Case contributed by Dr Mostafa Mahmoud El Feky


Pelvic pain.

Patient Data

Age: 20
Gender: Female

MRI pelvis

Multiple variable sized pelvic cysts, some of them showed high T1 signal with low T2 signal with shading sign; two of them showed T2 dark spot sign at the left side of the pelvis. Another large cystic lesion is noted extending intra-abdominally abutting the right psoas muscle with also high signal in T1 and low signal in T2 with no shading sign. These cysts show no definite internal soft tissue component identified with thin hypointense walls still of < 3 mm in thickness.

Multi-convoluted tubular structures show variable caliber averaging 1 – 1.5 cm with hypointense wall showing mural infolds (mostly dilated fallopian tubes). They show signal intensity of both blood and high proteinaceous material.

Walled off crescent like loculated pelvic collections are noted in intimate relation to the cysts and dilated tubes, mainly above the dome of urinary bladder are also noted, seen insinuating between the adnexal cysts and pelvic organs showing homogenous hypointense signal in T1 and hyper intense signals in T2 with clear fluid content mostly representing para-ovarian peritoneal inclusion cysts.

Both adnexa are seen approximated to the midline by markedly hypointense adhesive bands attached to the posterior serosal surface of the AVF uterus which is dextro-rotated ... mostly deep pelvic endometriotic focus.


Annotated images

The arrows points to T2 dark spot sign  that is charachteristic of endometrioma

Case Discussion

Features of multiple pelvic cysts, some of them showed high T1 signal with T2 shading suggestive of multiple endometriomas. This case also demonstrates T2 dark spot sign  which is a black dot adherent to cyst wall seen in T2 images as a result of chronic hemorrhage. It helps differentiating endometrioma from a functional haemorrhagic ovarian cys. The associated clear fluid cysts are mostly representing peritoneal inclusion cysts which can be present in the setting of endometriosis.

Features are mostly representing extra-uterine endometriosis manifested by bilateral combined endometriomas with hematosalpinx sequel to extra-uterine deep pelvic endometriosis notably on the uterine serosal surface.

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Case information

rID: 54028
Published: 25th Jun 2017
Last edited: 27th Jun 2017
System: Gynaecology
Inclusion in quiz mode: Included

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