0:00

So let's do this one here.

0:04

And I'll just say pelvic pain is the history over here.

0:08

There's no particular theme in these cases. The are just all interesting cases.

0:12

So we're going to go down to the pelvis.

0:14

And so I do have, I think,

0:16

all the sequences that I need to sort of show you this case.

0:18

So let's go through it.

0:20

Start off with the T-2s, non fat-saturated.

0:24

Something big over there.

0:27

Something as well big over there.

0:30

Very heterogeneous appearance.

0:35

Let me scroll through that up and down.

0:38

You can see that again on the T2 weighted fat saturated images.

0:42

You can see some of the things a little bit better, perhaps.

0:46

You can also appreciate, perhaps,

0:48

some of the free fluid in the pelvis in this patient.

0:52

You can see the uterus here are sort of sandwiched in between these findings.

0:57

Show it to you on the sagittal images, as well.

1:00

A lot of this is just showing the same thing.

1:03

But I want to show it to you in different planes because everyone sort of diagnosis

1:06

things differently, depending on the plane that you see it in.

1:09

And so we'll get rid of our T2 weighted

1:11

sequences to start with and then we'll go through some of the post con.

1:15

So this is the coronal.

1:17

Again, these large masses in a bliss.

1:22

Look at the T-1s in and out of phase.

1:25

Let me just link these so that we can just do one scroll through them.

1:31

So we're looking, of course,

1:33

for the presence of fat within these large masses,

1:37

looking for India ink artifact.

1:41

This is the out-of-phase here.

1:42

This is the in-phase over here.

1:44

I'll scroll up and down through these cases, these images, a couple of times

1:48

so you can get a good sense of what things look like.

1:52

And then, really, we're down to the pre and post.

1:54

I'll put the pre op here and i'll put the post here.

1:59

So in the pre, as you can see,

2:01

both of these masses contain some hyperintensity T1 content.

2:09

And so, in fact,

2:11

I won't show you the post, I'll show you the post-subtraction image.

2:14

That will eliminate all the hyperintensity T1 context.

2:17

You can actually see what's truly enhancing.

2:23

You can see these masses once again.

2:30

All right, so I'm just going to do a new layout for you,

2:36

just to sort of show you some of the findings that we see here.

2:40

T2 fat-saturated image.

2:43

And then I'll show you the same thing on the coronal,

2:46

perhaps, just to kind of give you a sense of what's going on over here.

2:51

Let's do a pre. Will do a post.

2:56

These are the findings.

2:59

Let's move on to the question and see if

3:01

we can sort out what is going on over here.

3:05

Again, another, what is the most likely diagnosis?

3:09

All four options contain ovaries.

3:11

So we've identified that

3:13

that is the issue over here.

3:15

Polycystic ovarian syndrome.

3:18

Ovarian hyperstimulation syndrome.

3:19

So we have two syndromes.

3:22

Could this be an ovarian cystadenoma?

3:25

Or could this be Tubo-ovarian abscess?

3:28

Somebody's coming in with a lot of pain.

3:32

Could these be large abscesses in this patient?

3:35

All right, good. This one is very well answered.

3:38

Ovarian hyperstimulation syndrome.

3:39

Very good.

3:40

And so we have none for polycystic ovarian syndrome.

3:44

One each for tubo-ovarian abscess and ovarian cystadenoma.

3:46

So, it looks like a lot of you sort of recognize the findings.

3:50

And so, this indeed was sort of ovarian hyperstimulation syndrome.

3:55

And the reason I wanted to show this case

3:58

is that, you learn about it, but you don't see it that often.

4:02

And so I want to make sure that when we do end up seeing it,

4:06

that we can recognize it for what it looks like and sort of tell

4:10

our referring providers confidently,

4:12

"This is what we think is going on."

4:14

So what is it?

4:14

It's an exaggerated ovarian response to ovulation induction.

4:18

It's seen very, almost exclusively

4:21

in patients who are undergoing intra-vitro fertilization.

4:25

But the incidence, even with those patients, about 1%.

4:28

And vast majority of these a have

4:31

very mild form of what they call OHSS,

4:35

Ovarian Hyperstimulation Syndrome.

4:36

About two thirds will have a mild form

4:38

and the rest will have maybe some moderate to severe symptoms.

4:44

And so, what do you see?

4:46

It's a clinical syndrome, right?

4:47

So there's much more than just imaging that goes into this.

4:49

From a radiologist perspective, you're going to see enlarged ovaries.

4:53

Now, how big is too big?

4:55

It's always hard to know the right answer to these things,

4:57

but what's been described is, if it's greater than 5cm.

5:00

So we can certainly measure these ovaries.

5:03

These are almost double that size, 9cm, bilaterally.

5:06

That's one sign of it.

5:08

And the whole parenchyma is sort of replaced with these large ovarian cysts.

5:12

You can see there's one large cyst here,

5:15

one large cyst here, one large cyst, one large cyst here.

5:18

Classically, it has a sort of wheel spoke appearance.

5:21

And some of these cysts can also contain hemorrhoids.

5:23

So that's sort of what you're seeing

5:25

within some of these cyst contents, this hyperintensity T1 content.

5:29

And it's essentially a syndrome where you

5:31

have hyperstimulation of the ovaries by the exogenous gonadotropins that are

5:34

given to patients who are undergoing assisted reproductive techniques.

5:39

And so, that's what you see in the ovaries.

5:42

But once they start getting enlarge, they can secrete these vasoactive substances.

5:47

That causes increased capillary permeability.

5:49

And really what that means is

5:51

that there is a fluid shift to fluid now occurring in extracellular spaces.

5:56

So you're going to start to see ascites, potentially.

6:00

Pleural effusions.

6:01

And so that really is something that we need to watch out for.

6:05

Now, there is a classification system of this.

6:10

I've not committed it to memory.

6:12

It's probably something I need to look up every time.

6:14

But what is important to sort of describe

6:17

in your reports is the presence of the enlarged ovaries,

6:19

their size.

6:20

Also describe the presence or

6:22

absence of ascites, if it's present.

6:26

And if you sort of scroll high enough or

6:28

you have a CAT scan or maybe a chest CT,

6:30

if there is a presence of pleural effusions,

6:31

or even just sort of diffuse anasarca.

6:34

So these are the things that are important

6:35

to describe in these patients who have a very hyperstimulation syndrome.

6:41

The other options, tubo-ovarian abscess, I thought, is not a bad thought.

6:46

However, this is sort of a bilateral process,

6:50

and you're not really seeing a lot of edema.

6:51

This is all just ascites that are surrounding these ovaries.

6:55

Not a lot of edema.

6:56

Often times, you'll see sort of thick rim-enhancements

6:59

surrounding these structures where this all looks pretty much

7:02

homogeneous, and it looks like these are all just sort of cysts.

7:05

And they're not particularly thickened.

7:07

They're all sort of about the same size.

7:09

You may see a pile of solvents in those instances as well.

7:12

So it's not my choice diagnosis.

7:14

Polycystic ovarian syndrome,

7:16

ovaries will be much smaller in size,

7:18

almost normal in size, with numerous peripherally displaced

7:21

follicles that are sort of the same size and not enlarged.

7:24

And then ovarian cystadenomas

7:30

are typically sort

7:32

of a unilateral process, with one cystic mass.

7:34

Typically simple.

7:35

You may have sort of, sometimes some septations within them.

7:40

And so, we have one question that's sort of been asked,

7:44

which I think is a very good teaching point,

7:47

and that,

7:48

these ovaries are sort of in weird locations.

7:50

If we were to follow sort of the gonadal veins to these ovaries,

7:54

you have one ovary that's sort of up here,

7:56

which, you know, you could maybe buy as

7:58

a good location, but this is way too posteriorly located.

8:01

And so, one of the risks that can happen

8:03

with patients with ovarian hyperstimulation syndrome is torsion.

8:06

These ovaries get so large that they can twist on their pedicles,

8:10

and certainly in this instance, I would bring up the possibility of torsion.

8:14

You can see even the ovarian parenchyma edematous over here.

8:17

I don't recall that these were actually torsed ovaries,

8:20

but given the appearance,

8:21

that's a very good observation that's been made.

8:23

Excellent. Very good.

8:25

So let's move on to our next case.