Case contributed by Mostafa El-Feky


Pelvic pain.

Patient Data

Age: 20 years
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.

Multiconvoluted tubular structures show variable caliber averaging 1-1.5 cm with hypointense wall showing mural infolds (mostly dilated fallopian tubes). They show high T1 signal intensity and low T2 signal intensity fluid reflecting hemorrhagic nature.

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

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

Annotated images


The arrows point to T2 dark spot sign that is characteristic of endometrioma

Case Discussion

The MRI findings 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.

Some of the multiple pelvic cysts seen demonstrate high T1 signal with T2 shading suggestive of hemorrhagic cysts. These cysts also demonstrate 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 to differentiate endometrioma from a functional hemorrhagic ovarian cyst. The associated clear fluid cysts are mostly representing peritoneal inclusion cysts which can be present in the setting of pelvic endometriosis.​

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