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Case Report Open Access

Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review

  • Authors:
    • Fani-Niki Varra
    • Apostolos Fasoulopoulos
    • Eleni Spathi
    • Ourania Tzirou
    • Viktoria-Konstantina Varra
    • Michail Varras
  • View Affiliations / Copyright

    Affiliations: Department of Pharmacy, School of Health Sciences, Frederick University, Nicosia 1036, Cyprus, Fourth Department of Obstetrics and Gynecology, ‘Elena Venizelou’ General and Maternity Hospital, 11521 Athens, Greece, Department of Ultrasound, ‘Elena Venizelou’ General and Maternity Hospital, 11521 Athens, Greece, School of Health Sciences, National and Kapodistrian University of Athens, 15771 Athens, Greece
    Copyright: © Varra et al. This is an open access article distributed under the terms of Creative Commons Attribution License [CC BY 4.0].
  • Article Number: 38
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    Published online on: May 12, 2026
       https://doi.org/10.3892/mi.2026.322
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Abstract

Adnexal torsion is a gynecological emergency resulting from the partial or complete rotation of the ovary, often involving the fallopian tube, around its vascular pedicle. Prompt diagnosis is crucial to prevent ischemic injury and preserve ovarian function. Mature cystic ovarian teratomas are common benign neoplasms and represent a frequent cause of torsion due to their size, mobility and mass effect. The present case report describes the case of a 36‑year‑old woman (gravida 2, para 2) who presented several hours following the sudden onset of right lower abdominal pain, initially accompanied by nausea, both of which had resolved by the time of evaluation. A transvaginal ultrasonography revealed a right ovarian mass measuring 6.13x5.20 cm, containing two mature cystic teratomas. Gray‑scale and color Doppler imaging clearly demonstrated the characteristic whirlpool sign, indicating torsion of the adnexal vascular pedicle. An emergency laparoscopy revealed the quadruple torsion of the adnexa (fallopian tube and ovary), and a right salpingo‑oophorectomy was performed, as the patient had completed her family. The post‑operative course of the patient was uneventful. A post‑operative pathological examination confirmed the torsion of mature ovarian teratomas with associated hemorrhagic necrosis. On the whole, the present study demonstrates that the ultrasonographic whirlpool sign is a highly specific pre‑operative marker for adnexal torsion, particularly in cases with multiple mature cystic teratomas. Early recognition facilitates prompt surgical intervention, minimizes ischemic injury, and may preserve ovarian function. Incorporating the focused assessment of the whirlpool sign into routine ultrasonography for acute pelvic pain enhances diagnostic accuracy and guides timely operative management.
View Figures

Figure 1

Transvaginal ultrasonography
illustrating a bilocular mass within the posterior pouch of Douglas
with mixed echogenicity, comprising solid, cystic and fat
components, measuring 6.13x5.20 cm; these findings are suggestive
of a dermoid cyst. The yellow ‘+’ symbols indicate the dimensions
of the mass.

Figure 2

Gray-scale transvaginal
ultrasonography, using cross-sectional imaging, illustrating the
characteristic whirlpool sign with visualization of a twisted
ovarian vascular pedicle in a plane perpendicular to the axis of
torsion. The twisted vascular pedicle is identified between the
right uterine cornu and the mass, measuring 3.99x2.74 cm in cross
section. The yellow ‘+’ symbols indicate the dimensions of the
mass.

Figure 3

Pelvic color Doppler ultrasound
illustrating the characteristic spiral ‘whirlpool sign’,
highlighting torsion of the ovarian vascular pedicle.

Figure 4

Intraoperative image illustrating a
6-cm bluish-black in color mass (red arrow) located in the
posterior pouch of Douglas, twisted 1440˚ (blue arrows) around its
infundibulopelvic ligament axis.
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Copy and paste a formatted citation
Spandidos Publications style
Varra F, Fasoulopoulos A, Spathi E, Tzirou O, Varra V and Varras M: Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review. Med Int 6: 38, 2026.
APA
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., & Varras, M. (2026). Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review. Medicine International, 6, 38. https://doi.org/10.3892/mi.2026.322
MLA
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., Varras, M."Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review". Medicine International 6.4 (2026): 38.
Chicago
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., Varras, M."Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review". Medicine International 6, no. 4 (2026): 38. https://doi.org/10.3892/mi.2026.322
Copy and paste a formatted citation
x
Spandidos Publications style
Varra F, Fasoulopoulos A, Spathi E, Tzirou O, Varra V and Varras M: Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review. Med Int 6: 38, 2026.
APA
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., & Varras, M. (2026). Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review. Medicine International, 6, 38. https://doi.org/10.3892/mi.2026.322
MLA
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., Varras, M."Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review". Medicine International 6.4 (2026): 38.
Chicago
Varra, F., Fasoulopoulos, A., Spathi, E., Tzirou, O., Varra, V., Varras, M."Ultrasonographic whirlpool sign in ovarian torsion with dual mature teratomas: A case report and literature review". Medicine International 6, no. 4 (2026): 38. https://doi.org/10.3892/mi.2026.322
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