduced or sent vsculriztion. In cses of undignosed or untreted complete twist, hemorrhgic necrosis my occur leding to complictions; in tht, peritonitis is the most frequent. Erly dignosis helps preventing irreversile dmge with conservtive tretment, therey sving the ovry. Limittions in performing physicl exmintion, possile inconclusive results in ultrsound nd exposure to rdition in computed tomogrphy mkes mgnetic resonnce imging vlule tool in emergency ssessment of gynecologicl diseses. The ojective of this study ws to report two confirmed cses of dnexil twist, emphsizing the contriution of mgnetic resonnce imging in the dignosis of this condition. Keywords: Ovry/pthology; Adnexl diseses/dignosis; Adnex uteri/dignosis; Mgnetic resonnce imging; Torsion normlity RESUMO A torção nexil é um evento incomum, porém constitui importnte cus de dor dominl em mulheres. Está frequentemente ssocid tumor ou cisto ovrino, ms pode ocorrer em ovários normis, principlmente em crinçs. A torção de estruturs nexiis pode envolver o ovário ou tu, ms gerlmente comete mos. N miori dos csos, é unilterl, com discret predileção pelo ldo direito. Como chdos de imgem, oservm-se msss ovrins e umento do volume ovrino, com redução ou usênci de su vsculrizção. Se torção for complet e não dignosticd ou trtd, pode ocorrer necrose hemorrágic, evoluindo com complicções, sendo peritonite mis frequente. O dignóstico precoce jud prevenir dnos que são irreversíveis com trtmento conservdor, poupndo-se o ovário. A limitção do exme físico, possiilidde de resultdos inconclusivos pel ultrssonogrfi e exposição à rdição pel tomogrfi computdorizd fzem d ressonânci mgnétic um complemento vlioso n vlição de emergênci ds doençs ginecológics. O ojetivo deste trlho foi reltr dois csos confirmdos de torção nexil, enftizndo contriuição d ressonânci mgnétic no dignóstico dess entidde. Descritores: Ovário/ptologi; Doençs dos nexos/dignóstico; Anexos uterinos/dignóstico; Imgem por ressonânci mgnétic; Anormlidde torcionl INTRODUCTION Adnexl torsion my ffect the ovry, fllopin tue or oth. It is n uncommon ut importnt cuse of low dominl pin in women, nd it is difficult to mke the differentil dignosis with other cuses of cute domen (1). It is frequently ssocited to cystic or solid ovrin msses (50 to 81%) (1-4) tht my develop pedicle, which is predisposing fctor for prtil or complete torsion. Torsion my lso ffect norml ovries, usully in children, nd is usully unilterl with slight predominnce on the right side, which could e explined y the left pelvis eing occupied y the colon, or y hypermoility of the cecum nd distl ileum, which re on the right pelvis (1). This report exmined two confirmed cse of dnexil torsion, stressing the contriution of mgnetic resonnce imging (MRI) in the dignosis of this condition. Study crried out t Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 1 Grdute student in Tomogrphy nd Mgnetic Resonnce of the Instituto de Ensino e Pesquis of Hospitl Isrelit Alert Einstein HIAE, São Pulo, Brzil. 2 PhD; Rdiologist of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 3 Resident of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 4 Grdute student in Tomogrphy nd Mgnetic Resonnce of the Instituto de Ensino e Pesquis of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 5 Rdiologist of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 6 Rdiologist of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. 7 PhD; Coordintor of the Imging Service of Hospitl Isrelit Alert Einstein HIAE, São Pulo (SP), Brzil. Corresponding uthor: Ronld Meir Cstro Trindde Ru Professor José Horácio Meireller Teixeir Vil Suzn CEP São Pulo (SP), Brsil Tel.: (11) e-mil: rtrindde@ einstein.r Received on Apr 23, 2008 Accepted on Jul 2, 2009

2 Mgnetic resonnce imging findings in dnexil torsion CASE REPORTS Cse 1 A two-yer old ptient with history of dominl discomfort nd low fever for one week. The initil lortory evlution presented leukocytosis with over 18,000 cells (74% segmented) nd the type I urine nlysis showed Grm-negtive cteriuri ssocited with discrete leucocyturi. Adominl ultrsound showed norml kidneys, ldder, uterus nd right ovry. A solid-cystic nodulr formtion ws oserved in the retrovesicl region, extending to the left dnexil region (Figure 1). On color Doppler, predominntly peripherl vsculriztion ws seen round the lesion. 93 c Figure 3. Weighted T2 imges () xil, () sgittl nd (c) coronl show enlrged left ovry (rrows), with predominnce of low signl, nd smll peripherl follicles of up to 1 cm Figure 1. Ultrsonogrphy showing solid-cystic nodulr formtion occupying the retrovesicl region extending to the left dnexil region In view of the fct tht the left ovry ws not oserved in its usul morphology, pelvic MRI ws requested in order to chrcterize the dnexil lesion more precisely (Figures 2, 3 nd 4). It showed lrge increse in volume of the left ovry nd uterine tue. A c Figure 4. Weighted T1 imges, fter contrst with ft suppression () xil, () sgittl nd (c) coronl, with no pproprite contrst of the left ovry. Oserve intense enhncement of periovrin ft plns Figure 2. Axil T1 weighted MRI imging with ft suppression, efore contrst, showing enlrged left ovry, with heterogeneous sign nd some high signl res heterogeneous signl of this nnex ws perceived with slight hypersignl res in T1 (suggesting hemorrhge) interspersed with smll cystic formtions, nd ssocited to intense ltertions in signl of the peridnexil dipose plnes. No enhncement of the lesion ws oserved in the postcontrst phses. This imge corroorted the

3 94 Trindde RMC, Broni RH, Rosemerg M, Qudros MS, Rcy MCJ, Tchin A, Funri MBG possiility of dnexil torsion, proly with ssocited hemorrhgic infrction. Bsed on the MRI findings, the ptient underwent surgery, chrcterizing left ovry/nnex with 720o, torsion nd well-defined necrosis re, eing sumitted to slpingo-oophorectomy. The pthologicl exmintion showed necrosis of the ovrin prenchym nd tue with extensive hemorrhgic res therey confirming the dignosis of hemorrhgic infrction (Figure 5). contour, chrcteristic ecotexture nd slightly incresed dimensions. In the left dnexil region, etween the uterus nd ovry, heterogeneous, irregulr nd unspecific formtion, with vsculriztion, ws identified. A miniml quntity of free liquid in the posterior cul de sc ws seen. In view of the findings the ptient ws referred to pelvic MRI, tht showed tenuous tissue with T2 low density signl posterior to the uterus, in the trnsition etween the corpus nd the cervix (Figures 7, 8, 9). The left ovry hd incresed volume with discreet hypersignl of the strom in weighted T2 imges, suggesting edem. There ws thickening nd heterogeneity in the left A B Figure 5. Histopthologic section (hemtoxylin-eosin, 40 X mgnifiction) demonstrting extensive hemorrhge res (lck rrow) nd necrosis (lue rrow) Cse 2 A 38-yer old ptient with history of low dominl pin for one dy, with nuse nd vomiting (four episodes). The lortory tests showed discreet leukocytosis, with 12,060 cells, with no shifts. The other exms were negtive including type I urine nlysis nd β-hcg. She hd een sumitted to cholecystectomy nd clinicl dignosis of polycystic ovry syndrome, with irregulr ovrin cysts oserved in prior ultrsonogrphy. The ostetric pst history included one pregnncy nd cesrin section for twins (ssisted reproduction). A trnsvginl ultrsonogrphy ws performed nd showed norml uterus nd right ovry (Figure 6). The left ovry presented with norml shpe nd Figure 7. Weighted T2 imges () xil, () sgittl nd (c) coronl show the left ovry very enlrged, with discreet hypersignl of its strom, suggesting edem (yellow rrows). There is thickening nd mild ectsi in the left uterine tue Figure 6. Trnsvginl ultrsonogrphy () shows the left ovry with norml shpe nd contour, chrcteristic ecotexture, with discreet increse in size, highlighting heterogenous nd irregulr provrin dnexil formtion, vsculrized on Doppler () Cc Figure 8. Weighted T2 imge (sgittl) with ft suppression shows peripherl distriution of follicles nd excessive ovrin strom with high signl

4 Mgnetic resonnce imging findings in dnexil torsion 95 Figure 9. In weighted T1 imges with ft suppression fter erly () nd lte () contrst there is no stisfctory contrst of the ovry nd tue on the left (rrows) uterine tue. After the venous injection of prmgnetic contrst, no stisfctory contrst of the left ovry ws oserved (Figure 9). The imge spect descried in the resonnce ws comptile with the hypothesis of torsion. The ptient ws sumitted to videolproscopic surgery tht showed n edemtous nd hyperemic left uterine tue, with enlrged ovry, with no signs of necrosis. The tul-ovrin peritoneum showed pelvic vricose veins. A slpingectomy ws performed nd lysis of the ovrin-uterine dherences, with the mnipultion (torsion reduction) nd preservtion of the left ovry. The ptient involved to significnt improvement of the pelvic pin nd remined symptomtic in the lte postopertive stges. DISCUSSION The most common presenttion of dnexil torsion consists in dominl pin of sudden onset, n unspecific symptom tht lso ppers in other clinicl conditions, such s hemorrhgic cute domen, ppendicitis nd slpingitis (2-3). Although it is considered n cute event, sucute or intermittent course my mke dignosis more difficult (2). The torsion of the ovrin pedicle produces circultory stsis tht is initilly venous nd tht evolves to n rteril component s the edem from the initil ffection increses. In cses of ostruction of the rteril supply, the clinicl sttus my lso evolve to hemorrhgic-gngrenous necrosis of the ovry, nd, if there is suspicion of full torsion, immedite surgery ecomes essentil to remove the dmged tissue nd void more serious evolution to peritonitis nd deth (1-3). In oth cses descried, the surgicl procedure ws crried out s soon s the MR dignosis ws mde. In the first cse, sucute history, with dominl discomfort nd low fever over period of week, the ptient ws received t the Emergency Service with no clinicl signls tht would suggest cute domen. In spite of this, mgnetic resonnce findings were highly suggestive of this condition, s confirmed in the surgicl procedure, 720 o dnexil torsion eing oserved, with hemorrhge res (previously oserved n the weighted T1 sequences) nd necrosis. Therefore, it ws decided to perform ooferectomy. In the second cse, the more cute clinicl sttus on onset of symptoms llows n erlier dignosis with immedite surgicl procedure through lproscopy which enled mnul distortion nd spring the gond. Ultrsound is usully the first exm to e performed in emergencies, though it does not hve well-estlished role in erly dignosis. Its most common findings re cystic or complex solid msses, with or without fluid ccumultion in the pelvis, cystic hemorrhge nd prietl thickenings which were considered not specific. Doppler my e useful in the nlyses of twisted structures y enling the detection of venous nd rteril flows in the vsculr pedicle, ut hs limited specificity s in some cses it my show norml rteril wves in the nnex (1,5-8). The multiplnr imging methods, such s tomogrphy nd MRI, enle glol pelvic nlysis, fvoring the evlution of the uterine tue, chrcteriztion of the vsculr pedicle nd dnexil mss, when present, s well s detection of other peritonel findings, such s scites nd hemoperitoneum. The rpid dvnce in MR techniques enled the differentil dignosis of cute gynecologicl conditions, nd the development of fst sequences sufficiently reduced the cquisition time for their use in emergencies (3). One comintion of weighted T1 imges with nd without ft suppression is useful to envisge the difference etween lood nd ft nd improves the detection of hyperintense (hemtic) lesions surrounded y ft (3). The T2 weighted sequences with nd without ft suppression improve conspicuousness of inflmmtory lesions, esides eing the idel sequences for ntomic evlution. The imges cquired fter the injection of intrvenous contrst, with protocols with dynmic sequences nd sutrction techniques, re useful to evlute the lesion vsculriztion (3). Kimur et l. (2) demonstrted the most prevlent signs of ovrin torsion s follows: devition of the uterus towrds the torsion side, ingurgittion of the ipsilterl lood vessels, smll mount of scites nd olitertion of the ftty plnes round the tumor (1-2,7), these however eing unspecific signs (1-2). The uterine devition towrds the twisting side is explined ecuse the torsion shortens the supporting structures of the uterus. The ingurgittion of the lood vessels represents distl venous congestion to torsion nd lso on the surfce of the tumor (2). Hemorrhgic necrosis due to ovrin torsion my e identified in MR exmintions with comintion of T1 weighted imges with the suppression of ft efore nd fter the ministrtion of prmgnetic contrst, the presence of high signls in the mss ws visulized (suggesting

5 96 Trindde RMC, Broni RH, Rosemerg M, Qudros MS, Rcy MCJ, Tchin A, Funri MBG hemorrhge), s well s the sence of enhncement in the postgdolinium dynmic sequences (3). Other hemorrhgic necrosis indictors include regulr nd excentric prietl thickening of the ovrin cystic mss, converging to thickened tue nd hemtom or twisted ovrin mss with the presence of hemoperitoneum (1). CONCLUSION Mgnetic resonnce imging cn help dignose the dnexil torsion, which is rre nd with unspecific clinicl presenttion, especilly in cses in which ultrsound presents negtive or non-chrcteristic findings. Acknowledgements To Doctor Denise Psqulin, pthologist t Hospitl Isrelit Alert Einstein (HIAE), for ssistnce in pthologicl nlysis nd description. REFERENCES 1. Rh SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, et l. CT nd MR imging fetures of dnexl torsion. Rdiogrphics. 2002;22(2): Kimur I, Togshi K, Kwkmi S, Tkkur K, Mori T, Konishi J. Ovrin torsion: CT nd MR imging ppernces. Rdiology. 1994;190(2): Dohke M, Wtne Y, Okumur A, Amoh Y, Hyshi T, Yoshizko T, et l. Comprehensive MR imging of cute gynecologic diseses. Rdiogrphics. 2000;20(6): Outwter EK, Dunton CJ. Imging of the ovry nd dnex: clinicl issues nd pplictions of MR imging. Rdiology. 1995;194(1): Byer AI, Wiskind AK. Adnexl torsion: cn the dnex e sved? Am J Ostet Gynecol. 1994;171(6): ; discussion Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Dignosis of ovrin torsion with color doppler sonogrphy: depiction of twisted vsculr pedicle. J Ultrsound Med. 1998;17(2): Rosdo WM Jr, Trmert MA, Gosink BB, Pretorius DH. Adnexl torsion: dignosis y using Doppler sonogrphy. AJR Am J Roentgenol. 1992;159(6): Nichols DH, Julin PJ. Torsion of the dnex. Clin Ostet Gynecol. 1985;28(2):