What every radiologist should know about adnexal torsion.

Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion. Main points Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament. The ovaries receive a dual blood supply from the ovarian artery and uterine artery. The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis. Persistence of adnexal vascularization does not exclude torsion. In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.

Female perineal diseases: spectrum of imaging findings.

The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.

An acute abdominal syndrome reveals a postoperative ilio-iliac arteriovenous fistula: about one case.

INTRODUCTION: Postoperative ilio-iliac arteriovenous fistula is an unusual but known complication after lumbar surgery. CASE REPORT: We report the case of a 74-year-old patient consulted at the emergency department for intense acute abdominal syndrome revealing a post-operative common ilio-iliac arteriovenous fistula 5 years after a lumbosacral arthrodesis L3-S1. The patient was treated with an endovascular arterial stent-graft with immediate vascular and clinical results. CONCLUSION: Arteriovenous fistula is a possible etiology of acute abdominal syndrome in patients with lumbar or abdominopelvic surgery history.

[Diagnosis of cervical and endometrial cancer]. / Diagnostic des cancers du col de l'utérus et de l'endomètre.

Updated French guidelines for clinical practice have been published by the National Cancer Institute in 2010, concerning the diagnosis and the treatment of cervix and endometrial cancers. The diagnosis of cervix cancer, suspected when a cervix tumour is observed in a patient presenting with vaginal bleeding, especially in women with risk factors (previous cervix dysplasia, HIV infection, tobacco use). The diagnosis is confirmed by pathology of cervix biopsy (macroscopic cervix tumour or microscopic lesions detected by screening). The diagnosis of endometrial cancer should be evoked in post-menopausal women presenting with vaginal bleeding, especially in high risk populations (obese, long exposure to estrogens). The diagnosis is based on histologic examination of endometrial biopsy. The assessment of pelvic extension must include clinical examination and pelvic and lombo-aortic MRI imaging.

Executive dysfunction in adults with moyamoya disease is associated with increased diffusion in frontal white matter.

BACKGROUND AND PURPOSE: Alteration of the cerebrovascular reserve (CVR) in the frontal lobes has been associated with cognitive dysfunction in adults with moyamoya disease (MMD). Elevation of the apparent diffusion coefficient (ADC) in normal-appearing white matter on conventional MRI may occur as a consequence of chronic haemodynamic failure. In the present study, the authors examined the relation of ADC with CVR and cognitive dysfunction in adults with MMD. METHODS: The authors measured ADC and CVR in the normal-appearing frontal white matter. CVR was calculated using dynamic susceptibility contrast-enhanced MRI and the acetazolamide challenge. A standardised and validated neuropsychological assessment test battery focusing on executive function was used. RESULTS: 14 patients, 9 women and 5 men (mean age 36.6±12.9 years), were included. The authors found executive dysfunction in 7 of 13 tested patients. ADC and CVR were negatively correlated (Spearman coefficient: -0.46; p=0.015). Elevation of ADC predicted executive dysfunction (area under receiver operating characteristic curve (95% CI): 0.85 (0.59 to 1.16); p=0.032). CONCLUSION: Elevation of ADC in the normal-appearing frontal white matter of adults with MMD was associated with reduced CVR and executive dysfunction. This preliminary study suggests that measurement of ADC might be used to detect patients at risk for cerebral ischaemia and cognitive impairment.

A rare cause of anaemia associated with hypertension in a 14-year-old girl.

We report a rare example of anaemia and hypertension due to an incomplete Carney triad in a 14-year-old girl with no previous medical history. This rare non-familial syndrome generally involves two disparate tumours: gastrointestinal stromal tumour, paraganglioma and/or pulmonary chondroma. The complete triad is a syndrome that involves at least five loci: stomach, oeophagus, lung, the paraganglionic system, adrenal (cortex or medulla). The pathogenesis is unclear as these tumours have different embryological origins. Surgical treatment is necessary, and long-term follow-up is advisable as patients with Carney triad may re-present with tumour(s), even several years after the first presentation.

Delivery induced intraperitoneal rupture of a cystic ovarian teratoma and associated chronic chemical peritonitis.

Intraperitoneal rupture of cystic ovarian teratoma is a rare complication. We report a case in a 29-year-old female, with increased abdominal circumference 2 months after vaginal delivery. MRI/CT raised this diagnosis associated to chemical peritonitis. A malignant ovarian mass with peritoneal carcinomatosis was excluded. Laparoscopic oophorectomy was performed and histologic analysis confirmed imaging findings. This case demonstrates the interest of imaging before surgery in pelvic masses to avoid misdiagnosing and to provide adequate treatment.