0:01

For our next case, this is of a

0:02

24-year-old patient who presented

0:04

to the ED with acute pelvic pain.

0:08

We'll start here with our sagittal

0:10

image of the uterus, and we'll go

0:12

through the still images first.

0:13

You can see a normal endometrium.

0:17

We come up through the cervix here.

0:18

The uterus so far, so good, looks okay.

0:22

No real abnormality that we're seeing.

0:27

We get a little bit further.

0:28

We go into the right adnexa.

0:30

We found a right ovary, which also looks normal,

0:34

until we get to what is labeled

0:36

the left ovary in this case.

0:37

So we see a very heterogeneous

0:39

structure in the left adnexa.

0:42

Well-circumscribed, maybe some calcifications

0:44

and it looks pretty solid; definitely

0:46

has shadowing, both at the margins

0:48

and from internal components of it.

0:50

We don't see any normal ovarian tissue,

0:53

and we really don't see any color

0:54

Doppler blood flow within the structure.

0:57

Initially, this was thought to be a

0:59

solid tumor of the left ovary, and

1:02

that's how it was initially read.

1:05

Show you the cine clips as well,

1:09

just to give you an idea of the

1:10

scope and the size of the structure.

1:13

You can see here, the uterus is right here.

1:16

Maybe this is the broad ligament here, kind

1:17

of draping over this left adnexal structure,

1:24

but pretty limited with the

1:25

ultrasound for what else you can do.

1:29

Patient also got a CT because we were in the ED

1:31

and needed to rule out other acute etiologies.

1:35

And as we scroll down into the pelvis here,

1:40

we have our uterus back here, and then

1:42

we have this big structure right here.

2:57

And you can even see a

2:57

little follicle right there.

2:59

Maybe another one back here.

3:01

So this is your ovary back here.

3:02

Your ovary is tucked back here, sort of

3:05

behind the uterus and broad ligament.

3:06

This mass lesion, that claw sign

3:08

is not coming from the ovary.

3:10

Therefore, you can say that this patient

3:11

does not have an ovarian tumor or malignancy.

3:14

This is coming from something else.

3:17

And if you go back to that ultrasound,

3:19

now that you have that in your mind that

3:20

this is not an ovarian primary structure.

3:24

You go back to this and you

3:25

imagine, if I saw this placed in the

3:26

uterus, what does this look like?

3:28

And it looks like a pretty classic,

3:29

albeit very large, fibroid.

3:32

So, going back one more time to the CT,

3:35

maybe this claw sign instead is coming

3:37

from the uterus, or maybe even the

3:39

broad ligament, hard to tell right here.

3:41

Maybe this is an exophytic fibroid

3:43

coming off of the uterus right here that

3:46

has infarcted, and that's why it's hypo

3:48

enhancing, why there was no color Doppler

3:50

flow in the ultrasound, and that's why there's

3:52

surrounding inflammatory change because

3:54

this is an acute process and it's painful.

3:56

So patients can present

3:57

acutely when this happens.

3:59

So we were able to fairly confidently

4:01

diagnose that this was likely a hemorrhagic

4:05

or acutely infarcting fibroid and said you

4:07

can get an MRI as an outpatient in follow-up

4:10

to prove this, but the patient does not have

4:12

an ovarian malignancy; they were able to be

4:14

discharged with that concern allayed at least.

4:18

In her particular case, she did end up

4:20

coming back for her MRI a few weeks later.

4:24

And I'll bring over some

4:25

of these images for you.

4:28

Here is your pre-contrast T1.

4:32

And we can see here, this is a

4:33

fat-saturated pre-contrast T1.

4:36

And here's our structure right here.

4:38

It is intrinsically T1 bright, right?

4:40

So that means it's either proteinaceous or

4:43

hemorrhagic component internally within it.

4:46

Here is our non-fat-saturated T2.

4:49

You can see your beautiful

4:50

endometrium right here.

4:51

We actually have some classic appearing T2

4:53

dark fibroids in the myometrium back here.

4:56

Bye.

4:57

But you have this T2 dark structure.

4:58

Again, this is the same

4:59

structure we're seeing on CT.

5:01

We have a dark ring or rim around

5:03

it, probably a hemocytin ring here.

5:06

And then lastly, of course, we're

5:07

going to skip the post-contrast

5:09

because that's going to be bright.

5:10

What you're going to want to look at is

5:12

your subtraction weighted imaging, right?

5:14

Because this is already intrinsically

5:15

T1 bright, you give contrast,

5:17

it's still going to be bright.

5:19

So you really want that subtraction image.

5:22

And as we get to that, we can see this is

5:23

essentially a black hole, very, very minimal

5:26

enhancement within that, if anything.

5:29

And that confirms that this is an acutely

5:32

infarcted fibroid or a red fibroid because

5:35

it has hemorrhage internally within it.

5:37

And that was the cause of the patient's pain.

5:39

No ovarian mass; the patient was able to confidently

5:41

be diagnosed with treatment just being to treat

5:45

the pain until the pain goes away, basically.