Presentation
Lower abdominal discomfort.
Patient Data
Large midline cyst of high T2 and Low T1 signal intensity which is related to the left ovary. The left ovary is enlarged and edematous with multiple peripheral located small cysts, the left ovary is not seen in the left adnexa but it is located in the right adnexa close to the right ovary due to torsion proved by the characteristic whirlpool appearance of pedicle of left ovary. Ovaries are touching each other (kissing ovaries). Post-contrast study shows non-enhancement of the left ovary
Case Discussion
This case was referred for pelvic MRI because the US scan showed right adnexal mass. She presented with lower abdominal discomfort but she referred to an episode of severe lower abdominal pain with vomiting about 5-7 days prior to the MRI date which is probably the day when the torsion occurred.
Ovarian torsion is sometimes a challenging diagnosis to be made by US scan, especially in cases with atypical history and late presentation like in this case.
Ovaries with focal lesions like cysts or tumors are prone to torsion like in this case with ovarian cyst.
Torsion causes the ovary to become edematous and enlarged. Stromal edema will displace the ovarian follicles peripherally. The most specific sign of ovarian torsion is the twisted pedicle which gives the appearance of whirlpool and it is clearly demonstrated in this case.
Non-enhancing ovary can suggest a dead ovary due to late presentation.
Severity and character of the pain change with time, when the pain becomes less severe and pain turn to discomfort which in turn causes more delay in medical attention.
Dead ovaries can eventually calcify if not treated and this is one of the rare differential diagnosis of calcific pelvic density which can be found incidentally on plain films in rare cases.
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