Interactive Transcript
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For our next case, this is of a
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24-year-old patient who presented
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to the ED with acute pelvic pain.
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We'll start here with our sagittal
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image of the uterus, and we'll go
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through the still images first.
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You can see a normal endometrium.
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We come up through the cervix here.
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The uterus so far, so good, looks okay.
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No real abnormality that we're seeing.
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We get a little bit further.
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We go into the right adnexa.
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We found a right ovary, which also looks normal,
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until we get to what is labeled
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the left ovary in this case.
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So we see a very heterogeneous
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structure in the left adnexa.
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Well-circumscribed, maybe some calcifications
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and it looks pretty solid; definitely
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has shadowing, both at the margins
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and from internal components of it.
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We don't see any normal ovarian tissue,
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and we really don't see any color
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Doppler blood flow within the structure.
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Initially, this was thought to be a
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solid tumor of the left ovary, and
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that's how it was initially read.
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Show you the cine clips as well,
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just to give you an idea of the
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scope and the size of the structure.
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You can see here, the uterus is right here.
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Maybe this is the broad ligament here, kind
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of draping over this left adnexal structure,
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but pretty limited with the
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ultrasound for what else you can do.
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Patient also got a CT because we were in the ED
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and needed to rule out other acute etiologies.
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And as we scroll down into the pelvis here,
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we have our uterus back here, and then
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we have this big structure right here.
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And you can even see a
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little follicle right there.
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Maybe another one back here.
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So this is your ovary back here.
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Your ovary is tucked back here, sort of
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behind the uterus and broad ligament.
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This mass lesion, that claw sign
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is not coming from the ovary.
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Therefore, you can say that this patient
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does not have an ovarian tumor or malignancy.
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This is coming from something else.
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And if you go back to that ultrasound,
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now that you have that in your mind that
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this is not an ovarian primary structure.
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You go back to this and you
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imagine, if I saw this placed in the
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uterus, what does this look like?
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And it looks like a pretty classic,
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albeit very large, fibroid.
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So, going back one more time to the CT,
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maybe this claw sign instead is coming
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from the uterus, or maybe even the
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broad ligament, hard to tell right here.
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Maybe this is an exophytic fibroid
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coming off of the uterus right here that
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has infarcted, and that's why it's hypo
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enhancing, why there was no color Doppler
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flow in the ultrasound, and that's why there's
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surrounding inflammatory change because
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this is an acute process and it's painful.
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So patients can present
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acutely when this happens.
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So we were able to fairly confidently
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diagnose that this was likely a hemorrhagic
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or acutely infarcting fibroid and said you
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can get an MRI as an outpatient in follow-up
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to prove this, but the patient does not have
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an ovarian malignancy; they were able to be
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discharged with that concern allayed at least.
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In her particular case, she did end up
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coming back for her MRI a few weeks later.
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And I'll bring over some
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of these images for you.
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Here is your pre-contrast T1.
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And we can see here, this is a
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fat-saturated pre-contrast T1.
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And here's our structure right here.
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It is intrinsically T1 bright, right?
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So that means it's either proteinaceous or
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hemorrhagic component internally within it.
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Here is our non-fat-saturated T2.
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You can see your beautiful
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endometrium right here.
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We actually have some classic appearing T2
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dark fibroids in the myometrium back here.
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Bye.
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But you have this T2 dark structure.
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Again, this is the same
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structure we're seeing on CT.
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We have a dark ring or rim around
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it, probably a hemocytin ring here.
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And then lastly, of course, we're
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going to skip the post-contrast
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because that's going to be bright.
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What you're going to want to look at is
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your subtraction weighted imaging, right?
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Because this is already intrinsically
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T1 bright, you give contrast,
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it's still going to be bright.
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So you really want that subtraction image.
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And as we get to that, we can see this is
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essentially a black hole, very, very minimal
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enhancement within that, if anything.
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And that confirms that this is an acutely
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infarcted fibroid or a red fibroid because
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it has hemorrhage internally within it.
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And that was the cause of the patient's pain.
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No ovarian mass; the patient was able to confidently
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be diagnosed with treatment just being to treat
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the pain until the pain goes away, basically.
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