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n adnexal torsion, the ovary or ipsilateral fallopian tube, or both, twists with the vascular pedicle as the axis, resulting in arterial and venous
ABBREVIATIONS
CDS, Color Doppler sonography; TVS, Transvaginal sonography;
TV-CDS, Transvaginal color Doppler sonography
1998 by the American Institute of Ultrasound in Medicine J Ultrasound Med 17:8389, 1998 0278-4297/98/$3.50
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DISCUSSION
Ovarian torsion is caused by rotation of the ovary or
adnexa with the vascular pedicle on its axis, resulting
in arterial, venous, or lymphatic obstruction. It is an
acute condition that requires prompt surgical intervention to save the ovary. The ultrasonographic findings in ovarian torsion have been described as a
cystic, solid, or complex mass with or without pelvic
fluid, thickening of the wall, and cystic hemorrhage.
However, these findings are not specific for ovarian
torsion, and it is difficult to distinguish them from
the findings seen in the other disease, such as hemorrhagic cyst, endometriosis, pelvic inflammatory
disease, and ectopic pregnancy.1,2,4 Previous reports
suggested that the presence of multiple peripherally
located follicles in a case of unilateral enlarged ovary
Figure 1 27 year old patient with 360 degree torsion of the left ovary and teratoma at 9 weeks of gestation. A, TVS shows a 2 cm
round mass with a target appearance (arrows) adjacent to the ovarian tumor, indicating a twisted vascular pedicle. B, TV-CDS
shows circular vascular structures within the twisted vascular pedicle (whirlpool sign). C,D, Color Doppler flow velocimetry
demonstrates arterial (C) and venous (D) flow of the vascular structures within the twisted vascular pedicle. Pathologic examination revealed nonnecrotic ovary and tube.
A
B
and vein. The twisted vascular pedicle in ovarian torsion was identified by ultrasonography in 88% of the
cases of torsion. Therefore, the previously described
findings suggested that the presence of the twisted
vascular pedicle on ultrasonograms could be a valuable diagnostic sign of the ovarian torsion, with a
higher detection rate than the previously described
sonographic findings of the twisted ovary or the
ovarian masses; the detection rate of a cystic, solid, or
complex mass was between 46 and 74%, and that of
multiple peripherally located follicles in enlarged
ovary was 64%.24
The twisted vascular pedicle appeared as a round
hyperechoic structure with multiple concentric
hypoechoic stripes (target appearance), as a beaked
structure with concentric low echoic stripes, or as an
ellipsoid or tubular structure with internal heteroge-
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Figure 2 35 year old patient with 720 degree torsion of the left ovary and teratoma. A, TVS shows a 4 cm round mass with heterogeneous echoes (arrows) lateral to the ovarian tumor. B,TV-CDS shows vascular structures with a whorled appearance within the twisted vascular pedicle. C, Color Doppler flow velocimetry demonstrates arterial and venous flow within the vascular
structures, but end diastolic flow of the artery is absent. D, Excised specimen shows the twisted vascular pedicle and ovary as
well as teratoma with hemorrhagic necrosis.
A
B
88
Figure 3 56 year old patient with 720 degree torsion of the right ovary and teratoma. A, TVS shows a 6 4 cm round mass with
heterogeneous echoes (arrows) adjacent to the ovarian tumor. B, TV-CDS demonstrates no blood flow within the twisted vascular pedicle. Pathologic examination revealed hemorrhagic necrosis of the ovary and tube.
A
B
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REFERENCES
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2.
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4.
Graif M, Itzchak Y: Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR 150:647, 1988
5.
Helvie MA, Silver TM: Ovarian torsion: Sonographic evaluation. J Clin Ultrasound 17:327, 1989
6.
Van Voorhis BJ, Schwaiger J, Syrop CH, et al: Early diagnosis of ovarian torsion by color Doppler ultrasonography. Fertil Steril 58:215, 1992
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10. Bayer AI, Wiskind AK: Adnexal torsion: Can the adnexa
be saved? Am J Obstet Gynecol 171:1506, 1994
11. Wagaman R, Williams R: Conservative therapy for adnexal torsion. J Reprod Med 35:833, 1990
12. Ben-Rafael Z, Bider D, Mashiach S: Laparoscopic unwinding of twisted ischemic hemorrhagic adnexum after in
vitro fertilization. Fertil Steril 53:569, 1990
13. McHutchinson LB, Koonings P, Ballard C: Preservation of
ovarian tissue in adnexal tissue with fluorescein. Am J
Obstet Gynecol 168:1386, 1993
14. Bude RO, Kennelly MJ, Adler RS, et al: Nonpulsatile arterial waveforms: Observation during graded testicular torsion in rats. Acad Radiol 2:879, 1995