Cloverleaf Sign in Pelvic Magnetic Resonance Imaging for Deep Infiltrating Endometriosis

Härmä K, Kirsi Härmä, Binda A, Aleksandra Binda, Michael Ith, Ith M, Poellinger A, Alexander Poellinger, Siegenthaler F, Franziska Siegenthaler, Johannes Heverhagen, Johannes T. Heverhagen, Sara Imboden, Imboden S, Mueller M, Michael Mueller, Michael D. Mueller
Investigative radiology · 2019 · vol. 55(1) , pp. 53–59 · doi:10.1097/rli.0000000000000612 · PMID:31633573 · W2980710725
article OA: green CC0 ⤵ 7 in-corpus citations
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⚙ AI-generated summary by claude@2026-06, 2026-06-28 ⓘ

The "cloverleaf sign" on pelvic MRI was associated with significantly longer operative times, increased blood loss, and a higher rate of bowel resection in deep infiltrating endometriosis patients.

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⚙ AI-generated deep summary by claude@2026-07, 2026-07-04 · read from full text ⓘ

I can’t access the paper content because the provided text is a web protection/anti-bot page rather than the study itself, so I’m unable to determine what was studied, the methods, or the reported findings. Without the actual abstract or results section, any summary would be speculative. The paper’s title suggests it may address imaging features of deep infiltrating endometriosis (the “cloverleaf sign” on pelvic MRI), but that cannot be confirmed from the text shown. This paper is centrally about endometriosis — specifically, it concerns pelvic MRI imaging of deep infiltrating endometriosis using the “cloverleaf sign.”

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Abstract

OBJECTIVES: The aim of this study was to evaluate the significance of a new imaging sign, the "cloverleaf sign," in diagnosing deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI) in concordance to intraoperative findings. MATERIALS AND METHODS: This retrospective study included 103 patients operated during the January 2016 to June 2018 period with preoperative 1.5 T and 3 T MRI, with or without vaginal and rectal gel filling. Magnetic resonance imaging scans were read blinded to intraoperative findings by a specialized gynecologic radiologist and a junior radiologist, and then compared with intraoperative findings by looking at the operation report, postoperative diagnosis, and intraoperative images and videos by an experienced gynecologist surgeon specialized in endometriosis surgery. All endometriosis lesions were confirmed by pathology. The "cloverleaf sign" was defined as a cloverleaf-like figure in imaging morphology; the "leaves" formed by at least 3 different organs come together in the center of the figure formed by constrictive adhesions including T2-weighted (T2W) hypointense DIE. Operation times, intraoperative blood loss, and the frequency of DIE and bowel resections were analyzed in cloverleaf and noncloverleaf groups. The 2-sample Wilcoxon rank-sum (Mann-Whitney U) test and multivariate analysis of variance were used to calculate the significance of an overall impact of cloverleaf sign on operation time, blood loss, and the amount of the bowel resection rate. P < 0.05 was considered statistically significant. RESULTS: The prevalence of DIE in the study population was 79.6%. A total of 11.5% of the patients had no endometriosis, 32.6% had rASRM I and II, and 55.9% had rASRM III and IV. Forty-six patients (45%) had received rectal and vaginal gel opacification before scanning, 57 (55%) did not. A cloverleaf sign on MRI was detected in 34 patients (15 in gel filling and 19 in nonfilling group). The interreader agreement was almost perfect 0.91 (κ). The median operation time in the cloverleaf group was 248 minutes (interquartile range [IQR], 165-330) compared with 145 minutes in the noncloverleaf group (IQR, 90-210), that is, significantly higher (P < 0.001). Intraoperative blood loss was also significantly higher in the conglomerate group (125 vs 50 mL; IQR, 100-300 vs 50-100; P < 0.001). Of the bowel resections in our study population, 41% (14/34) were performed on patients with a cloverleaf sign in the MRI, compared with 13% (9/69) in patients without the cloverleaf sign. CONCLUSIONS: The "cloverleaf" MRI sign was associated with significantly longer operation time, increased intraoperative blood loss, and higher rates of bowel resection in DIE patients.
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Outcome instruments

rASRM

Condition tags

endometriosisdie_deep_infiltrating

MeSH descriptors

Blood Loss, Surgical Endometriosis Endometriosis Intestines Magnetic Resonance Imaging Operative Time Adult Blood Loss, Surgical Endometriosis Female Humans Intestines Magnetic Resonance Imaging Pelvis Pelvis Retrospective Studies

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (20)

Cited by (7)

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