Emerg Radiol (2018) 25:51–59
DOI 10.1007/s10140-017-1549-8
REVIEW ARTICLE
What every radiologist should know about adnexal torsion
Guillaume Ssi-Yan-Kai 1 & Anne-Laure Rivain 2 & Caroline Trichot 2 &
Marie-Chantal Morcelet 3 & Sophie Prevot 3 & Xavier Deffieux 2 &
Jocelyne De Laveaucoupet 1
Received: 17 July 2017 / Accepted: 28 August 2017 / Published online: 7 September 2017
# American Society of Emergency Radiology 2017
Abstract Adnexal torsion is the fifth most common gyneco-
logic surgical emergency, requiring clinician and radiologist
awareness. It involves the rotation of the ovarian tissue on its
vascular pedicle leading to stromal edema, hemorrhagic in-
farction, and necrosis of the adnexal structures with the sub-
sequent sequelae. Expedient diagnosis poses a difficult chal-
lenge 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
* Guillaume Ssi-Yan-Kai
gusyk@hotmail.fr
1
Department of Radiology and Medical Imaging, Antoine Béclère
Hospital, University of Paris Sud, 157 Rue de la Porte de Trivaux,
92140 Clamart, France
2
Department of Obstetrics and Gynecology, Antoine Béclère Hospital,
University of Paris Sud, Clamart, France
3
Department of Pathology, Antoine Béclère Hospital, University of
Paris Sud, Clamart, France
ultrasound examination but should not be the first-line imag-
ing 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 find-
ings on physical examination makes this entity difficult to
diagnose. Since the right adnexa are most commonly in-
volved, 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.
Keywords Adnexa . Ovarian torsion . Ultrasound . Color
Doppler . CT . MRI
Introduction
Adnexal torsion is a well-known but infrequently encountered
clinical female affliction, accounting for about 3% of gyneco-
logic emergencies. It refers to the total or partial twist of the
52 Emerg Radiol (2018) 25:51–59

ovary around its vascular axis resulting in vascular compres-
sion. Diagnosis of torsion is based on clinical symptoms and
supported by imaging findings [1]. Radiologists’ awareness is
essential for prompt diagnosis of adnexal torsion and early
treatment. Indeed, surgical restoration of the blood supply is
necessary for the salvage of the Fallopian tube and ovary.
Delayed diagnosis and treatment may lead to hemorrhagic
infarction, necrosis, infection, peritonitis, and infertility [2, 3].
In this article, we present the relevant anatomy of the ad-
nexa with peritoneal attachments and vascular supply. Three
major topics of adnexal torsion will be discussed on gray-scale
ultrasound, color Doppler ultrasound, CT, and MRI: acute
tubo-ovarian torsion, isolated tubal torsion, and necrotic ad-
nexal torsion. This review details important aspects of the
main differential diagnoses.
Review of the normal anatomy of the adnexa
Gross anatomy
The adnexa include the Fallopian tubes and the ovaries.
The Fallopian tubes are paired serpentine structures filled
with interdigitating plicae, extending from the uterine
horn to the ovaries. Each Fallopian tube is approximately
10 cm in length and 1 cm in diameter and is located
within the layers of the broad ligament, the mesosalpinx.
The Fallopian tube is subdivided into four parts, from
lateral to medial: the infundibulum, ampulla, isthmus,
and intramural segments (Fig. 1). The ovaries are paired
glands lying in the peritoneal cavity. The location is var-
iable but often the ovaries are positioned in the angle
between the external iliac vein and the ureter. They are
ovoid in shape. Ovarian volume should be calculated on
the basis of the simplified formula for a prolate ellipsoid
(0.5 × length × width × thickness of the ovary). The
average ovarian volume is between 6 and 10 cm3 in wom-
en less than 30 years of age. Many studies have
established a range of the normal ovarian volume for
women related to age and to the use of exogenous estro-
gens. Ovarian size decreases with menopause. Recent da-
ta suggest that the upper limit of normal ovarian volume
is 20 cm3 in premenopausal women and 10 cm3 in post-
menopausal women [4].
Peritoneal attachments and vascular supply
The ovaries are anchored in the ovarian fossa behind the
broad ligament and linked to the junction of the
mesometrium and the mesosalpinx by a thin double fold of
peritoneum, the mesovarium. The suspensory ligament of
ovary, also called the infundibulopelvic ligament, is a peri-
toneal fold and extends outwards from the ovary to the
lateral abdominal wall. It contains the ovarian vessels and
nerves. The ovarian ligament is a fibrous band of tissue that
lies within the broad ligament and connects the ovary to the
side of the uterus (Fig. 1).
The ovaries receive a dual blood supply from the ovarian
artery and uterine artery. The ovarian artery arises directly
from the abdominal aorta below the renal artery and travels
in the infundibulopelvic ligament. The uterine artery is a
branch of the internal iliac artery and bifurcates in the tubo-
ovarian artery traveling in the ovarian ligament. The tubo-
ovarian branch of the uterine artery anastomoses with the
ovarian artery (Fig. 1) [5].
Background and pathophysiology of adnexal torsion
The severity of the vascular impairment is variable, depending
on the degree of rotation, which in turn causes varying degrees
of partial to complete obstruction of flow. It results in arterial,

Fig. 1 The posterior view of the

adnexa with peritoneal
attachments and vascular supply.
T = uterine Fallopian tube, Inf =
infundibulum, Amp = ampulla,
Ist = isthmus, M = intramural
segment, O = ovary, 1 =
suspensory ligament of ovary or
infundibulopelvic ligament, 2 =
broad ligament: mesovarium, 3 =
broad ligament: mesosalpinx, 4 =
ovarian ligament, 5 = broad
ligament: mesometrium, 6 =
ovarian artery, 7 = uterine artery,
8 = tubo-ovarian branch of the
uterine artery which anastomoses
with the ovarian artery
Emerg Radiol (2018) 25:51–59
Fig. 2 The four pathological patterns of a right adnexal torsion: tubo-
ovarian torsion, ovarian torsion, and the organoaxial form and
mesenteroaxial form of isolated Fallopian tube torsion
venous, and lymphatic obstruction [6]. Four pathological pat-
terns can be described: tubo-ovarian torsion, ovarian torsion,
organoaxial form, and mesenteroaxial form of isolated
Fallopian tube torsion (Fig. 2). The severity of the vascular
impairment is variable, depending on the number of twists and
the tightness of the twists.
Initially, the twisted vascular pedicle in the suspensory lig-
ament induces ovarian edema because venous and lymphatic
outflows are compromised. Arterial inflow is sustained be-
cause arteries have thicker walls and are relatively less col-
lapsible. Arterial ischemia and ultimately ovarian necrosis en-
sue. Alternative states of mild torsion and detorsion may occur
[7–9]. The twist involves more commonly the right than the
left adnexa in about two thirds of cases. This may be due to the
hypermobility of the cecum and ileum on the right, compared
with the proximity of the left ovary to the relatively fixed
rectosigmoid [10, 11].
The greatest risk factor for adnexal torsion is a history of
adnexal torsion [12, 13]. The other known risk factors include:
& Assisted conception and ovarian hyperstimulation syn-
drome (OHSS) [14]: ovulation induction in women under-
going in vitro fertilization (IVF) or intra-uterine insemina-
tion may lead to an increase in the size and weight of the
ovary and theca lutein cysts [15, 16]
& Successful pregnancy: enlarged corpus luteal cysts in-
crease the rate of torsion during pregnancy, especially in
the first trimester [8, 15]
53
& Benign adnexal masses and cysts: tumors that have under-
gone torsion are most likely to be benign, with dermoid
tumors the most commonly implicated [17–19]
& Polycystic ovarian syndrome
& Previous tubal ligation predisposes to torsion even if the
physiopathology remains unclear
Torsion is unusual in the setting of endometriosis, pel-
vic inflammatory disease, and malignant lesions because
of the adhesions that fix the ovary to the surrounding
structures [3, 20].
The clinical signs are nonspecific: acute pain (in 90% of
cases), nausea, vomiting, and fever. The lack of pathognomonic
symptoms and specific findings on physical examination makes
this entity difficult to diagnose [21, 22]. Since the right adnexa
is more commonly involved, symptoms may mimic acute ap-
pendicitis. Laboratory findings typically are not very helpful. A
slight leukocytosis may be seen. A laboratory test must be
performed to rule out ectopic pregnancy [10]. As necrotic and
infectious process evolves over time, signs of peritonitis can be
observed in cases of prolonged twisted adnexa [23].
Emergent laparoscopy is the preferred treatment [24]. The
treatment depends on the individual patient. It commonly in-
cludes detorsion, even if the adnexa initially seem necrotic
with removal of any associated cysts. The absence of reperfu-
sion after detorsion is not an indication for systematic oopho-
rectomy since functional recovery is possible especially in
nulligravids [25, 26]. An oophorectomy is recommended in
postmenopausal women [12].
Imaging findings
Pelvic ultrasonography (US) with adnexal Doppler remains
the initial study of choice to assess the etiology of pelvic
pain [27, 28]. It is readily available and relatively inexpen-
sive and does not use ionizing radiation. Transvaginal US
should be used whenever possible. MRI is a useful problem-
solving tool in the evaluation of pelvic pain when available,
especially in a patient of childbearing age [29]. However,
delays incurred by additional diagnostic studies may make
multimodal MR imaging inadvisable. In the emergency de-
partments, abdominopelvic CT may be performed before US
in the initial workup of patients presenting with acute undif-
ferentiated lower abdominal or pelvic pain. Therefore, it is
essential to be familiar with the computed tomography signs
of adnexal torsion, such as uterine deviation to the side of
the affected ovary, displacement of adnexa to contralateral
side, and ascites [6, 18]. CT provides the best diagnostic
performance in identifying the nongynecologic causes of
acute pelvic pain, such as gastrointestinal and urinary tract
causes.
54
Fig. 3 Right ovarian torsion at
the edematous stage in a 44-year-
old woman. a Longitudinal US
shows an enlarged ovary with
peripheral follicles, measuring
7 cm in the longest dimension.
The ovarian stroma appears
slightly hyperechoic. b Axial and
c sagittal MR T2-weighted im-
ages demonstrate that the ovarian
parenchyma is hyperintense due
to edema (black arrow) and the
twist of the ovarian pedicle (white
arrow). d At surgery, the viable
ovary was twisted around the
pedicle 720° with some petechiae
Acute ovarian and tubo-ovarian torsion
The ovary and its vascular pedicle twist in its suspensory
ligament. Torsion sometimes includes the Fallopian tube. In
a broad sense, ovarian torsion and tubo-ovarian torsion have
similar imaging features. In the acute stage, edematous con-
gestion of the ovarian parenchyma is the more accurate sign of
torsion [21, 30].
Gray-scale US findings include an increased size of the
ovary, more than > 4 cm with hyperechoic stromal edema
and peripherally displaced follicles (Fig. 3) [11]. An enlarged
ovary with central follicular stroma and multiple 8–12-mm
uniform peripheral follicles is associated with torsion in 74%
of cases [1]. Ovarian enlargement is the key diagnostic fea-
ture, early in the diagnosis, even before infarction has oc-
curred since most of the obstruction of blood flow to the ovary
is due to venous outflow. The other direct sonographic sign is
the Btwist^ of the ovarian pedicle. But, it is not always fully
detectable. It can be described as a round hyperechoic struc-
ture with multiple inner concentric hypoechoic broad rings
(including the broad ligament and/or the Fallopian tube).
Common ultrasound findings also include the Bfollicular ring
sign,^ an underlying ovarian mass such as mature teratoma
and free pelvic fluid (nonspecific) [11, 30]. The follicular ring
sign is defined as a hyperechoic ring around the antral follicles
compatible with perifollicular edema (Fig. 6). In a recent study
involving 15 consecutive patients with confirmed ovarian tor-
sion, the follicular ring sign was found in 80% of cases [31].
Emerg Radiol (2018) 25:51–59
The color and spectral Doppler US findings of ovarian
torsion include the Bwhirlpool sign^ of twisted vascular ped-
icle referring to the characteristic ellipsoid or spiral vascular-
ization within the Btwist^ [32–34]. Decreased or interrupted
intra-ovarian venous flow and absence of arterial flow may be
seen. However, the persistence of arterial flow does not rule
out adnexal torsion (Fig. 4). This may be due to the dual blood
supply to the ovary, to the intermittent and/or partial torsion,
or to the venous occlusion occurring before arterial obstruc-
tion [3, 11, 28]. Utility of color Doppler sonography may be in
determining the preoperative viability of the ovary. A study by
Fleischer et al. found that ovarian viability may be predicted if
central venous flow is present [35].
CT may be performed prior to ultrasound since the clinical
presentation can sometimes mimic nongynecologic causes of
acute lower abdominal pain. Common CT findings are dis-
placement of adnexa to the contralateral side or midline posi-
tion, deviation of uterus to the side of involved ovary, and
adnexal enlargement. Other diagnostic criteria that have been
described are the following: the twist of the ovarian pedicle,
infiltration of pelvic fat, and pelvic ascites [6, 36].
MR imaging is an accurate technique for the diagnosis of
adnexal torsion in patients with acute or subacute pelvic pain
and with an equivocal adnexal mass at US [37]. It allows the
distinction between the edema of the ovary appearing hyper-
intense on T2-weighted images and the adjacent thickness of
the Fallopian tube (Fig. 3) [38, 39]. Persistence of adnexal
enhancement does not exclude torsion [3, 11].
Emerg Radiol (2018) 25:51–59 55

Fig. 4 Left adnexal torsion in a

31-year-old female with subacute
left lower quadrant pain.
Endovaginal US demonstrates an
enlarged left ovary containing
peripheral small follicles
(arrowheads) and edematous
stroma. Color Doppler identifies
central vascularization (white ar-
row). Laparoscopic findings in-
cluded the left tubo-ovarian tor-
sion of 360° and viable ovary

Massive ovarian edema adnexal torsion. Accurate diagnosis is important to maximize

the likelihood of Fallopian tube salvage [47, 48].
Massive ovarian edema is a tumor-like condition occurring in
young women during their second and third life decades.
Kalstone first described this entity in 1969 [40]. The World Necrotic adnexal torsion
Health Organization defined it as an accumulation of edema
fluid within the ovarian stroma separating normal follicular Undiagnosed and/or recurrent torsion may result in ovarian
structures [41]. Massive ovarian edema is considered to be hemorrhagic necrosis. Evolution of an adnexal torsion from
the result of recurrent or partial torsion of the ovary to the edematous stage to necrotic stage gives way to the
extent that it interferes with venous and lymphatic drainage,
but is insufficient to cause necrosis. Multiple ovarian follicles
situated around the periphery of the cortex of the enlarged
ovary are the most characteristic of massive ovarian edema
[42]. It is important to recognize this condition as it is often
misdiagnosed for an ovarian neoplasm, putting the younger
patient at risk of overtreatment with the resultant loss of hor-
monal function and fertility.

Isolated Fallopian tube torsion

In imaging, it may be difficult to distinguish organoaxial from

mesenteroaxial tubal torsion. Organoaxial torsion occurs
when the Fallopian tube rotates 180° or more (either anteriorly
or posteriorly) in the distal portion. Mesenteroaxial torsion is
around the mesenteric axis (a perpendicular line across the
Fallopian tube) in the middle portion. There is only one twist
point in case of mesenteroaxial torsion. Isolated Fallopian tube
torsion may occur as a result of extrinsic masses such as ovar-
ian and paratubal cysts. Intrinsic leading causes include
hydrosalpinx, hematosalpinx, abnormal length of the
mesosalpinx, and spiral course of the salpinx [43–45].
In the acute stage, edema of the Fallopian tube results in
tubal thickening. A threshold of 15 mm is usually used Fig. 5 Isolated Fallopian tube torsion secondary to hydrosalpinx in a 56-
(Fig. 5). Sonographic whirlpool sign is the specific sign of year-old woman with right pelvic pain. Transvaginal sonography iden-
tubal torsion but is not always fully detectable, especially tifies a normal right ovary and a an ipsilateral hydrosalpinx (H), close to a
thickened echoic structure (arrow line), 1.5 cm in width. b Axial MR T2-
when a mass is present [46]. MRI, if readily available, might weighted image discloses the spiral appearance at the site of tubal torsion
be useful in these cases. Since the ovary is not involved, a (arrow). Laparoscopy showed the right Fallopian tube torsion and normal
normal ipsilateral ovary does not allow the exclusion of ovaries
56 Emerg Radiol (2018) 25:51–59

Fig. 6 Left ovarian torsion in

pregnancy. a Coronal True FISP
image of a 29-week pregnant fe-
male with twins and acute left
pain shows an enlarged ipsilateral
ovary (arrow). b Doppler US
demonstrates peripherally located
follicles and the typical Bfollicular
ring sign^ (arrow). c Correlative
axial MR T2-weighted image
confirms the perifollicular edema
(arrow) and d T1-weighted fat
suppression image with contrast
uptake shows absence of internal
enhancement (arrow).
Laparoscopy disclosed the left
adnexal torsion and discolored
ovary with areas of hemorrhagic
necrosis

hemoglobin derivatives and further complicates the diagnosis
on US. CT and MRI confirm the absence of contrast uptake
after contrast injection due to vascular supply failure (Fig. 6).
CT best shows the presence of air, though it is rare [49].
Diffusion-weighted imaging (DWI) facilitates the identifica-
tion of the torsed adnexa [50, 51]. Hyperintensity on DWI
with hypointensity on the ADC map may be seen in the fol-
lowing locations: the parenchyma of the twisted ovary, the
Fallopian tube, the wall of cystic lesion, and the intracystic
clots [52, 53]. In a recent study, the presence of a perifollicular
T2 hypointense rim on MRI in the setting of ovarian torsion
correlates with perifollicular hemorrhage on histopathologic
exam and may also be a useful predictor of ovarian viability
after intra-operative detorsion [54].
Special population: in childhood, in pregnancy,
and in the elderly
Adnexal torsion may affect females of all ages [55–57]. The
diagnosis of pediatric adnexal torsion is difficult and often
delayed [22]. In the pediatric age group, ultrasound is the best
modality of choice [30]. Obtaining CT and/or MR images
should not delay treatment in order to preserve ovarian viabil-
ity [58, 59]. Up to 25% of cases of adnexal torsion occur in
pregnant women (Fig. 6). In pregnancy, untreated ovarian
torsion may lead to infarction, secondary infection, and
preterm labor [57, 60]. Adnexal torsion is not limited to wom-
en of reproductive age. In elderly subjects, neglected torsion
may lead to chronicity. Underlying masses may present sus-
picious changes such as a thicker and irregular wall. Severe
necrosis of the adnexal tissue and extensive pelvic adhesion
are the most frequent associated conditions in chronic adnexal
torsion. The differentiation of malignant ovarian tumors from
chronic adnexal torsion can be challenging (Fig. 7) [61].
Imaging pitfalls
A wide variety of entities may mimic adnexal torsion: appen-
dicitis, hemorrhagic functional cyst, hemorrhagic corpus lute-
al cyst, OHSS, pelvic inflammatory disease (tubo-ovarian ab-
scess, pyosalpinx), torsion of uterine fibroid, nephrolithiasis,
ureterolithiasis, pyelonephritis, ectopic pregnancy, enterocoli-
tis, and others. As the differential diagnosis of adnexal torsion
is large and may be difficult to assess, we have described the
common mimickers and pitfalls of adnexal torsions.
Appendicitis
Acute appendicitis is the most common cause of acute abdom-
inal pain requiring surgery [10]. The presentation of appendi-
citis can mimic right adnexal torsion [62]. The right ovary has
Emerg Radiol (2018) 25:51–59 57

Fig. 7 Chronic adnexal torsion in

the elderly. a Axial and b sagittal
MR T2-weighted images of a 69-
year-old female with neglected
pelvic pain and nausea show a
complex and septated solid and
cystic adnexal mass. Note the
blood sediment (arrowhead) and
papillary projections (arrow). c
T1-weighted fat saturation gado-
linium image demonstrates het-
erogeneous enhancement (arrow).
d Photography of the surgical
specimen discloses an ovarian
papillary cystadenoma with hem-
orrhagic necrosis secondary to
chronic torsion

increased in size and inflamed from adjacent appendicitis.
Screening the appendix must be routinely performed along
with ultrasound evaluation of the right ovary for suspected
adnexal torsion [63].
Hemorrhagic corpus luteal cyst
Clinically, patients often present with subacute lower abdom-
inal pain in the luteal phase of the menstrual cycle.
Radiologists should correctly identify the absence of torsion
to avoid unnecessary invasive procedures [64]. Diagnosis can
reliably be made on US. Commonly described findings in-
clude an avascular hypoechoic rounded lesion with fishnet
weave or fine reticular pattern. There are typically multiple
fine strands of fibrin giving a net-like appearance. Clot forma-
tion with subsequent retraction, echogenic material, and
thicker septations within the cyst can be observed, simulating
a solid ovarian mass [62, 65]. MRI features depend on the age
of the blood. Fluid-fluid or fluid-debris levels, representing
residual fibrin strands, are usually clearly depicted on T2-
weighted images. If the cyst is characteristic for a hemorrhagic
cyst in an asymptomatic and premenopausal female, it only
needs to be followed at 6–12 weeks if it measures over 5 cm in
diameter [66].
Ovarian hyperstimulation syndrome
This syndrome affects women undergoing assisted conception
and taking injectable hormone medications to stimulate the
development of follicles. It commonly occurs during the luteal
phase or early pregnancy. Various grades of severity are de-
scribed: mild, moderate, and severe. Patients present increased
blood viscosity due to hemoconcentration, coagulation abnor-
malities, kidney failure, and breathing difficulties due to pleu-
ral effusion [67]. The ovaries are enlarged with multiple cysts,
sometimes as much as 25 cm. A nontwisted hyperstimulated
ovary demonstrates cysts separated by thin tissue septa and
presents a relatively symmetric size compared to the opposite
side [14].
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a broad term that en-
compasses a spectrum of infections and inflammations of
the upper female genital tract. The infection ascends from
the vagina/cervix to the endometrium (endometritis), then
to the Fallopian tube (salpingitis, pyosalpinx) and the ovary
(tubo-ovarian abscess). Common causative organisms are
Chlamydia trachomatis and Neisseria gonorrhoeae. Tubo-
ovarian abscess can mimic ovarian torsion. On US, it con-
sists of a complex latero-uterine mass with septations, irreg-
ular wall thickness, and heterogeneous echo pattern.
Vascular flow is strongly increased on Doppler. MRI best
appreciates the diffusely enhancing pelvic mass with debris,
thickened septa, and high contrast uptake. Due to reduced
water diffusion in high viscosity purulent fluids, high signal
intensity representing pus with a low ADC value is useful to
make the correct diagnosis [68].
58
Conclusion
Adnexal torsion stands as a serious cause of lower abdominal
pain in female patients and is often difficult to distinguish
from other acute abdominal conditions. Various degrees of
arterial, venous, and lymphatic occlusions of the ovary can
occur, causing edematous congestion of the ovarian parenchy-
ma initially and hemorrhagic infarction later. Adnexal torsion
requires prompt surgical intervention. Diagnosis is usually
delayed because clinical presentation is nonspecific. The ma-
jor pitfalls in imaging have been highlighted in this review.
Further detailed imaging with multimodal CT/MRI must not
delay treatment, especially in children and young adults. The
challenge for the radiologists is to recognize this entity and
differentiate it from other etiologies in order to maximize the
likelihood of adnexal salvage.
Acknowledgements The authors are grateful to Pierre Le Pouesard for
his valuable editing of the manuscript. They also would like to thank
Benjamin Giroux for providing the drawings shown in Figs. 1 and 2.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical statement The authors declare that they comply with the men-
tioned ethical guidelines.
Financial disclosure statements The authors report no financial
interests.
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