According to the European Society of Urogenital Radiology (ESUR) guidelines, gadolinium-enhanced fat-suppressed T1-weighted sequences are useful (a) to assess a lesions contrast enhancement pattern, (b) to depict enhancing mural nodules within adnexal masses, (c) to identify contrast extravasation indicating active bleeding, (d) to differentiate PID from endometriosis, (e) to identify inflammatory enhancement of perivisceral fat and peritoneum and (f) for characterisation of leiomyomas and differential diagnosis from leiomyosarcomas and adnexal masses [13, 16].
In a recent study (5) that determined the risk factors for surgical treatment for ovarian cyst rupture, the total pelvic fluid collection depth on a CT scan (TFCD_CT) showed a significant difference between the surgery and conservative management groups and was confirmed as a significant risk factor for surgery, with an OR of 1.59. unstable cardiac disease, tachycardia, diabetes, acute angle-closure glaucoma and phaeochromocytoma) can be administered intravenously or intramuscularly to reduce bowel motion artefacts [13, 14]. described a perifollicular T2 hypointense rim correlating with perifollicular haemorrhage; the absence of this finding should be useful as a predictor of ovarian viability [51]. MRI shows a similar appearance with internal fluid-like hypointense and hyperintense signal on T1- and T2-weighted images, respectively, and intense wall enhancement after gadolinium administration (Fig. The patient underwent laparoscopic detorsion with adnexal sparing. On MRI pelvic examinations, orthopaedic metal implants such as hip prosthesis may determine signal loss, geometric distortion, and failure of fat suppression. Weeks later, MRI showed cyst enlargement with homogeneous T2-weighted fluid signal (c), without evidence of blood on precontrast fat-suppressed T1-weighted sequence (d), with unrestricted diffusion on apparent diffusion coefficient map (e) and thin uniform enhancing wall on post-gadolinium acquisition (f), MRI of a functional cyst causing pelvic pain in the periovulatory phase in a 37-year-old woman. Congested, enhancing ovarian blood vessels are generally seen; in this regard, it should be recalled that the pathognomonic twisted pedicle usually shows a spiral configuration, but may also present as a solid-like component adjacent to the ovarian mass. Hemorrhagic ovarian cysts in patients on anticoagulation therapy: CT findings. Multiplanar T2-weighted (ad), oblique-axial precontrast fat-suppressed T1-weighted (e) and oblique-axial gadolinium-enhanced fat-suppressed T1-weighted (f) images show an enlarged (10cm diameter) right ovary (arrowheads) with afollicular T2-hyperintense central stroma (asterisk in b and c), peripheral follicles (pearl string sign, thin arrows in b and d) and corpus luteum (arrow in a). The most usual appearance is that of a unilocular, unilateral cyst with relatively high signal intensity on T1-weighted images and variable, heterogeneous T2-weighted signal intensity; intracystic fluid-fluid levels are commonly seen [8, 23]. Korean J Radiol 2003;4:4245. AJR Am J Roentgenol 202:904911, Kubik-Huch RA, Weston M, Nougaret S et al (2018) European Society of Urogenital Radiology (ESUR) guidelines: MR imaging of leiomyomas. At CT and MRI, the cystic mass may show variable peripheral enhancement, corresponding to the sonographic ring of fire sign; similarly, tubal wall enhancement has been reported, albeit the use of gadolinium contrast is controversial [9, 15, 38, 39]. Haemoperitoneum shown at CT (ac) as pelvic effusion (asterisk) with attenuation higher than that of water, caused by ruptured corpus luteum seen as a 3-cm right adnexal cystic lesion (arrowheads) with enhancing wall, surrounded by high-attenuation sentinel clot (arrows), Two cases of haemoperitoneum from bleeding corpus luteum. Right adnexal torsion in a 24-year-old woman with acute abdominal pain and leukocytosis. The researchers divided the study population into surgically treated and conservatively managed groups. Subtraction techniques that suppress the T1 hyperintense background of the cystic content allow to detect true gadolinium enhancement in suspicious solid mural nodules (a finding suggesting tumour arising from endometrioma), which may be hardly identifiable at visual assessment alone [14, 28]. 
Ovarian cyst rupture causing hemoperitoneum: imaging features and the potential for misdiagnosis. Although very complete, the abovementioned protocol (Table1) lasts approximately 30min (40min including urographic acquisitions) and seems hardly applicable in an emergency setting.
Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Therefore, active bleeding detected on a CT scan is suggestive of ruptured corpus luteal cyst. Rate of surgical treatment based on coexistent CT predictors. At CT, the unilaterally enlarged ovary (usually greater than 5cm) is displaced from its expected site and often located on the midline, and the uterus is attracted towards the ipsilateral side by the shortened adnexal ligament. Therefore, familiarity with these conditions and their imaging appearances is crucial to avoid missing or misinterpreting clinically important entities which may require surgical treatment. D. Patient was surgically treated with right ovarian cystectomy and hematoma evacuation, and active bleeding focus was observed at right ovary (arrow), based on operation record. From January 2009 to December 2014, a total of 106 female patients (mean age, 26.1 years; range, 1744 years) who visited the emergency room of our institute for acute abdominal pain and were subsequently diagnosed with ruptured corpus luteal cyst with hemoperitoneum were included in the retrospective study. The rate of surgical treatment was 45.5% in patients having both a positive AB_PVP and a hemoperitoneum depth > 5.8 cm (5/11 patients), 24.4% in those having either a positive AB_PVP or a hemoperitoneum depth > 5.8 cm (10/41 patients), and only 7.4% in those with neither a positive AB_PVP nor a hemoperitoneum depth > 5.8 cm (4/54 patients) (p = 0.001, chi-square for trend) (Fig. Although limited by scanner availability, exam duration and cost, the use of MRI in urgent settings has steadily grown over the last decade, particularly in paediatric patients and child-bearing age women, to avoid the risks of administering ionising radiation to the genital organs [5,6,7]. In addition, the previous study (5) defined TFCD_CT as the sum of the depths in the anterior and posterior cul-de-sac; whereas, we defined the depth of hemoperitoneum as the deepest pocket in the pelvic cavity on an axial scan. reported MRI to have levels of sensitivity and specificity for PGS respectively of 88% and 67% for ovarian veins, 100% and 38% for iliac veins and 91 and 42% for pelvic plexus [72]. Radiographics 25:320, Phillips D, Deipolyi AR, Hesketh RL et al (2014) Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management. 19). Additional MRI-like oblique-axial and oblique-coronal reconstructions (perpendicular and parallel to the main uterine axis, respectively) may be helpful to discriminate extra-uterine structures and to better assess topography of uterine abnormalities such as subserosal or pedunculated leiomyomas [1,2,3,4, 11]. Clin Imaging 40:10291033, Kato H, Kanematsu M, Uchiyama M et al (2014) Diffusion-weighted imaging of ovarian torsion: usefulness of apparent diffusion coefficient (ADC) values for the detection of haemorrhagic infarction. In this latter syndrome, the abrupt narrowing, with a triangular shape, of the proximally dilated left renal vein between the abdominal aorta and the superior mesenteric artery is referred to as the beak sign. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided. Some authors proposed the use of CT to predict the clinical outcome, stating that in their experience, active bleeding and massive pelvic haemoperitoneum (anteroposterior diameter >6cm) dictate the need for operative treatment [20, 33]. The following second instalment will present acute uterine disorders causing abnormal vaginal bleeding in non-pregnant women (including endometrial polyps, complicated leiomyomas and uterine inversion) and the imaging spectrum of PID and atypical genital infections. In reproductive age women with unspecific abdominal complaints, a limited CT protocol that includes a single acquisition in the portal venous phase is beneficial to limit the ionising radiation dose. 22 and 23) [64]. Nowadays, laparoscopic detorsion is the treatment of choice in reproductive age females. J Comput Assist Tomogr 1993;17:623625. Insights Imaging 10, 119 (2019). We included those cases if the CT met the following criteria: taken using multidetector CT; including at a minimum precontrast, and the portal venous phase covering the liver dome to symphysis pubis; and saved as a DICOM file for PACS. On sagittal (c) and oblique-coronal (d) precontrast fat-suppressed T1-weighted images, the cysts demonstrate high signal intensity (arrowheads). Additional sagittal maximum-intensity projection (MIP) reconstruction (b) demonstrates the left renal vein (arrow) within a narrow angle between the abdominal aorta and the superior mesenteric artery (thin arrow), consistent with nutcracker syndrome.
Bennett GL, Slywotzky CM, Giovanniello G (2002) Gynecologic causes of acute pelvic pain: spectrum of CT findings. In the former case, bleeding is caused by the hypervascularity and fragile vessels of the granulosa layer within the wall of the cyst. Oblique coronal T2-weighted image (b) demonstrates the normal-appearing left ovary (black arrowhead). Additionally, up to 50% of women with PVI present cystic formations in the ovary, ranging from scant cysts to classic polycystic ovary aspect (Fig. J Clin Ultrasound 1986;14:449453. Emerg Radiol 24:681688, Pedrosa I, Zeikus EA, Levine D, Rofsky NM (2007) MR imaging of acute right lower quadrant pain in pregnant and nonpregnant patients. Insights Imaging 3:265275, PubMed Tech Vasc Interv Radiol 9:1923, Kuligowska E, Deeds L 3rd, Lu K 3rd (2005) Pelvic pain: overlooked and underdiagnosed gynecologic conditions. Eur Radiol 27:22482257, Kao LY, Scheinfeld MH, Chernyak V et al (2014) Beyond ultrasound: CT and MRI of ectopic pregnancy. Sonography of hemorrhagic ovarian cysts. The other uncommon implantation sites are listed in Table4 [34, 35]. It is one of the most useful CT findings for the diagnosis of nutcracker syndrome, with a sensitivity of 91.7% and a specificity of 88.9% according to the literature [66, 67].
The blood in different stages of evolution appears as iso- to hyperintense fluid on T1-weighted MR images. PubMed Radiographics 32:17511773, Lubner M, Menias C, Rucker C et al (2007) Blood in the belly: CT findings of hemoperitoneum. Ten patients visited our emergency department via another hospital; and had undergone CT elsewhere. Note the ipsilateral attraction of uterus (+), minimal fluid in the peritoneal cul-de sac (asterisk in a). 7). The normal, non-dilated fallopian tubes are usually hardly recognizable at MRI unless outlined by pelvic fluid. The diagnostic accuracy of the direct sign was 92%, with a sensitivity of 91.3% and specificity of 100%, more accurate than that of any single indirect sign; accuracy increased up to 100% when diagnostic criteria required the presence of a direct sign or at least two indirect signs [41]. The usual presentation is abrupt-onset lower abdominal pain radiating to the ipsilateral flank or groin, with adnexal tenderness. Curr Opin Obstet Gynecol 17:483489, Balci O, Energin H, Gorkemli H et al (2019) Management of adnexal torsion: a 13-year experience in single tertiary center. Insights into Imaging Isolated torsion of paraovarian/paratubal cysts rarely occurs and its prevalence is higher in children than in adults. One patient, who had acute appendicitis and underwent removal of suspicious ruptured ovarian cyst during appendectomy, was also excluded because the decision for treatment strategy of the ruptured ovarian cyst was interrupted by the appendicitis, which required surgical treatment. PubMed Central This state-of-the-art MRI protocol (Table1) relies on T2- and T1-weighted sequences with and without fat suppression and diffusion-weighted imaging (DWI) sequences. Kim JH, Lee SM, Lee JH, Jo YR, Moon MH, Shin J, et al. In this study, we described the CT findings of corpus luteal cyst ruptures and determined pretreatment CT findings that are potential risk factors for surgical treatment of a ruptured corpus luteal cyst with hemoperitoneum. The rate of surgical treatment was 17.9% (n = 19) and that of conservative management was 82.1% (n = 87). Korean J Radiol.
Surgical treatment should be performed within 48h from the onset of pain to improve the outcome. Radiographics 38:450461, Yitta S, Hecht EM, Mausner EV et al (2011) Normal or abnormal? Because of the great clinical variability of the disease, delayed diagnosis up to 710years after initial symptoms is common [25]. Regarding the sentinel clot sign, it is likely that sentinel clots decelerate active bleeding by sealing cyst wall defects and, consequently, lower the risk of surgical intervention. Later, a fluid-fluid level can be seen, with the dependent portion of the bloody ascites being hyperintense compared with the supernatant on T1-weighted images; on T2-weighted images, the signal intensity relationship is reversed. Radiology 2013;268:7988. The detailed parameters were as follows: detector configuration, 16 1.25 mm; tube voltage, 120 kVp; noise index, 12.35 with automatic exposure control (smart mA, GE Healthcare, Milwaukee, WI, USA); gantry rotation period, 0.6 second; pitch factor, 1.375; table speed, 27.5 mm per rotation; reconstructed section width, 3.75 mm; and reconstructed section interval, 3.75 mm. Corresponding oblique-coronal gadolinium-enhanced fat-suppressed T1-weighted image (b) demonstrates vascular enhancement of the abovementioned structures (arrowheads), thus confirming pelvic varices, Pelvic varices from nutcracker syndrome in a 24-year-old woman with severe pelvic pain. After intravenous contrast, the walls of luteal cysts appear thicker than those of follicular cysts and highly vascularised. As a result, CT often provides the first diagnosis of female genital emergencies. On oblique-coronal fat-suppressed T1-weighted image (d), the distended fallopian tube displays a thick hyperintense wall (arrow) consistent with haematosalpinx. A recent retrospective study analyzed the risk factors for surgery to treat a corpus luteal cyst rupture among multiple clinical and CT findings; however, the diameter of the ovarian cyst and the depth of hemoperitoneum were the only CT findings analyzed (5). Unfortunately, US has a high specificity (near to 100%) but low sensitivity (about 1520%) [34, 36]. AJR Am J Roentgenol 204:448458, Asciutto G, Mumme A, Marpe B et al (2008) MR venography in the detection of pelvic venous congestion. 12 and 13). Amenorrhoea, vaginal bleeding, early pregnancy signs and elevated beta human chorionic gonadotropin (-hCG) are absent [31, 32]. Computed tomography of corpus luteal cysts. Magn Reson Med Sci 13:3944, Moribata Y, Kido A, Yamaoka T et al (2015) MR imaging findings of ovarian torsion correlate with pathological haemorrhagic infarction. HU = Hounsfield unit.
However, patients clinical history generally records self-limiting episodes of abdominal pain of different durations. Moderate peritoneal effusion (asterisk) coexists. US represents the primary imaging modality to assess ovarian torsion. Occasionally, patients with EP may undergo CT under the clinical diagnosis of severe acute abdomen or haemoperitoneum, sometimes without prior US. The ovaries are located anterior or antero-medial to the pelvic ureters, conversely iliac lymph nodes lie lateral or posterolaterally [3, 12]. An antispasmodic agent such as glucagon or N-butyl-scopolamine, unless contraindicated (e.g. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. In reproductive age females, the normal ovary shows homogenous soft-tissue T1-weighted signal intensity and is often barely perceptible from adjacent bowel. Note the peritoneal effusion (asterisk) and congested ovarian vessels on the right side.
In the second section, uterine emergencies and the spectrum of pelvic inflammatory disease (PID) will be presented [8, 9]. J Vasc Interv Radiol 25:725733, Ananthan K, Onida S, Davies AH (2017) Nutcracker syndrome: an update on current diagnostic criteria and management guidelines.
J Laparoendosc Adv Surg Tech A 29:293297, Duigenan S, Oliva E, Lee SI (2012) Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. Unfortunately, the cystic component may not be visible, and in these cases, EP appears as a heterogeneous, mostly T2-hyperintense mass. The adnexal mass corresponding to the gestational sac appears as a thick-walled cystic structure which typically has high signal on T2-weighted sequences and frequently contains foci of acute blood (with variable T1-weighted signal intensity according to haemoglobin degradation stages). AB_PVP = active bleeding in the portal venous phase. World J Nephrol 3:277281, Desimpelaere JH, Seynaeve PC, Hagers YM et al (1999) Pelvic congestion syndrome: demonstration and diagnosis by helical CT. Abdom Imaging 24:100102, Coakley FV, Varghese SL, Hricak H (1999) CT and MRI of pelvic varices in women. 2) [8, 9, 20]. Metal artefact reduction sequences (MARS) is a general definition which does not refer to a single specific technique, but rather encompasses a variety of sequences optimised to reduce artefacts from metal. These similar trends of rate indicate that AB_PVP might represent dBP and concurrent significant bleeding, which is supported by our result of a high OR (5.786) for surgical treatment in patients with a hemoperitoneum depth > 5.8 cm as well as a positive AB_PVP.
Clinical parameters and imaging findings of the two groups were compared. Fertil Steril 108:886894, Jeong YY, Outwater EK, Kang HK (2000) Imaging evaluation of ovarian masses. DWI sequences are helpful in the characterisation of fluids: hypercellular fluids, such as pus, show restricted diffusion and therefore appear hyperintense on DWI images and hypointense on the corresponding apparent diffusion coefficient (ADC) map. PubMedGoogle Scholar. Article
The oedematous ovary may show eccentric or concentric wall thickening or a target-like pattern corresponding to peripheral displacement of follicles. The Az value of 0.711 for hemoperitoneum depth using surgery as the endpoint indicated fair diagnostic performance. Moreover, currently, there is no gold standard for surgical treatment of a ruptured corpus luteal cyst. Whereas in the past, the majority of cases were treated surgically, nowadays, in haemodynamically stable patients, the management approach is increasingly conservative with close observation and roughly 20% of patients ultimately require laparoscopic surgery [31, 32]. The presentation includes acute abdominal pain closely similar to that produced by ruptured corpus luteum, but associated with amenorrhoea, vaginal bleeding and positive beta human chorionic gonadotropin (-hCG) [34].
Typical appearance of an uncomplicated corpus luteum in the second half (luteal phase) of the menstrual cycle on axial (a) and coronal (b) CT images: the normal-sized right ovary (arrowhead) contains a 1.5-cm cystic structure demarcated by a crenulated, strongly enhancing peripheral rim (arrow), Usual MRI appearance of an uncomplicated corpus luteum in a 26-year-old woman. In patients with metal implants, these sequences, associated with advanced image acquisition techniques such as parallel imaging, allow to acquire MARS in a clinically feasible scan time [18]. Privacy 12 and 13) [3, 8, 20, 29, 30]. Haemorrhagic ovarian cyst is suggested over endometrioma when the cyst is solitary and unilocular, without the shading sign, and disappears at follow-up (612weeks). Gradient-echo fat-suppressed T1-weighted sequences after intravenous administration of contrast material demonstrate vascular enhancement of pelvic varices, thus confirming the diagnosis (Figs. In the same patient as in Fig. Advantages of MRI over CT include the lack of radiation exposure, native multiplanar acquisition, optimal soft-tissue contrast and tissue characterisation including the possibility of demonstrating the presence of fat and blood products. In this stage, heterogeneous, minimal or absent enhancement on gadolinium-enhanced subtraction of fat-saturated T1-weighted images confirm the evolution towards infarction [9, 42, 45, 47,48,49,50].. Petkovska et al. 2) (8). Wilbur AC, Goldstein LD, Prywitch BA. Each CT finding was compared between the surgically treated and conservatively managed groups using the Mann-Whitney U-Test for continuous numeric data or chi-square test for binary categorical data. Also in acute and in subacute settings, MRI may depict more clearly both direct and indirect findings of AT. 8. Cookies policy. Article J Surg Case Rep. 2015 Oct 01; [doi: 10.1093/jscr/rjv120]. Google Scholar, Iraha Y, Okada M, Iraha R et al (2017) CT and MR imaging of gynecologic emergencies. Several studies have reported active bleeding, which appears as contrast media extravasation on CT in corpus luteal cyst ruptures (10, 11); however, to our best knowledge, we are the first to report the percentage of patients with active bleeding shown on CT from a ruptured corpus luteum. Oblique-coronal T2-weighted image (a) shows ectatic vascular structures in the parametria, showing predominantly high signal intensity (arrowheads); in the left parametrium, some varices (arrow) display low signal intensity. Isolated fallopian tube torsion without ovarian torsion is exceptionally rare and requires surgical intervention too. Finally, the identification of vascularised projections and nodular septa should suggest malignancy [17, 22, 26, 27]. Sample image of shrunken (A) and tensile (B) shape cysts (arrowheads). Cite this article. Mostly encountered in the fourth decade of life, EP occurs in approximately 1.32.4% of all pregnancies and refers to the implantation of a blastocyst at a different location from the endometrium of uterine cavity, most usually in the fallopian tube (about 95% of all ectopic pregnancies, involving the ampulla, isthmus and fimbria in descending order of incidence). Although liberal use of CT should be discouraged in childbearing age women, radiologists performing urgent CT studies may encounter an unsuspected acute female genital disorder that warrants immediate gynaecologic examination, further workup or prompt intervention.