eMedicine Specialties > Radiology > Obstetrics/Gynecology

Ovarian Torsion: Imaging

Author: Arthur C Fleischer, MD, Professor, Chief of Diagnostic Sonography, Departments of Radiology and Obstetrics/Gynecology, Vanderbilt University Medical Center
Coauthor(s): Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Mar 13, 2009

Computed Tomography

Findings

CT scans may demonstrate ovarian enlargement, small or immature peripheral follicles, and intraperitoneal fluid. In a study by Kimura et al, the following 3 findings were seen in patients with hemorrhagic infarction: (1) protrusion of the lesion on the twisted side; (2) thick, straight blood vessels draped around the lesion; and (3) complete absence of enhancement.9,12

In another study, by Moore et al, prior to surgery for ovarian torsion, 28 of 28 patients had had CT confirmation of an enlarged ovary, ovarian cyst, or adnexal mass of the involved ovary. The authors therefore concluded that ovarian torsion can be ruled out by well-visualized normally appearing ovaries on CT and that either abnormal findings or inability to visualize the ovaries on CT necessitates further evaluation for possible ovarian torsion.13

Magnetic Resonance Imaging

Findings

MRI may demonstrate ovarian enlargement and intraperitoneal fluid. In one case report, MRI demonstrated a twisted pedicle. If hemorrhagic infarction is present, MRI can demonstrate an enlarged ovary with displaced follicles. T2-weighted images show low signal intensity caused by interstitial hemorrhage, and T1-weighted images show a thin rim of high signal intensity without contrast enhancement.9,11,14,15

Ultrasonography

Findings


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Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.

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Video depicts 2 findings: first, it shows an enla...

Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.


One of the most frequent findings on sonograms is ovarian enlargement. The ovary usually contains several immature follicles along its periphery. In addition, there may be irregular echogenic areas within the ovary corresponding to stromal edema and/or hemorrhage. On color Doppler sonograms, little or no intraovarian venous flow is present; this finding is followed by a lack of intraovarian arterial flow. Flow within the adnexal vessels may be preserved.

Occasionally, the twisted pedicle of the affected ovary can be recognized. A twisted pedicle is a relatively specific sign for ovarian torsion. With isolated tubal torsion, the tube is usually distended and lacks flow or has reversed flow during diastole. Because venous flow is under low pressure, it is the first flow to be affected by the increased interstitial pressure of a twisted ovary. In chronic torsion, arterial waveforms can mimic venous waveforms. When torsion is complete, no arterial waveforms can be detected within the ovary.

Intraperitoneal fluid may surround the twisted ovary. This usually is the result of interstitial fluid that weeps of an affected ovary rather than a true rupture of the capsule and extrusion of blood.4,5,6,7,8

In a study of 39 patients by Shadinger et al, ovarian enlargement and the absence of ovarian venous Doppler flow were the most frequent sonographic indications of ovarian torsion. Frequent clinical symptoms included abdominal pain and vomiting. The authors concluded that ovarian torsion should be highly suspected in the presence of ovarian enlargement and clinical symptoms, even if arterial and venous Doppler flow are present.16

Degree of Confidence

The presence of an enlarged ovary with lack of intraovarian arterial or venous flow is highly indicative of torsion, particularly if the typical appearance of an enlarged ovary with small peripheral cysts is depicted.5,7 Do not be dissuaded from the diagnosis of this entity if flow is present in the adnexal vessels; this finding may indicate incomplete torsion.

False Positives/Negatives

Chronic tuboovarian abscesses and/or complexes may mimic torsion, particularly torsion with contained areas of infarction.

More on Ovarian Torsion

Overview: Ovarian Torsion
Imaging: Ovarian Torsion
Multimedia: Ovarian Torsion
References
Further Reading
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References

  1. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet. Nov 1991;173(5):363-6. [Medline].

  2. Griffin D, Shiver SA. Unusual presentation of acute ovarian torsion in an adolescent. Am J Emerg Med. May 2008;26(4):520.e1-3. [Medline].

  3. Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. Nov 4 2008;[Medline].

  4. Fleischer AC, Brader KR. Sonographic depiction of ovarian vascularity and flow: current improvements and future applications. J Ultrasound Med. Mar 2001;20(3):241-50. [Medline].

  5. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. Feb 1998;17(2):83-9. [Medline].

  6. Fleischer AC, Stein SM, Cullinan JA, Warner MA. Color Doppler sonography of adnexal torsion. J Ultrasound Med. Jul 1995;14(7):523-8. [Medline].

  7. Peña JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril. May 2000;73(5):1047-50. [Medline].

  8. Filho SM, Júnior EA, Serafini P, Filho HA, Pires CR, Nardozza LM, et al. Diagnosis of ovarian torsion by three-dimensional power Doppler in first trimester of pregnancy. J Obstet Gynaecol Res. Apr 2008;34(2):266-70. [Medline].

  9. Kimura I, Togashi K, Kawakami S, Takakura K, Mori T, Konishi J. Ovarian torsion: CT and MR imaging appearances. Radiology. Feb 1994;190(2):337-41. [Medline].

  10. Siegelman ES, Outwater EK. Tissue characterization in the female pelvis by means of MR imaging. Radiology. Jul 1999;212(1):5-18. [Medline].

  11. Van Kerkhove F, Cannie M, Op de Beeck K, Timmerman D, Pienaar A, Smet MH, et al. Ovarian torsion in a premenarcheal girl: MRI findings. Abdom Imaging. May-Jun 2007;32(3):424-7. [Medline].

  12. Gittleman AM, Price AP, Goffner L, Katz DS. Ovarian torsion: CT findings in a child. J Pediatr Surg. Aug 2004;39(8):1270-2. [Medline].

  13. Moore C, Meyers AB, Capotasto J, Bokhari J. Prevalence of abnormal CT findings in patients with proven ovarian torsion and a proposed triage schema. Emerg Radiol. Aug 5 2008;[Medline].

  14. Kawakami K, Murata K, Kawaguchi N, Furukawa A, Morita R, Tenzaki T, et al. Hemorrhagic infarction of the diseased ovary: a common MR finding in two cases. Magn Reson Imaging. 1993;11(4):595-7. [Medline].

  15. MacDuff R, Anthony GS, MacLennan AC. Ovarian torsion diagnosed by MRI. J Obstet Gynaecol. Oct 2007;27(7):743-4. [Medline].

  16. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. Jan 2008;27(1):7-13. [Medline].

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Keywords

ovarian torsion, ovary torsion, adnexal torsion, twisted ovary, fallopian tubes

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Contributor Information and Disclosures

Author

Arthur C Fleischer, MD, Professor, Chief of Diagnostic Sonography, Departments of Radiology and Obstetrics/Gynecology, Vanderbilt University Medical Center
Arthur C Fleischer, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Coauthor(s)

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Medical Editor

Harris L Cohen, MD, FACR, Vice Chairman/Associate Chairman (Research Activities), Director, Division of Body Imaging, Professor of Radiology, Stony Brook School of Medicine; Visiting Professor of Radiology, Johns Hopkins School of Medicine
Harris L Cohen, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, Association of Program Directors in Radiology, Radiological Society of North America, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center
Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Lawrence M Davis, MD, Assistant Professor of Diagnostic Imaging (Clinical), Department of Diagnostic Imaging, Warren Alpert Medical School at Brown University
Lawrence M Davis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North America, and Rhode Island Medical Society
Disclosure: Nothing to disclose.

 
 
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