(Radiographics. 2000;20:1551-1566.)
© RSNA, 2000
Comprehensive MR Imaging of Acute Gynecologic Diseases1
Masako Dohke, MD ,
Yuji Watanabe, MD, PhD,
Akira Okumura, MD,
Yoshiki Amoh, MD,
Takafumi Hayashi, MD,
Takeshi Yoshizako, MD,
Masayasu Yasui, MD,
Satoru Nakashita, MD,
Junko Nakanishi, MD and
Yoshihiro Dodo, MD, PhD
1 From the Department of Radiology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki 710-8602, Japan. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received March 2, 2000; revision requested March 29 and received May 22; accepted May 26. Address correspondence to Y.W. (e-mail: yw5904@kchnet.or.jp).
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Abstract
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Rapid advances in techniques of magnetic resonance (MR) imaging have enabled diagnosis of acute gynecologic conditions, which are characterized by sudden onset of lower abdominal pain, fever, genital bleeding, intraperitoneal bleeding, or symptoms of shock. The chemical-selective fat-suppression technique not only helps establish the characteristics of lesions that contain fat components but also increases the conspicuity of inflammatory lesions. When a T2-weighted image is obtained with a very long effective echo time (>250 msec), even a small amount of ascites can be easily identified and the contrast between urine and complex fluid becomes more conspicuous. T2*-weighted images are useful for identification of hemorrhagic lesions by demonstrating deoxyhemoglobin and hemosiderin. Contrast material–enhanced dynamic subtraction MR imaging performed with a three-dimensional fast field-echo sequence and a rapid bolus injection of gadopentetate dimeglumine allows evaluation of lesion vascularity and the anatomic relationship between pelvic vessels and a lesion and allows identification of the bleeding point by demonstrating extravasation of contrast material. To optimize the MR imaging examination, attention should be given to the parameters of each pulse sequence and proper combination of the sequences.
Index Terms: Arteriovenous malformations, uterine, 854.494 • Magnetic resonance (MR), technology • Ovary, cysts, 852.31171 • Ovary, neoplasms, 852.313, 852.3192 • Ovary, torsion, 852.899 • Pelvic organs, inflammation, 85.217 • Placenta, abnormalities, 857.3199, 857.8249, 857.8255 • Pregnancy, ectopic, 85.823
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LEARNING OBJECTIVES FOR TEST 2
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After reading this article and taking the test, the reader will be able to:
- List the clinical features of acute gynecologic diseases.
- Recognize the MR imaging features of each acute gynecologic disease.
- Describe the characteristics and usefulness of each pulse sequence in diagnosis of acute gynecologic diseases.
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Introduction
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An acute gynecologic condition is characterized by sudden onset of lower abdominal pain, fever, genital bleeding, intraperitoneal bleeding, or symptoms of shock. It is important to differentiate diseases such as ovarian torsion, rupture of an ectopic pregnancy, and uterine arteriovenous malformations, which require an immediate surgical or interventional approach, from conditions such as pelvic peritonitis and ovarian hemorrhage, which can be treated with conservative therapy. Physical examination has a limited role in diagnosis of acute gynecologic conditions. Ultrasonography (US) is a useful imaging modality for evaluation of patients suspected to have acute gynecologic diseases. However, US findings are not always conclusive. Computed tomography exposes patients to ionizing radiation, which is problematic among young women.
Magnetic resonance (MR) imaging is a valuable complement to US when used as an emergency examination in a patient with suspected acute gynecologic disease. The recent development of fast MR imaging has shortened the imaging time enough for emergency use. In addition, the fat-suppression technique has enabled increased lesion conspicuity relative to that achieved with conventional MR imaging. Selective use of contrast material in combination with the three-dimensional fast field-echo sequence can provide information about the active bleeding point in addition to information about lesion vascularity and the anatomic relationship between the lesion and pelvic vessels.
In this article, we demonstrate the usefulness of comprehensive fast MR imaging performed with selective use of contrast material in patients with acute gynecologic conditions. Clinical examples include rupture of an ovarian endometrioma, hemorrhagic ovarian cyst, rupture of an ovarian cystic teratoma, ovarian torsion, ectopic pregnancy, uterine arteriovenous malformation, placental polyp and retained products of conception, and pelvic inflammatory disease. Limitations of MR imaging and differential diagnoses are also discussed.
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Techniques
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We perform MR imaging with a 1.5-T unit (Gyroscan ACS-NT; Philips Medical Systems, Best, the Netherlands) with 15-mT/m gradients. After obtaining localizing images of the female pelvis, we perform the following pulse sequences, usually in the axial plane: T1-weighted fast spin-echo (repetition time msec/echo time msec, 480/15) or gradient- and spin-echo (550/15–30); fat-suppressed T1-weighted fast spin-echo or gradient- and spin-echo; fat-suppressed T2-weighted fast spin-echo (3,000/100); heavily T2-weighted fast spin-echo (5,500/300–350); and T2*-weighted (530/20, 25° flip angle) imaging. Coronal or sagittal fat-suppressed T2-weighted fast spin-echo images are also obtained. Fat suppression is performed by using spectral presaturation with an inversion-recovery pulse, which provides excellent suppression of fat signals.
Contrast material is used selectively when pelvic inflammation or active genital or intraperitoneal bleeding is suspected. Contrast material–enhanced dynamic subtraction MR imaging is performed with a three-dimensional fast field-echo sequence (8.6/2.3, 35° flip angle). Late contrast-enhanced images are obtained with fat-suppressed fast spin-echo or gradient- and spin-echo sequences.
In contrast-enhanced dynamic subtraction MR imaging, images are obtained in the coronal or sagittal plane before and after rapid intravenous injection of a 0.1-mmol/kg bolus of gadopentetate dimeglumine (Magnevist; Schering AG, Berlin, Germany). A rapid injection of gadopentetate dimeglumine is performed within 5 seconds, followed by flushing with 20 mL of physiologic saline solution. Five imaging sets are consecutively acquired after the injection of gadopentetate dimeglumine. The three-dimensional data set obtained immediately before administration of gadopentetate dimeglumine is used as a mask for subsequent image subtraction and is subtracted section by section from each of the five original three-dimensional data sets acquired after administration of gadopentetate dimeglumine. The subtraction is performed by using commercially available software (Philips Medical Systems). By repeating the sequence after gadopentetate dimeglumine injection, the gadopentetate dimeglumine bolus can be tracked; such tracking helps demonstrate circulation dynamics and lesion vascularity. A dynamic subtraction MR angiogram is created by compressing subtracted images of each phase by means of maximum-intensity projection postprocessing (1,2).
The characteristics and usefulness of each sequence are shown in the Table. Knowledge of the characteristics of each sequence is necessary not only to perform an appropriate MR imaging examination but also to interpret the MR images.
Fat-suppressed T1-weighted Imaging
A combination of T1-weighted images and fat-suppressed T1-weighted images is useful not only for demonstration of fat components in cystic teratoma but also for differentiation of blood from fat. The addition of fat suppression to T1-weighted imaging improves the detection and conspicuity of hyperintense lesions surrounded by fat. In rupture of an endometrioma, hyperintense fluid contents that have flowed out of the endometrioma are clearly demonstrated. Bloody ascites in the pelvic cavity is easily detected as hyperintense areas.
Fat-suppressed T2-weighted Imaging
Fat-suppressed T2-weighted images improve the conspicuity of inflammatory lesions and demonstrate their extents by excluding hyperintense fat signals. Abscesses, fluid-filled fallopian tubes, and free pelvic fluid are clearly demonstrated as hyperintense areas. Inflammatory infiltration and edema are shown as ill-defined, slightly hyperintense areas.
Heavily T2-weighted Imaging
When a long effective echo time (250–350 msec) is used in fast spin-echo sequences, heavily T2-weighted images can be obtained. Simple fluid is markedly hyperintense, whereas fat is moderately hyperintense. Therefore, a small amount of ascites can be easily identified. The contrast between urine and complex fluid is more conspicuous on heavily T2-weighted images than on mildly T2-weighted images. Layering debris and clot in the fluid may be clearly demonstrated as lower signal intensities.
T2*-weighted Imaging
Fast spin-echo images are not sensitive to magnetic susceptibility effects as a result of the rephasing effect of multiple 180° pulses. However, gradient-echo sequences with a low flip angle yield T2*-weighted images, which are very sensitive to differences in magnetic susceptibility. T2*-weighted images are useful for identification of hemorrhage by demonstrating deoxyhemoglobin and hemosiderin contents (3,4). Air bubbles in an abscess may be easily identified on T2*-weighted images.
Contrast-enhanced Fat-suppressed T1-weighted Imaging
Enhanced areas are easily detected on fat-suppressed T1-weighted images. In patients with pelvic inflammatory disease, rim enhancement of an abscess wall, the extent of soft-tissue inflammatory changes, and peritoneal enhancement are clearly shown. In patients with rupture of a cystic teratoma, rupture of an endometrioma, or a hemorrhagic ovarian cyst, enhanced thick peritoneum secondary to chemical peritonitis is clearly demonstrated owing to exclusion of fat signals.
Contrast-enhanced Dynamic MR Imaging with Subtraction and Dynamic Subtraction MR Angiography
Contrast-enhanced dynamic MR imaging is useful for evaluation of lesion vascularity. The subtraction technique facilitates evaluation of the degree of enhancement. In a patient with suspected ovarian torsion, it is easy to determine whether a tumor is enhanced even if the tumor is hyperintense on a nonenhanced image. In hemorrhagic lesions with persistent bleeding, the bleeding point can be revealed as extravasation of contrast material. Subtraction also enables clear demonstration of an enhanced vascular lumen by eliminating background signals (1). Therefore, dynamic subtraction MR angiography can demonstrate vascular anatomy and abnormal vessels such as uterine arteriovenous malformations clearly and noninvasively.
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Clinical Examples
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Rupture of Ovarian Endometrioma
Rupture of an ovarian endometrioma causes acute abdomen. This condition requires emergency surgery due to severe abdominal pain secondary to chemical peritonitis when massive fluid contents flow out of the endometrioma. Rupture may occur during pregnancy (5). Endometriomas usually include contents that are hyperintense on T1- and T2-weighted images. A thick wall, shading (a low-signal-intensity layer) on T2-weighted images, and multiplicity are characteristic of endometriomas (6). Rupture can be detected by demonstration of fluid contents that are hyperintense on T1- and T2-weighted images with or without shading outside an endometrioma in the free intraperitoneal space. In particular, mark-edly hyperintense fluid on fat-suppressed T1-weighted images in the acute phase is characteristic of rupture of an endometrioma because acute hemorrhage caused by other conditions usually has intermediate or slightly high signal intensity on fat-suppressed T1-weighted images. Ruptured endometriomas have a distorted shape. The part of the wall that is thinner and irregular is considered to be the rupture site (Fig 1).
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Figure 1a. Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.
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Figure 1b. Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.
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Figure 1c. Rupture of ovarian endometrioma in a 35-year-old woman with sudden pelvic pain. Axial fat-suppressed T1-weighted (a, b) and fat-suppressed T2-weighted (c) MR images show massive hyperintense fluid contents (solid arrows) that have flowed out of a right ovarian endometrioma (arrowheads). The T1-weighted images (a, b) allow differentiation of the hyperintense fluid contents outside the endometrioma from fat. The endometrioma is seen as a hyperintense mass with a distorted shape and hypointense areas on both the T1-weighted (a, b) and T2-weighted (c) images. The posterior part of the wall, which is thinner than the other parts, was considered to be the rupture site (open arrow). * = uterus.
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Hemorrhagic Ovarian Cyst
Functional ovarian cysts can develop internal hemorrhage and rupture into the intraperitoneal space. Hemorrhagic cysts are hyperintense on both T1- and T2-weighted images or hyperintense on T1-weighted images and hypointense on T2-weighted images (Fig 2) (7). It is not always possible to distinguish a hemorrhagic ovarian cyst from an adnexal hematoma due to ectopic pregnancy (8). The serum level of b–human chorionic gonadotropin may be helpful in this regard.
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Figure 2a. Hemorrhagic ovarian cyst with hemoperitoneum in a 20-year-old woman with pelvic pain. Axial fat-suppressed T2-weighted (a) and fat-suppressed T1-weighted (b) MR images show a complex left adnexal mass (solid arrows). The mass is mostly hypointense with a small hyperintense portion on the T2-weighted image (a); it is hyperintense and isointense on the T1-weighted image (b). There is a fluid collection (open arrow), which is hyperintense on the T2-weighted image (a) and slightly hyperintense relative to urine (±) on the T1-weighted image (b), an appearance suggestive of bloody ascites. Note the layering low signal intensity (arrowhead) on the T2-weighted image (a); this finding is considered to represent fibrin debris or clots. large * = right ovary, small * = uterus.
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Figure 2b. Hemorrhagic ovarian cyst with hemoperitoneum in a 20-year-old woman with pelvic pain. Axial fat-suppressed T2-weighted (a) and fat-suppressed T1-weighted (b) MR images show a complex left adnexal mass (solid arrows). The mass is mostly hypointense with a small hyperintense portion on the T2-weighted image (a); it is hyperintense and isointense on the T1-weighted image (b). There is a fluid collection (open arrow), which is hyperintense on the T2-weighted image (a) and slightly hyperintense relative to urine (±) on the T1-weighted image (b), an appearance suggestive of bloody ascites. Note the layering low signal intensity (arrowhead) on the T2-weighted image (a); this finding is considered to represent fibrin debris or clots. large * = right ovary, small * = uterus.
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Rupture of Ovarian Cystic Teratoma
Rupture of an ovarian cystic teratoma causes acute abdomen secondary to severe chemical peritonitis due to the irritative effect of the spilled contents on the peritoneum (9). Rupture may result from torsion, infarction, trauma, infection, malignant change, or prolonged pressure during labor or be idiopathic. The prevalence is increased in pregnant patients (9). Slow leakage from a weak spot leads to progressive abdominal distention, whereas sudden rupture leads to severe chemical peritonitis and acute abdomen (10).
Diagnosis of cystic teratoma is not difficult with a combination of T1-weighted images and fat-suppressed T1-weighted images, which is useful for detection of fat components within the tumor (6). In cases of rupture, sebaceous material and a hair ball spilled out of the teratoma may be identified on MR images. Contrast-enhanced fat-suppressed T1-weighted images can clearly show thickened peritoneum (Fig 3), intraperitoneal adhesions, or masses with granulomatous peritoneal reaction. Rupture of an ovarian cystic teratoma may be mistaken for tubercular peritonitis or carcinomatosis (10). A combination of T1-weighted images and fat-suppressed T1-weighted images also allows differentiation of fatty contents spilled out of a cystic teratoma from fluid contents that have flowed out of an endometrioma (Fig 1).
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Figure 3a. Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.
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Figure 3b. Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.
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Figure 3c. Rupture of ovarian cystic teratoma in a 64-year-old woman with pelvic pain and abdominal distention. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic teratoma (arrows) with a fat-fluid level. The signal intensity of the fat (small *) floating within the tumor is suppressed on the fat-suppressed image (b). Note the massive ascites (large *). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image clearly shows thickened peritoneum (arrowheads), which suggests chemical peritonitis due to rupture of the tumor.
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Ovarian Torsion
Torsion is a well-known complication of ovarian tumors and cysts. The symptoms include gradual or sudden onset of pain. When complete torsion is suspected, immediate surgery is required.
Hemorrhagic necrosis due to torsion can be established with a combination of fat-suppressed T1-weighted images and contrast-enhanced fat-suppressed T1-weighted images. High signal intensity of a tumor on fat-suppressed T1-weighted images suggests hemorrhage or vascular congestion (Fig 4). MR imaging findings indicative of ovarian torsion are lack of enhancement of the solid component, a thickened cyst wall, or a mural nodule; these findings are directly indicative of interruption of blood flow and can lead to the diagnosis of ovarian torsion (Fig 4) (6,8,11). Contrast-enhanced dynamic subtraction MR imaging allows one to easily confirm that the tumor is not enhanced (Fig 5). The degree and extent of the enhancement are clearly demonstrated on the subtraction image, even if the tumor has high signal intensity due to hemorrhage (Fig 5).
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Figure 4a. Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.
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Figure 4b. Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.
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Figure 4c. Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.
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Figure 4d. Twisted left ovarian cystic teratoma with hemorrhagic necrosis in a 10-year-old girl with pelvic pain and nausea. (a, b) Axial T1-weighted (a) and fat-suppressed T1-weighted (b) MR images show a cystic tumor (solid arrows) with a markedly thickened wall, which is slightly hyperintense. A small fat component (open arrow) within the tumor is hyperintense on the T1-weighted image (a) and hypointense on the fat-suppressed T1-weighted image (b). (c) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows that the wall is not enhanced, a finding indicative of hemorrhagic necrosis due to torsion. (d) Photograph of the cut surface of the resected tumor shows that the wall is thick and dark red (arrowheads), an appearance suggestive of hemorrhagic necrosis. Scale is in millimeters.
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Figure 5a. Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.
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Figure 5b. Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.
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Figure 5c. Twisted left ovarian fibroma with hemorrhagic necrosis in a 60-year-old woman with sudden pelvic pain and vomiting. (a) Sagittal dynamic MR image (nonenhanced) shows a tumor with a slightly hyperintense portion at the posterior margin (arrows) due to the T1-weighted nature of the sequence. This appearance is suggestive of congestion or hemorrhagic necrosis. (b) Sagittal contrast-enhanced dynamic MR image (late phase) shows no enhancement of most of the tumor. The posterior margin of the tumor demonstrates moderate enhancement (arrows). However, it is difficult to determine the degree and extent of the enhancement because of the superimposed high signal intensity. (c) Sagittal contrast-enhanced dynamic subtraction MR image (late phase) shows that most of the tumor is not enhanced, a finding indicative of interruption of blood flow and strongly suggestive of necrosis of the tumor. Moderate enhancement of the posterior margin of the tumor (arrows) is more clearly identified because of exclusion of the superimposed high signal intensity.
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Ectopic Pregnancy
Ectopic pregnancy usually manifests as lower abdominal pain and hemoperitoneum. Ninety-five percent of ectopic pregnancies occur within the fallopian tube, a location associated with a high risk of tubal abortion or tubal rupture. Other sites are the ovary, cervix, and peritoneal cavity. The serum level of b–human chorionic gonadotropin is generally elevated (12). Massive hemorrhage from a ruptured tubal or ovarian pregnancy leads to symptoms of shock.
MR imaging findings include hemosalpinx, bloody ascites, and a heterogeneous adnexal mass composed of a hematoma and gestational sac. The hemosalpinx and bloody ascites are slightly hyperintense relative to urine on fat-suppressed T1-weighted images. The heterogeneous mass has mixed signal intensity on fat-suppressed T1- and T2-weighted images (Fig 6) (8,13,14). The bleeding point can be revealed with contrast-enhanced dynamic subtraction MR imaging. Extravasation of contrast material can be seen as a hyperintense spot in the hematoma (Fig 6).
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Figure 6a. Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.
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Figure 6b. Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.
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Figure 6c. Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.
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Figure 6d. Histologically proved ovarian pregnancy in a 22-year-old woman with pelvic pain. (a, b) Axial fat-suppressed T1-weighted (a) and T2-weighted (b) MR images show a heterogeneous, hyperintense mass (long arrows) on the right side of the uterus (*). The margin of the mass has irregular low signal intensity (short arrows) on the T2-weighted image (b). Note the small amount of bloody ascites, which appears as a slightly hyperintense area (arrowheads) on both images. (c) Axial T2*-weighted MR image shows that the hypointense rim on the fat-suppressed T2-weighted image (b) is more enhanced (short arrows). This finding suggests that the effect is due to susceptibility artifact and that the mass (long arrows) is a hemorrhagic lesion. (d) Coronal contrast-enhanced dynamic subtraction MR image (late arterial phase) clearly shows extravasation of contrast material (open arrow) within the hemorrhagic mass (solid arrows). This finding indicates persistence of bleeding. * = uterus.
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Uterine Arteriovenous Malformation
Uterine arteriovenous malformation is referred to by various synonyms, such as "uterine arteriovenous fistula" and "uterine cirsoid aneurysm" (15). It is usually associated with dilation and curettage, endometrial carcinoma, or gestational trophoblastic disease (15,16). The most common symptom is genital bleeding, which often requires blood transfusions. Confirmation of the diagnosis has traditionally been achieved with angiography.
Tortuous and tubular signal voids in the myometrium, in the parametrium, and protruding into the endometrial cavity are seen on both T1- and T2-weighted images (Figs 7, 8). A vascular lake with sluggish flow is demonstrated as a hyperintense structure mimicking a tumor or placental polyp on T2-weighted images (Fig 8). Contrast-enhanced dynamic subtraction imaging reveals that the lesion enhances as intensely as vessels (Figs 7, 8). Dynamic subtraction MR angiography clearly demonstrates vascular anatomy, abnormal vessels, and hemodynamics and enables noninvasive confirmation of a diagnosis of uterine arteriovenous malformations (Fig 8).
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Figure 7a. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 2 months after dilation and curettage. (a) Sagittal fat-suppressed T2-weighted MR image shows tangled signal voids protruding into the endometrial cavity (arrows). (b) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal voids (arrows) enhance as intensely as the abdominal aorta (*), a finding indicative of a vascular lesion.
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Figure 7b. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 2 months after dilation and curettage. (a) Sagittal fat-suppressed T2-weighted MR image shows tangled signal voids protruding into the endometrial cavity (arrows). (b) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal voids (arrows) enhance as intensely as the abdominal aorta (*), a finding indicative of a vascular lesion.
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Figure 8a. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)
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Figure 8b. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)
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Figure 8c. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)
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Figure 8d. Uterine arteriovenous malformations in a 28-year-old woman with massive genital bleeding 1 week after dilation and curettage. (a) Axial T1-weighted MR image shows multiple signal voids (arrows) in the myometrium and parametrium. (b) Sagittal fat-suppressed T2-weighted MR image shows a hyperintense mass (arrow) protruding into the endometrial cavity, mimicking a polypoid tumor. (c) Sagittal contrast-enhanced dynamic subtraction MR image (arterial phase) shows that the signal intensity of the mass (arrow) is identical with that of the abdominal aorta (*), a finding suggestive of a vascular lesion. (d) Coronal dynamic subtraction MR angiogram shows a uterine vascular lesion with dilated left uterine vessels and early venous return (arrows). Note the massive hemorrhage in the vaginal and endometrial cavities, which is seen as moderate high signal intensity on the T2-weighted image (* in b) and a nonenhanced area on the contrast-enhanced dynamic subtraction image (c). The findings of dynamic subtraction MR angiography were confirmed with conventional angiography, and transarterial embolization was performed. (Fig 8d reprinted, with permission, from reference 1.)
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Placental Polyp and Retained Products of Conception
A placental polyp is an intrauterine polypoid mass that is thought to be formed by a retained fragment of placental tissue attached to the uterine wall after an abortion or term pregnancy (17). The polyp may occur days to weeks after an abortion or delivery and is then referred to as retained products of conception. Placental polyps and retained products of conception may cause massive and life-threatening genital bleeding, and hysterectomy is often needed. The bleeding may occur months or years after the last delivery or abortion (17). Placental polyps are often seen in patients with placenta accreta, in which the placental villi attach to the myometrium without an intervening decidual membrane (18).
Placental polyp and retained products of conception appear as a hyperintense polypoid mass on T2-weighted images (Fig 9) (17). The risk of severe bleeding depends on the depth of invasion into the myometrium and the vascularity of the mass. Contrast-enhanced dynamic MR imaging can provide information about these factors. The differential diagnosis of placental polyp should include uterine arteriovenous malformation, trophoblastic diseases, endometrial polyp, and submucosal myoma (17,19). Choriocarcinoma can have imaging findings similar to those of placental polyp (17). However, the serum or urinary level of human chorionic gonadotropin is extremely high in choriocarcinoma; therefore, differential diagnosis from placental polyp may not be difficult. Uterine arteriovenous malformations appear as tortuous and tubular signal voids in the uterus and parametrium that enhance as intensely as vessels on contrast-enhanced dynamic MR images and dynamic subtraction MR angiograms (Figs 7, 8).
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Figure 9a. Retained products of conception in a 29-year-old woman with massive genital bleeding 1 month after delivery. (a) Sagittal fat-suppressed T2-weighted MR image shows hyperintense retained placenta (straight arrows) protruding into the dilated uterine lumen and multiple signal voids (arrowheads) in the myometrium. (b) Sagittal contrast-enhanced dynamic subtraction MR image shows that the retained placenta (straight solid arrows) is strongly hypervascular and attached to the posterior wall with deep invasion into the myometrium (open arrows). Note the massive clots (curved arrows) superimposed on the retained placenta, which are hypointense on the T2-weighted image (a) and nonenhanced on the contrast-enhanced dynamic subtraction image (b). Total hysterectomy was performed instead of dilation and curettage, which increases the risk of massive hemorrhage.
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Figure 9b. Retained products of conception in a 29-year-old woman with massive genital bleeding 1 month after delivery. (a) Sagittal fat-suppressed T2-weighted MR image shows hyperintense retained placenta (straight arrows) protruding into the dilated uterine lumen and multiple signal voids (arrowheads) in the myometrium. (b) Sagittal contrast-enhanced dynamic subtraction MR image shows that the retained placenta (straight solid arrows) is strongly hypervascular and attached to the posterior wall with deep invasion into the myometrium (open arrows). Note the massive clots (curved arrows) superimposed on the retained placenta, which are hypointense on the T2-weighted image (a) and nonenhanced on the contrast-enhanced dynamic subtraction image (b). Total hysterectomy was performed instead of dilation and curettage, which increases the risk of massive hemorrhage.
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Pelvic Inflammatory Disease
Pelvic inflammatory disease is a common condition among women of reproductive age. Patients often have lower abdominal pain, fever, an elevated blood level of C-reactive protein, and adnexal tenderness. Delay of adequate treatment may lead to tubo-ovarian abscess and pyosalpinx resulting from adhesions within the fallopian tubes and increases the risk of long-term complications such as infertility, ectopic pregnancy, and chronic pelvic pain (20). Endometritis and myometritis can be treated conservatively with antibiotic therapy. However, tubo-ovarian abscess and pyosalpinx often need to be treated surgically.
The extent of inflammation can be demonstrated as ill-defined hyperintense areas on fat-suppressed T2-weighted images with intense enhancement on contrast-enhanced fat-suppressed T1-weighted images (Figs 10, 11).
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Figure 10a. Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.
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Figure 10b. Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.
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Figure 10c. Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.
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Figure 10d. Pyosalpinx in a 48-year-old woman with pelvic pain and an elevated blood level of C-reactive protein. (a) Axial fat-suppressed T2-weighted MR image shows a pyosalpinx as a hyperintense, fluid-filled, dilated tube (arrows) with a thick wall. (b) Axial heavily T2-weighted MR image shows that the fluid (large *) within the pyosalpinx (arrows) is hypointense relative to urine (small *), an appearance suggestive of debris or hemorrhage. (c, d) Axial (c) and sagittal (d) contrast-enhanced fat-suppressed T1-weighted MR images clearly show intense enhancement of the wall of the pyosalpinx and adjacent soft tissue (arrows). The sagittal image is useful for recognition of a dilated, tortuous salpinx.
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Figure 11a. Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.
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Figure 11b. Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.
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Figure 11c. Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.
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Figure 11d. Postpartum myometritis and pelvic abscesses in a 30-year-old woman with a high fever. (a, b) Axial fat-suppressed T2-weighted MR images obtained at the level of the fundus of the uterus (a) and the body of the uterus (b) show multiple small, markedly hyperintense areas (arrows) surrounded by slightly hyperintense regions adjacent to the uterus. (c, d) Axial contrast-enhanced fat-suppressed T1-weighted MR images obtained at the same levels as a and b, respectively, show ill-defined intense enhancement of the myometrium and parametrium (large arrows) surrounding small abscesses (small arrows). Note the peritoneal enhancement (large *) and the small amount of ascites (small *) due to peritonitis.
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Pyosalpinx appears as a fluid-filled, dilated, tortuous structure. Multiplane images are useful to distinguish it from fluid-filled bowel loops or
a multilocular cystic mass (Fig 10) (20). The wall of a pyosalpinx is well enhanced and usually thicker than that of a hydrosalpinx (20).
An abscess manifests as a thick-walled, fluid-filled mass in an adnexal location. The abscess wall and adjacent soft-tissue inflammation enhance intensely (Fig 11) (21). Internal gas bubbles, which are unusual, are the most specific sign of an abscess (21). They may be best detected on T2*-weighted images due to differences in magnetic susceptibility. The differential diagnosis of tubo-ovarian abscess should include endometrioma, ovarian tumor, infected cyst, and abscesses from other sources, such as Crohn disease or appendicitis.
The contents of a pyosalpinx or abscess are slightly hyperintense on T1-weighted images and slightly hypointense on T2-weighted images relative to urine because of the presence of hemorrhage or debris. The contrast between the contents and urine is more conspicuous on heavily T2-weighted images (Fig 10).
A special form of pelvic inflammatory disease is pelvic actinomycosis. Actinomycosis is a chronic suppurative infection characterized by multiple abscesses, abundant granulation tissue, and fibrosis. The prevalence is increased in women who use intrauterine contraceptive devices. The response to treatment with high doses of penicillin is favorable.
Characteristic MR imaging findings are an ill-defined, heterogeneous mass with intense enhancement. Involvement of surrounding organs such as the colon and small intestine is seen as well-enhanced areas (Fig 12). It is not always possible to distinguish pelvic actinomycosis from peritonitis carcinomatosa due to neoplasms of the ovaries and fallopian tubes (22).
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Figure 12a. Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.
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Figure 12b. Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.
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Figure 12c. Pelvic actinomycosis associated with long-term use of an intrauterine contraceptive device in a 48-year-old woman with symptoms of ileus. (a) Image from a barium enema examination (lateral view) shows marked narrowing of the rectosigmoid (arrows) with irregularity of the mucosal margin. (b, c) Axial fat-suppressed T2-weighted MR images show a markedly thickened rectosigmoid wall (arrowheads) and an ill-defined mass (open arrows). Solid arrow = uterus. (d, e) Axial contrast-enhanced fat-suppressed T1-weighted MR images show intense enhancement of the rectosigmoid (arrowheads) and the mass (open arrows). Solid arrow = uterus.
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Abstract
LEARNING OBJECTIVES FOR TEST...
