Hemorrhagic Infarct of Torted Ovary: A Case Report

: Ovarian torsion, the twisting of the ovary on its supporting tissues, occurs primarily in premenopausal women, causing acute abdominal or pelvic pain. Without prompt diagnosis and surgical intervention, adnexal torsion may lead to ovarian infarction and a resulting reduction in fertility. Radiologic methodologies including ultrasound, color Doppler ultrasound, and magnetic resonance imaging (MRI) can play key roles in the diagnosis of this entity by allowing for the visualization of blood flow to the ovary.

Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) images showed diffusion restriction in the right ovary (Figures 2E  and 2F).The patient was diagnosed with a hemorrhagic infarct of a torted right ovary.She was treated conservatively, and her pain subsequently resolved.
A Abstract: Ovarian torsion, the twisting of the ovary on its supporting tissues, occurs primarily in premenopausal women, causing acute abdominal or pelvic pain.Without prompt diagnosis and surgical intervention, adnexal torsion may lead to ovarian infarction and a resulting reduction in fertility.Radiologic methodologies including ultrasound, color Doppler ultrasound, and magnetic resonance imaging (MRI) can play key roles in the diagnosis of this entity by allowing for the visualization of blood flow to the ovary.

General Epidemiology and Clinical Presentation
Prompt diagnosis of ovarian torsion, also known as adnexal torsion, is crucial, as salvage rates of ovaries in cases of acute torsion are low but improve with prompt treatment. 1Clinically, patients typically present with severe pelvic pain, with other common associated symptoms including nausea, vomiting, and fever. 1,2Delayed diagnosis of ovarian torsion can lead to ovarian infarction/necrosis. [1][2][3] Infarction may be a source of significant morbidity and mortality, as patients may go on to develop superinfection of the necrotic ovary, thrombophlebitis, peritonitis, or sepsis. 3The severity of vascular impairment and rate of ovarian necrosis are usually based on the degree to which the ovary and its vascular pedicle are rotated along the long axis, as well as on the duration of the rotation and frequency of torsiondetorsion events. 1 The presence of hemorrhage in cases of ovarian torsion is a strong indicator of poor ovarian viability. 1

Imaging Characteristics
2][3][4] Classically, reduced flow is visible with color Doppler, the standard imaging technology deployed when ovarian torsion is being considered. 1 Flow can be significantly reduced or even nonexistent in cases where torsion progresses to infarction.Ovarian cysts may act as lead points and can be found within the infarcted, torted ovary and can themselves become hemorrhagic. 1,2Paraovarian inflammatory change and pelvic free fluid may also be visible. 1,3Unlike acute ovarian torsion, in which an enlarged, medially displaced ovary may be visible with a twisted pedicle, an infarcted torted ovary may appear normal or small in size with or without a twisted pedicle. 3,5hile ultrasound imaging, especially with color Doppler, should be used for acute examination, MRI can be useful for clarifying findings in complex cases. 1 On MRI, restricted diffusion, which may be mistaken for malignant tissue, can indicate tissue infarction. 1 A hyperintense ovarian stroma may be seen on T2-weighted imaging due to edema in the setting of torsion. 4On T2-weighted images, a hypointense ring surrounding the torted ovary can indicate old blood products (hemosiderin) when torsion has progressed to hemorrhagic infarction. 2 T1-weighted sequences can show hyperintensity in the same ring distribution. 2No contrast enhancement is expected in a completely hemorrhagic infarcted ovary. 2,3]5

Differential Diagnoses
Important differential considerations include a ruptured hemorrhagic ovarian cyst, massive ovarian edema, and ovarian hyperstimulation. 1 Ruptured hemorrhagic cysts are common causes of pelvic pain in premenopausal women. 1 Ultrasound may demonstrate an avascular cystic ovarian lesion, possibly angulated or crenulated in appearance with lace-like reticulations and hyperechoic debris. 1 CT may show a cystic ovarian/adnexal lesion with heterogeneous attenuation and surrounding hemoperitoneum. 1 Ovarian edema may occur due to many pathologies, ranging from torsion and detorsion events to underlying malignancy to acute hormonal changes. 1 With massive ovarian edema, the ovary is enlarged and edematous in appearance, heterogeneous hypoechoic on ultrasound, and hypodense on CT, and displays high signal intensity on T2-weighted MR images. 1 Ovarian hyperstimulation syndrome (OHSS) is a potential side effect of fertility treatments involving follicle stimulation. 1Unique imaging features of OHSS include enlarged ovarian follicles arranged in a spoke-wheel distribution with normal central ovarian tissue, marked enlargement of the ovaries, and pleural effusions and ascites, all of which occur bilaterally. 1 This contrasts with ovarian torsion, in which the center of the ovary is usually expanded and edematous, and peripheral follicles appear normal. 1

Prognosis, Treatment, and Therapeutic Options
2][3][4][5] Typically, a laparoscopic approach is adequate to approach the pathologic region and detorse or resect tissue, although open abdominal surgery may be required in certain instances. 13]5 When multiple cysts or an ovarian mass is tied to the torsion event, treatment of the cysts or mass is crucial to preventing future torsion. 1 Treatment options for such cysts or masses may consist of hormonal therapy or unilateral or bilateral oophoropexy, a laparoscopic procedure in which the utero-ovarian ligament is shortened or the ovary, if enlarged, is sutured to the uterosacral ligament to stabilize the ovary.

Conclusion
Ovarian torsion occurs when an ovary rotates along its long axis, impeding blood flow to the ovary and fallopian tube.Torsion may occur spontaneously, although underlying conditions including polycystic ovaries or large adnexal masses can be precipitating factors.If ovarian torsion is not treated acutely, progression to gangrenous hemorrhagic infarction can occur.Ovarian salvage rates in cases of acute torsion improve with prompt diagnosis and treatment, which is enabled by imaging, especially through MRI as well as standard and Doppler ultrasound imaging.

AFigure 1 .
Figure 1.Ultrasound Images of the Right Ovary of a 52-Year-Old Woman

AFigure 2 .
Figure 2. Magnetic Resonance Imaging (MRI) of the Right Ovary of a 52-Year-Old Woman.