2023 ARRS ANNUAL MEETING - ABSTRACTS

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E2294. Into the Vortex: The Whirlpool Sign in Pediatric Ultrasound
Authors
  1. Hassan Aboughalia; University of Washington Medical Center
  2. Alp Oztek; University of Washington Medical Center
  3. Sakura Noda; Seattle Children's Hospital; University of Washington Medical Center
Background
A whirlpool describes rotating water created by opposing currents or upon an encounter with an obstacle. On imaging, it refers to a twist of the vascular pedicle of an organ, with a subsequent characteristic appearance on color Doppler images. Multiple abdominal pediatric emergencies are associated with a whirlpool sign, including midgut and other intestinal volvuli, testicular torsion, and ovarian torsion. This exhibit aims to review the underlying embryologic mechanism predisposing to this characteristic appearance, the role of this sign in the diagnosis of these conditions, the supporting imaging features that can help further define the diagnosis, as well as some pitfalls and differential diagnoses that can lead to a fallacious diagnosis.

Educational Goals / Teaching Points
Summarize the underlying embryologic mechanisms predisposing to whirlpool appearance. Illustrate the role of the whirlpool sign in the diagnosis of midgut volvulus, adnexal, and scrotal torsion. Review the supporting imaging features in these diagnoses. Discuss some pitfalls that can lead to a fallacious diagnosis.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Whirlpool sign refers to a twist of the vascular pedicle of an organ, with a subsequent characteristic appearance on color Doppler images. Although the whirlpool sign does not determine the underlying cause of torsion, it is most often specific for torsion, which is the driving force for management in most scenarios. In the mesentery, it corresponds to the fluoroscopic corkscrew appearance of the small bowel and is very specific for midgut malrotation and torsion. Adnexal whirlpool sign is highly specific for ovarian torsion; however, it is less observed in the pediatric population given that this patient population is commonly evaluated transabdominally limiting evaluation of the vascular pedicle. Finally, scrotal whirlpool sign is one of the definitive signs of testicular torsion, in addition to the boggy pseudomass sign and absent testicular flow on color Doppler ultrasound.

Conclusion
Recognition of the whirlpool sign is of paramount importance to avoid the downsides of delayed recognition and improper treatment in the aforementioned pediatric emergencies.