Hemorrhagic Ovarian Cyst

Eranga Perera's picture
Author(s)
Eranga Perera, Shweta Bhatt,MD, Vikram S Dogra,MD.
Research assistant
University of Rochester.
Images

Figure Legends : 

Fig 1: Grey scale transabdominal ultrasonography of left adenexa showing the left ovary with hemorrhagic ovarian cyst (arrow). The cyst contains low level internal echoes. Fig 2: Transvaginal ultrasonography of left ovary demonstrates the hemorrhagic cyst (C) contain numerous fine, interdigitating strands. Fig 3: Color Doppler imaging does not demonstrate flow within the internal fine reticulations ( arrow). Fig 4 A and 4B: CT scan of pelvis Axial section and coronal reconstructed images show homogenously hypodense cystic lesion in the left adenexa (C), comparing with ultrasonograpic features compatible with a hemorrhagic ovarian cyst in subacute stage.

Case Description

Clinical History: 

32 year old lady with lower abdominal pain.

Diagnosis: 

Hemorrhagic Ovarian Cyst

Discussion: 

Most Ovarian cysts are functional cysts which result due to failure of rupture or regression of an ovarian follicle. Different kinds of functional cysts can develop during a normal menstrual cycle such as follicular cysts, corpus luteal cysts and theca luteal cysts[1]. Physiological ovarian cysts are found in all age groups, however they are extremely common in women of reproductive age group. These cysts are also found in early postmenauposal women and post menauposal women who are on hormone replacement therapy.[1,2] Follicular and luteal cyst can vary in size from 3 to 8 cm but most are smaller than 5 cm. Majority of functional cysts are asymptomatic and hormonally inactive. These physiological cysts can become symptomatic when they are complicated by hemorrhage, rupture and torsion.[1,2] During the mid cycle the granulosa cells become highly vascularize and the vessels become more fragile which can rupture easily and give rise to hemorrhagic cyst. Patients with hemorrhagic ovarian cysts clinically presents with an acute onset of pelvic pain or lower abdominal pain and pelvic mass. [3] Rupture of hemorrhagic ovarian cyst resulting hemoperitonium which can closely mimic a ruptured ectopic pregnancy in a woman of childbearing age. Adenexal torsion due to hemorrhagic cyst has been reported occasionally. Hemorrhagic cyst evolve in various stages of acute hemorrhage such as clot formation and clot retraction and it gives changing sonograghic appearances till they are completely resolved.[3] In Grey scale sonography the hemorrhagic ovarian cyst can vary from 2.5cm to 8.5cm in size and consist a uniform thin wall of 2 to 3 mm in thickness with posterior enhancement. The level of internal echoes and the echotexture will vary according to the stage of hemorrhage, and will be better evaluated in transvaginal sonography. [3] In acute stage the fresh blood will be almost anechoic. As the hemorrhage evolves into subacute stage the echogenicity will be hypoecoic or hyperecoic. The commonest two appearances of hemorrhagic ovarian cyst in Grey scale sonography are [3] 1. Cystic mass with multiple interdigitating fine strands. These strands which give a fishnet weave or fine reticular appearance are due to fibrin deposition in the clot and they do not contain blood vessels. Similar appearance with multiple septae is described in neoplasms such as Mucinous cystadenomas. However the septae in these neoplasms are thicker, more reflective and visualized in a continuous manner than the fibrin strands of a hemorrhagic cyst. [3,4] 2. Retracting blood clot in an anechoic cyst. When the blood clot is retracted and small it can simulate a mural nodule in a cystic neoplasm such as Papillary cystadenoma. Some Grey scale sonographic features may help to differentiate it from a neoplasm. The blood clot of a cyst will be triangular or curvilinear in shape where as a mural nodule will have convex margins. The echogenicity of the clot is usually hypoecoic compared to the cyst wall and a mural nodule usually will be Isoechoic to the cyst wall. The retracting clot can have a homogenous echotexture or reticular pattern. [3,4] Other rare appearances of hemorrhagic cyst in Grey scale sonography are a cyst with a fluid debris level, thick echogenic rind surrounding an anechoic cyst, dense internal echoes with poor through transmission and a cyst with solid and cystic components. [3] Color or Power Doppler imaging may help to differentiate hemorrhagic ovarian cyst from neoplasm. Fine reticulations of a hemorrhagic cyst or the retracting clot do not form blood vessels within. Identification of flow in Color or Power Doppler within septae or the clot would exclude the possibility of it being a hemorrhagic ovarian cyst. [4] On MRI and CT functional cysts appear as well circumscribed unilocular masses. When the cysts are complicated with hemorrhage and according to the time of presentation the attenuation can vary from hyperdense to isoodense. Uncomplicated functional cysts appear low signal intensity on T1W and high signal intensity on T2W images. When they contain blood products the hemorrhagic cyst will display intermediate to high signal intensity on T1W images. To differentiate it from fat and protinaceous material fat saturated techniques are useful.[5] Correct diagnosis can be made with imaging in most of the patient with hemorrhagic ovarian cysts. In cases which the diagnosis cannot be made easily follow up ultrasound scans are done after one to two cycles. Spontaneous resolution or decrease in size to a considerable amount is seen sonographically within six to eight weeks.

References / Suggested Reading: 

1. John R Haaga, MD,FACR,FSIR, Vikram S Dogra, MD. Michael Frosting, MD, PhD, Robert C. Gilkerson, MD. Hyun Kwon Ha, MD. Murali Sundaram. CT & MRI of the whole body. 5th edition. 2. Walter W Valesky Jr, MD. Mark A Silverberg, MD, FACEP, MMB. Andrew A Aroson, MD. Ovarian cyst. emedicine 3. Kiran A Jain, MD. Sonographic spectrum of hemorrhagic ovarian cyst. J Ultrasoun Med 21:879-886. 2002. 4. Maitray D Patel, MD. Vickie A. Fledstein, MD. Roy A. Filly, MD. The likelihood ratio of sonographic findings for the diagnosis of hemorrhagic ovarian cyst. JUM 2005. 24, 607-614. 5. Izumi Imaoka, MD. Akihiko Wada, MD. Yasushi Kaji, MD. Tafumi Hayashi, MD. Michiharu Hayashi, MD. Michimasa Matsuo, MD. Kazuro Sugimura, MD. Developing an MR imaging strategy for Diagnosis of ovarian masses. Radiographics 2006: 26 :1431-1448.

Citation:

Hemorrhagic Ovarian Cyst, Eranga Perera, Shweta Bhatt,MD, Vikram S Dogra,MD., Imaging Science Today, 2010, 844.