Presentation
Sudden onset severe abdominal pain. No history of vomiting, fever or dysuria.
Patient Data
A large para tubal cyst with mild T1 hyperintensity and shading in T2 is noted in the midline indenting the fundus of uterus and dome of bladder. A well defined T2 hypointense focus in the posterior aspect of the cyst showing blooming on the GRE sequence, suggestive of hemorrhagic components.
The right sided vascular pedicle is twisted with areas of GRE blooming suggesting hemorrhagic components within. The right ovary is mildly bulky and located in abnormal position , antero-superior to bladder.
Within the left ovary there is a well defined, unilocular, fluid signal cyst.
The uterus, cervix and vagina are normal.
Case Discussion
Initial ultrasound in this premenopausal woman had demonstrated bilateral adnexal cystic lesions (not shown here). Subsequent MRI shows torsion of right ovarian pedicle with abnormally located right ovary and a large para ovarian cyst. The para-ovarian cyst and ovarian pedicle showed hemorrhagic components. Another large cyst was detected to arise from left ovary.
The patient underwent laporoscopic right ovarian cystectomy, right salpingectomy, left ovarian cystostomy and left fimbrial cystectomy.
Ovarian torsion is a common cause of sudden onset abdominal pain and torsion with ovarian mass is also described in literature. Isolated twisting of ovarian pedicle and torsion of para-ovarian cyst is relatively uncommon and usually presents in reproductive age group.
Ultrasound is the most common first line investigation, however MRI of pelvis is very helpful in demonstrating torsion of vascular pedicle as we can see in this case.
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