0:01

Okay, so now let's look at

0:02

a case of kissing ovaries.

0:04

So remember that kissing ovaries really

0:07

happens when there are adhesions near

0:10

the ovaries that draw the ovaries

0:13

together to the midline of the pelvis.

0:16

And the ovaries themselves might be abnormal

0:19

or the ovaries may just be deviated towards the

0:23

midline because of adhesions from endometriosis.

0:26

So this is a reproductive

0:27

age woman with endometriosis.

0:29

So I'm just going to start off by looking

0:31

at the sagittal T2-weighted images.

0:34

So this is a really good sequence

0:36

just to get an overview of what's

0:37

going on in general in the pelvis.

0:39

And it's usually the first sequence that we

0:41

get because it's what we use for planning.

0:43

Okay.

0:44

So here we've got the urinary bladder

0:46

here anteriorly, and then we've

0:48

got the cervix and the uterus, and

0:51

the uterus is kind of retroverted.

0:53

Then we've got this structure back here, which

0:55

you can see on the other sequences as well.

0:57

And then the rectum is back here.

0:59

So obviously we know that there's

1:01

something strange going on.

1:03

We've got sort of this tubular

1:04

cystic-looking structure.

1:06

So now we go over to the axial T2

1:09

weighted images and I like to start

1:12

by looking for normal ovaries.

1:14

So here we've got the common iliac vessels

1:18

bilaterally, and typically the ovaries are

1:20

situated lateral to the common iliac vessels.

1:23

They can be a little bit higher than this

1:26

point in some patients, which is why I

1:28

like to get a full T2 axial series of the

1:33

whole pelvis, starting at the IMA, just

1:35

in case the ovaries are displaced higher.

1:38

But typically you'd find them in this general

1:41

area, but lateral to the common iliac vessels.

1:45

So we're scrolling down, scrolling down,

1:47

we're scrolling down, and now we're

1:49

starting to get into this very bizarre

1:51

looking disorganized structure, and

1:54

we're not seeing any normal ovaries.

1:57

So here we've got a structure that looks

2:00

like it's kind of tubular looking, it

2:03

might represent a dilated tube, and

2:07

it's really hard to see a normal ovary.

2:10

And it looks as though there's

2:11

maybe a second structure here.

2:13

So we can see round ligaments here that are kind

2:16

of drawn into the middle of the pelvis where

2:20

normally they'd be a little bit more lateral.

2:22

And then we've got a second structure here.

2:24

That's quite large, very similar

2:26

appearance with lots of fluid in it.

2:29

and no normal ovary.

2:33

Okay.

2:33

So no normal ovaries.

2:34

And we see that the round ligaments are kind

2:38

of drawn more centrally towards the pelvis.

2:41

So that gives us a clue that maybe these

2:43

structures that we're looking at are the

2:45

ovaries and they're just grossly abnormal.

2:47

And you almost get the sense that there might be

2:49

little follicles here on the T2-weighted images.

2:52

So the next step is let's evaluate the

2:54

signal characteristics of what we

2:57

think are grossly abnormal ovaries.

2:59

So on T2, we can see potentially some small

3:03

follicles here, maybe we'll have to check on

3:06

T1 what they're actually like, and then maybe

3:09

some other little follicles here still don't

3:11

know, haven't looked at the T1, but we can

3:14

see that there's a fluid-fluid level in what

3:18

looks like an enlarged left ovary.

3:20

So notice that you've got some high

3:23

signal fluid, which is layering

3:25

dependently and superficially.

3:27

And then we've got this intermediate

3:29

signal fluid, which occupies the

3:31

rest of the cyst and is lower signal.

3:34

So this is T2 shading.

3:36

The other example I showed you was much

3:38

more dramatic in terms of the decrease

3:41

in T2 signal, but this is a nice example

3:44

of a fluid-fluid level with T2 shading.

3:47

And then we've got another area that's a

3:49

little bit more dark in terms of T2 signal.

3:53

So on the bottom here we've got pre and post

3:56

contrast T1 weighted images with fat saturation.

4:00

So now we need to look at whether the

4:02

T2 signal corresponds to hemorrhage.

4:04

And quite obviously you can see that.

4:06

Without contrast, there is markedly increased

4:09

T1 signal in both of those ovaries.

4:13

So the areas that we thought maybe were

4:15

follicles, let's see what they look like.

4:18

So you can see that maybe anteriorly here

4:21

and here, we've got some high signal.

4:23

So those are probably hemorrhage.

4:25

These guys here posteriorly maintain low signal.

4:29

So those are probably normal follicles.

4:31

But we've got lots of hemorrhagic products.

4:35

So this is a nice example of kissing ovaries.

4:38

And we've probably also got on the right side,

4:41

we've got this kind of tubular structure here.

4:44

Let's see what it looks like on the sagittal.

4:46

Yeah, again, it looks kind

4:47

of superficial and tubular.

4:50

I would be happy calling this a distended

4:52

fallopian tube on the right, and you can

4:54

see that there's some blood in it, so this

4:56

is a hematosalpinx, and that's also a

4:58

common feature in endometriosis, and I will

5:02

talk about that a little bit more as well.

5:05

But very nice example of kissing ovaries,

5:08

very kind of florid example in this case

5:11

as well, but hopefully you got some tips on

5:14

what to look for and how to use the different

5:16

sequences to arrive at your conclusion.

5:18

Thanks again.