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In the and uh now we are going to move on to if SBA questions first learning outcome E three. Let me stop sharing this and then Sure. Sure. Screwed and mhm And that second, it's cream with no uh sure uh So on their first learning outcome which is compare and contrast uh consciousness and unconscious state. Uh First question, uh 32 year old male has been ice skating and has slipped on the ice and hit his head. He's unconscious and it is on the initial assessment. His arm is abnormally flexed and leg is internally irritated. The patient occasionally makes the sound of our and and does not open. I when pinching their shoulder due to his low G C S, he's undergoing intubation and ventilated by the anesthetic team. Given the information above was his G C S score. Alex. Can you launch the pole for me? And, and the correct answer is B uh the server posture is scored as three and verbal uh incomprehensible speech is scored as to and not opening. The I was in response to the pain of voice is scored one and the G C S scored is total up to six. So the option B is the correct answer. Next question. Uh neurosurgical S H O receives a phone call from E D from a neuro uh for a neurosurgical review of 25 year old female patient who had a road traffic accident was obvious uh lacerations, trauma to the head, face and neck. Uh He has fracture of the skull and manageable from the initial investigation is shown that his uh PA 02 is six point to kill Apasco. And P A CO2 is some kill Apasco and his G C S is equal to eight. And from the CT images, it is clear that he has a subdural hematoma. He begins to undergo seizure after taking CT images. What is the best uh initial management for this patient? So the correct answer is b she has severe oh hematoma which uh commonly occurs after a detailed relation injury. And from the 80 assessment uh is the first step when approaching patient was head injury. Um From this, we find out that she has type two respiratory failure and that she has decisive less than eight because of that. Uh intubation is indicated for this patient and they can be uh intubated by rapid sequence induction technique. Next question, there is 56 year old male who has been transferred to E D. They called ambulance after he suddenly collapsed and fell after sudden weakness in the his arm and leg. He has no consciousness. And his G C S is three uh from taking collateral history from his wife. It is found that he has a past medical history of hypertension and atrial fibrillation. He was taking initially taking uh Apixaban but he stopped taking after feeling uh tired and weak from ce angiography. He's found to have clots and basilar artery, which structure has been damaged as a result of the skeptics stroke. So the correct answer is e uh well done to people who go to correct patient with ischemia in um internal capsule also often presents with contralateral polaris paralysis and uh it's often uh supplied with lenticular straight artery. So is not the correct answer. And frontal lobe and hospital lobe presents with different symptoms, uh symptoms that is not presented here and uh the most likely answer is ridiculous, er activating system because it's necessary for consciousness and it's supplied by vascular artery. Next uh six year old female patient is found to have meningitis caused by HSV two. She's also receiving chemotherapy from leukemia. Her G C S score is seven and it's written as E two V three M two. Her motor response is affected by increased I C P and meningitis. What is the motor response seen in patient who scored empty? So, the correct answer is see and um uh if the patient is a normally flex uh abnormal extension and uh and if their posture like that, they scores too. Next 28 year old uh man is brought today and e who has reduced level of consciousness. His friend is believes he has ingested large quantities of unknown substance. He says, uh we're like difficult, painful doctor, but he's not able to make full sentences. What is his verbal response score? So the correct answer is see, well done to uh whoever got it. And if the patient's spots are worse rather than sentences, they will usually score three. So that's the correct answer. Uh Next, the second learning outcome of the day is I don't find the mechanism, nerve cell damage and response to injury. So the first question is uh a 25 year old male presents. The uh patient was drinking and he has decided to play a knife game which has resulted in injury of his ring finger and he has completely transected his nerve. Uh if this is left untreated, a nerve and artery in his finger is not suit your back under microscope. One is the first thing that could happen. So the correct answer is uh the uh nerve is injured. First, costing iron enters the cytosol which result the activation of CAL pain, which would result in the breakdown of sight, a skeleton, second Schwann cells, phagocytose degrees and myelin sheath and they secrete factors promoting external growth. Schwann cells, then differential uh d differentiate and start dividing and um they become contained within this basal cell, basal lamina which previously contained the axons. Then after that macrophage inflow infiltrates and uh they promote the growth of Schwann cells. And Axons. Then for the last step, new Axon start sprouting. So the correct answer is D which is the first step. Next. Uh 72 year old female was driving and she has a mistaken acceleration pedals with deceleration pedal. This has resulted in the car colliding into the wall. Uh She has no major external injury due to the uh airbag activating. However, she seems to have lost consciousness in the car and she has not waken up from her coma. CT images were taken to investigate the cause of her symptoms. Uh What is the best? Uh what is the diagnosis which best fits the description and sorry. Uh You need a CT image because that quite this question. So the correct answer is diffuse axonal injury um because there's a particular hemorrhage that can be seen on the CT image and loss of consciousness followed by coma is common presentation of a diffuse axonal injury. And unfortunately, it's not e because you don't see any kind of bleeding into the ventricles. Next question. Uh 54 year old male patient is undergoing recovery after ischemic stroke, uh frontal and temporal lobe, there was there has been cell death due to a scheme ischemia because of this. There is a response by C N S in response to this injury. What sells most involved in the removal of debris and uh in this response. So the correct uh the answer is uh micro glial cells because they in response to tissue damage, there is removal. Usually a removal of debris is by microbial cells. Schwann cells are also involved somewhat and removal of debris is but um in this case, it's in the uh C N S. So it wouldn't be uh Schwann cells. Next your second year medical student that's currently learning about the mechanism which are, which causes apotheosis of neurons. You learn uh that certain neurotransmitter allow for entry of sodium and uh cause the Mayans. What neuro transmitter cause uh this excite excited toxicity. So the correct answer is glutamate and glutamine is the main excitatory exciting story. Neurotransmitter injury to the brain can raise the extracellular levels of glutamate. And glutamine binds to the NMDA receptors which causes the influx of sodium and cause millions. And because of the high levels of cat iron, they causes automatic swelling and then sell ruptures. Uh Your second uh medical uh for the first question. Uh you are a second year medical student and you just had a lecture on oxidative stress, which can be seen in almost old issues including the brain, uh which of the following enzymes are involved in the removal, reactive oxygen species. Uh So the correct answer is superoxide, this mutates and some superoxide. This mutates is involved information hydrogen peroxide from reactive uh from reacting, react reactive RS and H D O and Um the one tricky one is D because um the one that removes um reactive oxygen species catalysts instead of capsizes tap stages are involved in uh apoptosis. Next question, uh relate the changes intercranial pressure uh to the brain function. So a 60 year 1, 61 year old female presents to the E D after acute onset of confusion and impairment and short term memory. After CT image, there's a large region in the brain which is found and with MRI, it is confirmed to be a brain tumor was the compensate ori mechanism which prevents suddenly increase in I C P. Uh So the correct answer is be uh so there's a increased, increased venous australia's where you're a venous sinus which occurs to prevent increase in I C P. Um There's also um increased CSF drainage vera ventricular system, so she wouldn't be correct. Uh Next, a 63 year old male has subdural hematoma and results in the compression of brain. Uh parenchyma, the patient's are, is looking down and out and is dilated. The patient seems to be dragging his own feet as he moves. What is the most likely type of herniation given the patient's signs and symptoms? So, the correct answer is uncle herniation, which um the person uh is your organ a correct and uncle herniation results in compressive uh compression of uh cranial nerve three, which results in alkaline monitoring near palsy, which results in I looking down and dilated uh there's also compression of a posterior cerebral artery which results in a uh scheme stroke of uh hospital oh which results in the anemia, sorry. Harmonium MS hemianopia with macula's preparing, there's also compression of cerebral peduncles which is uh involved in motor control which results in hemiparalysis. As you can see the patient is dragging his feet. Uh there's also compression of uh there can be a compression of paramedian basilar artery which can cause common death. So uncle herniation are quite uh dangerous if anyone has them. Okay. Next 32 year old female patient presents to E D after hitting, hitting the head on the metal bar in the playground and it's bleeding profusely from the scalp. You find out that her BP is 129 over 80 and that her uh cerebral profusion pressure is 60 mmh G. What is the intercranial pressure which can be estimated from the uh measurement provided in the description uh rounding up to whole numbers. I think this is a pretty challenging question but just, just have a guess of the answer. So you got it correct. Um The correct answer is the um uh me uh so me on third or a Tariel pressure is calculated as diastolic pressure plus one third of systolic pressure. Uh sorry, one third of uh systolic pressure minus diastolic pressure, which is called pulse pressure. And because the material pressure is 96.3 M M A G and intercranial pressure is calculated as me on material pressure, minus cerebral perfusion pressure. So 96.3 minus 60 eagles eagles to 36.3. So the correct answer is the next question. Um So 50 year old female presents to E D after some uh thunder crap headache upon upon image mint a patient she's found to have subarachnoid hemorrhage. There is increased intracranial pressure from hemorrhage. What is three feature which can be seen in this patient? So the correct answer is see and when the ICP is increased, the cushion reflects the scene and which results in depressed respiration, bradycardia. Why didn't pulse pressure? So yeah. Uh So on to the first question, uh you're a second year medical student and you're learning about the different factors which affect uh increase or decrease in I C P. And during CBL sessions, you're given an example patient with uh severe arachnoid hemorrhage in E D. What can be done for this patient to decrease I C P? Okay. Well, it doesn't label that but the correct answer is high hyperventilation. Uh No, it labels it. And hyperventilation can be close to decrease in P 02 which causes vase uh result inveighs a construction and thus decreasing cerebral blood flow, which results and decreased uh I C P. Uh the propofol uh coughing and sneezing can further increase the ICP and also hyperventilation can also produce the the opposite effect which results increase ICP. So, a and D is definitely a no, no uh propofol can cause a patient to have respiratory depression. So it will also cause a negative effect as well. Next, describe the mechanism of neck injury and the roll and roll of stabilization. Next, first question, your second year medical student and you have just witnessed person falling down uh on the stairs. She is found to be unresponsive with no signs of life and the ambulance is called immediately and basic life support is initiated due to the dangerous mechanism. A cervical spine injury is suspected which of the following uh is the best way to manage patient's airway in the setting. So the correct answer is e hold on. Uh the correct option is e because the patient is suspected of c spine injury, but you need to check the for the patient's airway. Uh So the Joe's Trust is the most appropriate response in this patient. Next. So second question is 32 year old female lies on the ground after being thrown out of the vehicle uh from a traffic accent, an ambulance is called immediately and basic life support is initiated due to the dangerous mechanism. A cervical spine injury is suspected. Basic observation is as follows heart rate of 110 respiratory rate of 21. What is the best next step for this patient? So the correct answer is see uh 33 point C spine demobilisation is the correct um management for this patient because um you suspect the c spine injury. And um it is more important to mobilize the patient's head fully with uh those hand technique rather than applying original color. But applying original color doesn't become important in the later stage. But in the initial um stage, it is more important to just um secure them using your hands. Uh Next 50 year old man is brought to the A and E after being thrown out uh of the uh bicycle from decelerating suddenly, uh the injury is suspected to have called hyper extension of the head on CT scan. There's fracture through the past into articular, inter inter articular. A list of the CT by laterally. What is the type of the fracture which is seen? Okay Hangman's fracture? Right. So the correct answer is B hangman fracture is a fracture through the pause, interact realize as or inter arctic to Dallas of see two bilaterally. There's also subluxation of uh C two vertebra on C three, which is you really see in hangman's fracture. Um There are usually closed by cervical hyperextension which uh fits the presentation. This patient, a 72 year old male is found to have cervical facet subluxation at the level of see to upon CD scan due to her COPD, she's assessed to have uh A S A grade three and her operative risk is high. What is the most definitive management for this patient? So, moving on to the answer. So using a traction device is the most correct way of uh most definitive way of managing this patient because the patient uh unfit to have a surgery. So CND wouldn't be a suitable option, but using a uh c spine collar wouldn't be appropriate for long term management. So the most definitive management is a uh 52 year old male is found in the car unconscious after he lost control of his vehicle and drove off the cliff. He hits the back of his head against uh the roof of vehicle. He is given a CT scan and he is found to have burst fracture. At C one. What type of fracture is seeing in this patient? So the correct answer is Jefferson uh fracture, which is C uh Jefferson fracture is burst fracture of the Atlas is caused by um a hit, hitting the head against uh for example, the roof of vehicle or some actual roading on the cervical spine spine which causes um hospital condyles to be driven into the lateral masses of C one, they're often um associated with head injuries. And these fractures are um usually unstable and account for approximately a third of all. See one fractures. And why is B D M E S B and E is wrong is because it's uh like uh foot fracture rather than a neck fracture. So and hang my fracture doesn't present like this. So the most correct answer is see. So now on to uh second speaker which is Alex. I'm not sure. Uh All right. So I'll be doing L5 too late. I'm start showing now. Uh maybe something since. Okay. So the first question, we got to pull it out of the way. Next question, which of the blow symptoms will help differentiate between upper motor neuron and low to motor neuron nerve public. See in the facial enough eight option A is pet osis. Second is changing hearing and then third one, facial droop, people constriction and unable to lift eyebrows. Yeah, sorry, I didn't think accidentally messed up facial nerve in question. Uh huh. Uh So unfortunately they can't answer is e unable to lift eyebrows and to explain that as facial nerve supplies. Um, um, some of hearing taste and the facial muscles in the low of the face and upper motor neuron supplies, um, forehead and eyebrows. Yeah, but then lower moods in your own supplies, each face separately. But then I promote on your forehead. Every point on your forehead and your eyebrows. You get both sides innovations. So nerve palsy of one side, you won't affect it. You still be able to lift your eyebrows and yeah, that's why second question, which of the following of posey is likely effective when patient presents with this, this picture on the top. Right. Yeah. The correct answer is hyper glass. Oh Enough. And I'll go through each nerve glass of firing Jill supplies, taste in the front two thirds, biggest nerve supplies is the motion of um swallowing in terms of this area. And the hypoglossal nerve is uh supplies the musculature. Uh in terms of your tongue, moving facial nerves applies for the taste in the posterior one third of the tongue. Mandela mandible, a branch of the trigeminal nerve supplies the sensation around your jaw and below the maxilla region. Third question, patient presents of unilateral left eye deviation downwards um and outwards with ketosis and pupil dilation, which nerve is most likely to be affected. Okay. Got the correct answer is oculomotor nerve. Um Oculomotor nerve moves eyes in and up. Uh chocolate nurse moves I out. Abdullah nerve moves that I um down. And then now the patient presents with hormone unanimous, left, lower quadrant quadra quadrant anopia. Where is this? Where is a lesion likely to be on the visual pathway? Correct answers. See left temporal lobe optic radiation. Let me check it back. Yeah. And that's because if you have right optic nerve damage, you will get a complete right. Uh Right. What's the word? You won't see anything out of your right optic as um it would be, it will not be both, it will not be a harmony, homonymous. It'll be on both sides and proud. It'll parietal lobe optic radiation that will be on the top of the left. Um quadrant and left occipital lobe will be, will be both sides on the left. Okay. And then which of the following nerve gives rise to recurrent laryngeal nerve, just some anatomy. Um Yeah, recurrent recurrent laryngeal nerve actually is a branch of the vagus nerve that goes down and the loops around um loops around pulmonary artery and comes back up to the Lawrence describe the function of the Minges L 06. That's about the meninges. Okay. So which of the following drugs? It works in early stage of men and judges but are not effective later on. This is um quite something that forgot which lecturer, but this was described actually in case it's slightly harder if you don't remember the lecture specifically. Yeah. So the answer is penicillin. Um the brain blood brain barrier is maintained, it is also maintained in um uh meningea as and penicillin and all the other stuff. Um cephalosporins other than cefTRIAXone will not be able to penetrate the blood brain barrier. But in early stage of meningitis because of the inflammation and dilation of blood vessels, um and basement membranes, penicillin, uh penicillin and some of the other cephalosporins actually can get through. So that's something you can use when you're not sure what the cost of Asian is, which artery is most likely to be damaged in blunt trauma to decide of the head. It's just classic presentation. Alright. Middle meningeal artery, correct. Yeah. Nothing much to it. That's where it is. And it's the most common meningea, most common artery to be damaged and blunt trauma to the head and it can cause subdural human toners which raises intracranial pressure, which very sort of stuff has been explained by Chris early on. Okay. So which part of my ninjas does the brain cross during a herniation? I think I specified which type of herniation. And uh huh. Uh sorry, it should be uh a should be a uncle herniation. The question that's been missed out in the plantation. Apologies. And the answer is tentorium. Cerebri, that's the one going across and that's, that's the one that gets crossed by the ankles of the brain during um the uncle herniation. Sorry about the question being risen up wrong. That would be fixed in SBA pack which type of hydrocephalus is likely to be caused by meningitis. Uh The answer is a communicating hydrocephalus. Um So noncommunicating hydrocephalus is when you see specific parts of the ventricles swelling up. So specific parts of the CSF drainage has been blocked. Whereas communicating hydrocephalus will be the whole ventricular system swelling up. You'll see in a CT scan and normal pressure. Hydrocephalus is when you don't have a race intracranial pressure. This is commonly happen in old people. So the ventricle swells up when the brain starts shrinking. Hydrocephalus, eggs Vacco is apologies. Hey, uh worst minutes go about that. That would be added to the presentation. At the end. All these a child presents an A and E with symptoms of meningitis upon further questioning the child has been fully vaccinated up to date was the most likely cause it'd agent. Yeah, the correct answer is uh streptococcus pneumonia and Japanese encephalitis virus cause encephalitis. As the name suggests, Meningococcal group B and human Phyllis influenza type B is um vaccinated against and yellow fever virus is very uncommon and also it causes encephalitis and set up meningitis most commonly. Um, patient is being investigated for meningitis. Lumbar puncture results is as follows. Pressure is high CSF is yellow. Um There's increased neutrophil count's normal lymphocyte counts, decreased glucose. Which of the following is a likely type of course of agent. This actually can come up in best to I remember and the correct answer is a bacteria in bacteria, glucose come down because later questions go through this again. Uh The lumbar puncture results, I want to explain the other variables yet. So next question. CSF, the longer puncture again, uh CSF is yellow with normal pressure, normal glucose has increased protein, increased lymphocytes. Which of the following would, would not help guide differentials. Okay. The answer is HPV because HPV won't help you rule out anything really um other than HPV itself and that's very uncommon and you can actually deduce HPV from all the other um test you can do. Firstly, blood cultures can help you differentiate a bacterial meningitis, occupational history, can help you rule out things like tuberculosis or other types of rarer causes of agents C D force outcomes can help you find out whether the patient has HIV and help you deduce whether they have a opportunistic infection from HIV. And Man talks test is the test you use for tuberculosis. Next question, which of the following organism is most commonly seen in HIV. Patient presenting with meningitis and you've got this correct? And then impressive. Yeah, nothing much to it. These are just the things you have to learn. Cryptococcus is the most common one. I believe histoplasma is the next. That's common. One patient presents of fever, headache, nausea, vomiting in generalized tonic seizure was the likely cost of agent patient from Korea. Sorry I said huh. That's a keep up alright. Answers be some of you have got that correct. Um Yeah. Um so to keep out of the question is the patient comes from Korea and that's something to pay attention in this Kianne exams where uh some of some other background history, travel history for from patient's and Japanese encephalitis virus is common in Asian countries, China, Japan, Southeast Asia Korea. And that's it. And West Niles is more common in America and North Africa. Whereas the other ones are just fairly common ones you see in our patient population. Normally in the UK uh seven is uh some people have asked us about hydrocephalus X vac you and just to add, it's uh when there's a compensate ori uh enlargement of the C S S space and when there's a enlargement of the liberal ventricles and subarachnoid space. Uh It can be classified as a communicating hydrocephalus but there's no disruption to um uh CSF uh absorption. That's uh hydrocephalus X VAC. You just uh okay, thank you, Chris. Um Next one, uh pharmacological management for reducing intracranial swelling, which was the foreign drug is used to avoid acute brain herniation as a result of acute intracranial hypertension due to brain abscess. The correct answer is see cortical steroids. Um an acute setting cortical steroids um is used to bring down the inflammation and therefore swelling in terms of brain abscesses. And you would use IV Track's owner, metroNIDAZOLE late um later on to treat the root cause of the problem, which is infection, but you started cortical steroids first. Um If you're worried about brain herniation because uh integrated pressure is so high, which is a definitive method to reduce intracranial pressure for patient's with a confirmed diagnosis of sub arachnoid hemorrhage. So the correct answer is numbness up in as a calcium channel blocker that will help clamp down on the blood vessels and no other way around. It will clamp down on the blood vessels and prevent um more bleeding from a subarachnoid hemorrhage, which is usually a aneurysm eruption. Why might man it'll be contraindicated in managing ray raised intracranial pressure. Sorry about the amount of typo in this presentation. Correct. The answer is a an urea. Um You wouldn't want to give Manitoba's Mannitol acts by helping auto escape through the kidney. And if you, if the patient has an urea, they won't be able to x cream the drug and mortar together and will cause the level of Mannitol to build up beyond therapeutic therapeutic um concentration. Which of the following clinical feature would make a patient with brain abscess, empyema. That's the other name for it. A suitable candidate for pharmacological management. Instead of surgical, the correct answer is multifocal abscess more to the infection being multifocal abscess because you wouldn't want to go, go in removing multiple different small nodules that be very high risk for very little response. And in other patient's, these are not exactly um indications but it can be uh can surgical surgical management can be indicated in these um settings and that's the end of my S pas except we'll be Saillant. I believe so silent. Um If you can share the presentations, I'll regret. Yeah. Oh, just get up now. Um One second. Sorry about this. Just having some my shoes. Okay. Can you see that? Yeah, I can see it. Cool, thanks. Okay. So my name is Shai and I'll be doing the next bunch of questions. Okay. So first question, what is the definition of a transient ischemic attack? So A T I A. So we've got a, a transient episode of neurological dysfunction with acute infarction and tissue injury. Be transient episode of neurological dysfunction with acute infarction without tissue injury. See, transient episode of neurological dysfunction without acute infarction and with tissue injury, d transient episode of neurological dysfunction without acute and functional tissue injury, and transient episode of neurological dysfunction with resolution within seven gates. Okay. So the answer to this is deep and essentially a tia is defined as a transient episode of neurological dysfunction without acute infarction or tissue injury. Therefore, ruling out the other options. E is correct in a way but it's broad. So it's better if you specify that there's no infarctional injury. And more specifically that T I A is actually most of them resolve within an hour even though they can last up to 24 hours. So next question, a two month old baby is admitted into hospital with symptoms of meningitis. A lumber puncture is performed and CSF culture reveals the caused hip organism to be listeria monocytogenes. What were the most likely lumber puncture results? So I just have a read of those yourself. Okay. So be is the correct answer. So B are the results you'd get from a lumber puncture with a patient who has bacterial meningitis since listeria is bacteria. Um So a would be the lumber puncture results you get from viral meningitis. See a normal lumbar puncture results. D this is a kind of pitch you'd get if somebody had TB um and E R fungal meningitis number bunch results. So question three, a patient suffers a stroke and presents to the E D with the following signs and symptoms. So they have contralateral hemi praecis and sensory loss of the upper limbs and trunk. More so than the lower limbs. They also have contralateral. Oh, don't go back. Sorry. They also have contralateral homonymous hemianopia and aphasia. So, based off of these signs and symptoms, what's the most likely location of the stroke? So, the A C A, the M C A, the PCA, the posterior inferior cerebellar cerebellar artery or the anterior inferior cerebellar artery. Okay, so well done to whoever put B. So the middle cerebral artery is correct. Um It's not only because the middle cerebral artery is most likely site of the stroke. Um due to the fact that it's a direct continuation of the internal carotid artery, which is one of the main blood supplies of the brain if you can remember back to the circle of Willis diagram. Um But also the M C A supplies both blockers and Wanaka varia. Hence a symptom of aphasia, as well as the primary motor and premotor cortex for the upper limb and trunk. And it also supplies auditory cortex. Um So just to briefly go over the other options, uh the A C A supplies the prefrontal cortex as well as the primary motor and premotor cortex. But for the lower limbs more so than the up limbs. Therefore, stroke here would cause symptoms or contralateral hemiparesis and sensory loss of the lower limbs more than in the upper limbs. Um For see, the PCA supplies are acceptable low, which is responsible for vision. So, a stroke, hair will cause contralateral homonymous hemianopia with macula sparing as well as visual agnosia. For D A stroke resulting from the posterior inferior cerebellar artery is also called lateral medullary syndrome syndrome or Wallenberg Syndrome. So, this produces symptoms of ipsilateral loss of pain and temperature on the face and contralateral loss of pain and temperature on the trunk and limbs as well as a taxi in stag hmas. Um for E A stroke resulting from the anterior inferior cerebellar artery is also known as lateral pontine syndrome. And it has symptoms similar to lateral medullary syndrome, but it also has ipsilateral facial paralysis and deafness. Okay. So, moving on. So a 56 year old man is involved in a high impact trauma and presents to the E D with confusion, nausea and worsening headache. He's taken two CT and your author of you the imaging and come up with a definitive treatment for his acute presentation was the definitive treatment for this case. And you have the CT on the right there. Uh So the options, clinical and radiological observation, craniotomy, craniectomy burr Holes on Mannitol. I think if you can, oh I think if you can show the CT image again. Now we probably could of course, uh CT okay. So the answer is see. So a decompressive um craniectomy would actually be the correct answer and you follow this up with ICP monitoring. Um This is because the CT actually show the subdural hemorrhage. Um an acute one because the blood is white, a chronic subdural will show black blood. And unlike with an extradural hemorrhage, a subdural hemorrhage crosses the suture lines. And therefore, it has the capacity to cause mass effect and midline shift from the rising intracranial pressure. Um And when I see P rises, decompressions needed and if this were the chronic subdural, so if you saw black blood definitive management would be with burn holes. But since this is an acute um presentation, the definitive management is a craniectomy. Um And the reason it's not be a craniotomy is because in a craniotomy, the portion of the skull is removed and the hematoma is evacuated and then the portion of the skull that was removed is immediately replaced. Um But in a craniectomy, the portion of the skull removed isn't immediately replaced and it can be kept out of the skull usually in the abdominal cavity. Um Whilst ICP monitoring takes place to ensure that I C P levels don't creep back up. Oh, um I don't know if we go back quickly. Um A is also incorrect because it's not definitive management plan and it's done if the hemorrhage is small and instantly found or asymptomatic and isn't causing neurological deficits or mass effect. E is also incorrect. Um because Mannitol is just not a definitive management plan. Um And in a scenario like this is just used as a short term measure to decrease ICP. Okay. So question five, a 45 year old man was involved in a pub fight and falls over backwards, hitting his head on the pavement upon arrival to the E D. Following an 80 assessment, you order head ct whilst waiting for the CT, take a close look at his face based off of what you see to get ahead. You think about the possible locations of the injury, which bones do you suspect trauma could have occurred too? So quickly, look at the options. So could trauma have occurred to the frontal, temporal price for bones, the frontal temporal zygomatic bones, nasal ethmoid or the bomber, temporal zygomatic or mandibular, frontal, temporal or acceptable. And then we'll go back to um the image if you'd like. So that's showing huma tim tim panel, which is blood behind the eardrum, the battle signs. So, bruising behind the ear and recognize which is bruising around eyes. Essentially, he said the options again, okay. So um the image essentially shows signs characteristic of a base of skull fracture. Um therefore, there are certain bones you can suspect that make up the base of the skull, that you might think a fracture could have occurred in. Um So the bones of the skull base include the frontal ethmoidal sphenoid, a little temporal and acceptable bones. Therefore, is the only option with all three of those bones listed as being part of the skull base. So he is a correct answer. So, congratulations who have got e and for reference, 70% of school based fractures occur in the anterior fossil, 20% in the middle, central school base and 5% in the middle and posterior fossil. So the next learning objective. So the question, a man suffers a blow to the head and loses consciousness. He regains consciousness and is convinced to go to the hospital where you meet him, he complains of headaches and shortly after loses consciousness again, what type of imaging do you request to help confirm a diagnosis of an extradural hematoma to an MRI A CT noncontrast, an X ray, a CT with contrast or a bone scan. Okay. So the answer is b um So when you're looking for an extra dural subdural or subarachnoid hemorrhage, in particular, you'd want a CT head image. And the reason you do a non contrasted CT is because they're very good at depicting um is because non contrasting CTS. Um uh Well, you essentially use them when you don't need contrast. So things you need contract just for our things like capitate ing lesion's. So um okay. Well, I won't say too much because I'll give away the next question, but acute blood has no capsule or cavity. So it's just blood in a localized area. So contrast would not provide any benefit here. Um A an MRI this is better at looking at soft tissue. So if you're looking for, I don't know spinal cord compression, for example, and an X ray is better at looking at bones, but here we're just looking for blood. Um So an X ray won't be very helpful and a bone scan, um this is kind of the entire skeleton and it's used in situations um such as identifying metastatic spread of a primary tumor by showing Metz's darker spots on the scan. So next question, a woman presents to the hospital with fevers, headaches and focal neurological deficits. After bedside and blood investigations, you send her for imaging for a suspected intra cerebral abscess. What imaging is most likely done? So, a MRI BCT noncontrast, see X ray D CT with contrast or E bone scan. So D is a correct answer. CT with contrast because an abscess is localized collection of passed in a cavity. So the contrast here will really help to outline that. So next, a woman with known polycystic kidney disease, complaints of headaches and informed that this disease is linked with the potential to develop intracranial aneurysms particularly of the anterior communicating artery um which is specifically called a berry aneurysm. She undergoes imaging and the picture on the right is obtained. What kind of imaging has been performed here? So the options are MRI had a pet CT, the CT noncontrast had a CT intracranial angiogram and a CT contrast head. Okay. Yeah. So D is correct. This is a CT intracranial and angiogram. And if we go back. The purple arrow here um depicts the berry aneurysm of the A C A. And this is first line for um investigating intracranial and you aneurysms. So the next question, a woman's admitted hospital following a sudden and unprovoked seizure, she has no significant past medical history or history of seizures. What's the first line investigative imaging done? An MRI A CT, an X ray, a CT angiogram or pet CT? Okay. So the answer is a an MRI. So MRI head is the first line investigation for all unprovoked first time seizures. So question five name the radiological imaging from left to right. So I've been able uh labeled them 12 and three. Um and I'll flip to the next side. So you might do sorry, money to flip between. Okay. Yeah, I'm just going to show the options quickly and then um we'll flip back. Okay. Yeah. So see is correct. Um Let me go back and talk about them. So the middle image number two uh CT you can tell this from the bright white hyperdense skull um which is outlining the brain one in three of both MRI S T one. Um In T one sequence is fat is brighter and water is dark in 22 sequences, fat is bright and water is also bright. Um To help remember this use the I've forgotten what the word is, but essentially I remember it as World War Two. So water white into um So CSF is white and T to imaging and you can also look at the gray white matter. Um T one sequences will have grey matter being dark for the white matter, but T two sequences will, whether fluid attenuated or not will have white matter being darker than gray matter specifically. And um MRI had so next learning objective. So following neurosurgery, the patient may experience some deficits that they did not before and may require adjustments to their house to help them get around and help cope with their deficits. Who would you contact to help organize these adjustments? So, an occupational therapist and physiotherapist, a speech and language therapist, an advanced nurse practitioner or a neurologist. Yeah, that's correct. So the answer is a occupational therapist. So these people help find help, find ways to help patients' in their day to day life. Um such as provide equipment for their houses like rails and stairs. Um Well, physiotherapists, they help make exercise plans to improve patients' fitness levels and speech and language therapists can help with speech and swallowing problems, post surgery. So those would be wrong question too. Um Following brain surgery or any kind of depressed goal fracture. A person is at risk of developing seizures during a seizure. What should you not do? A cushion? The patient's head, be turn their head to one side or the person onto their side to help with breathing, see, move items that may cause injury to the patient d stay with the person until they're fully recovered or e restrain the person and hold them still. So, what should you not do? Yeah. Good. So, the answer's eat this one's pretty self explanatory. The first four things that you should do. Um, but essentially try not to restrain the patient, other things not to do with someone's having a seizure. Um, don't put anything in their mouths and don't try to give them anything to drink until they're fully recovered and don't move them unless they're in danger. So, yeah, again, pretty self explanatory. So question three, neuro behavioral disability, NBD can follow brain injury. Commonly, those of traumatic nature. NBD can have serious impacts on a person's decision making and, and capacity for social independence, which of the following is not a form of NBD. So a executive and attentional dysfunction be poor, insight, problems with awareness and social judgment. See labor, mood and altered emotional control, regression D problems, reading, writing and speaking, e problems with drive and motivation. Okay. Is this a bit of a tricky one? Um But yeah, day um what's mentioned indeed can be a side effect of neurosurgery and brain injury. It's not strictly classified um as features, it's not, yeah, it's not strictly classified as features as MBD. Um The other features listed are related mostly to higher cognitive function. So one form of NBTY as mentioned is aggressive behavior following brain injury to understand aggression and its impact on a patient's psychosocial outcomes after brain injury. A scale can be used to assess the severity of aggression, which scale can be used to do this. So, A the O A S M and our scale be curb 65 C wells D orbit or E faced. Okay. Well, the answer is a um the O A S M N R which stands for the overt aggression scale modified from neuro rehab, it'd neuro rehabilitation. Um So another scale that can be used as the O B S which is the overt behavior scale. So curb 65 you might have heard of is the 30 day mortality of pneumonia. Wells is the likelihood of a person having a DVT or PE the orbit school, assesses risk of major bleeding with anti coagulation in adult patient's who have atrial fibrillation and the faced score, assesses severity of non cystic fibrosis, bronchiectasis iss. So next, in some instances, brain injury can lead to mental health problems such as depression, anxiety, cognitive issues and problems with regulating behavior as with mental health problems without brain injury, this can result in stigma and further psychosocial problems through not seeking out the appropriate help. Many teams are involved in dealing with mental health problems arising from brain injury, which of the following healthcare professionals can help. So, clinical psychologist, neuropsychologist, neuropsychiatrist mental health crisis team or all of the above. So, e all of the above healthcare professionals can help. So clinical psychologists that professionals trained in a range of mental health issues and they'll have some understanding of brain injury. Um Neuropsychologists are trained as clinical psychologist and then they can go on to specialize into psychosocial cognitive, emotional and behavioral effects of brain injury. Um neuropsychiatrist, some MediQuip medically qualified doctors who have specialized to train in mental health. Um and they have a special interest in how diseases of the nervous system such as brain injuries can result and impact um mental health. And they'll have um expertise in dealing with dual diagnosis cases and mental health crisis. Team support people who might otherwise need to go to the hospital, but not necessarily a trained in brain injury in depth, but they can recognize serious and dangerous mental health presentations in which admission to hospital might be wise. So the next learning objective, which is the last one, so name each of the paranasal site sinuses. So we've got them highlighted here. 123 and four. Um I'll go to the options and then we'll flag back. So here are the options and then to go back. So the answer is e so you have one is the frontal sinus too, is the ethmoid sinus. Three is a sphenoid sinus and four is a mix salary sinus. So 123 and four. Um and essentially you can get an inflammation of these spaces um called sinusitis. So, inflammation, um information of the sinuses can be caused by infection particularly following an upper respiratory tract infection. Um allergies like hay fever um with allergic rhinitis or obstruction of drainage, for example, or due to a foreign body trauma or pull IPs. And it can also be caused by smoking and patient's with asthma more likely to suffer from sinusitis. So the next question at what vertebral level and rib level is the carina located. So that's this point here where the trickier bifurcate aches. So the rib and the level. Okay. Yeah, that's correct. So the answer's see, the trachea bifurcates into the left and right, main bronchus at the level of the sternal angle, also called the angle of Louis. And this is that rib too. And this also co aligns with the virtual level of T 4 to 5 and where they biff okay. Anna economically is called the carina, as we said. Um So this is quite significant because when you're intubating a patient to ventilate them, you want to make sure that the endotracheal tube stops just above the carina as if the endotracheal tube is push too deep and it goes down either the left or the right main bronchus who only ventilate one lung. Okay. So what is the name of this artery pointed out by the blue arrow? Let's have a look at the options. So the greater palantine artery littles area, the superior labor artery or labia artery, the anterior ethmoidal artery or the sphenopalatine artery. You want to have a look again, that's artery. These are the options. Okay. So the answer is this vino palantine artery, um and this is relevant for nosebleeds. So, nosebleeds can be classified as anterior or posterior. Anterior is far more common, um, especially in like little nose picking kids. Um And it usually originates from Kaisal backs plexus, which is located in little's area and littles areas, this little blue space here at the front of the nose. So that's when anterior nosebleed originates from um but posturing nosebleeds are from higher up this phenotype Allentown artery and they're much higher volume and can be stopped by cocaine paste in um in like medical practice. Um as it's a vasoconstrictor and this is usually occurring in like older population. So elderly people question for which nervous, the cricothyroid muscle innovated by. So the current laryngeal nerve, the vagus nerve, the superior laryngeal nerve, the phrenic nerve or the inferior laryngeal nerve. Yeah. So it is so all the muscles of the larynx are supplied by the recurrent laryngeal nerve, except the cricothyroid muscle, which is supplied by the superior laryngeal nerve. Um The phrenic nerve innovates the diaphragm. So it's not that the vagus nerve has various parasympathetic innovations on various vista in the body. Um Yeah. So large, your nerve damage or large your nerve palsy has some symptoms. So this could include difficulty speaking, difficulty swallowing or hoarseness and last but not least. What are the names of the tonsils? The diagram might be a bit small, but you have one tonsil that's quite big higher up here. And then you've got a set of two tonsils on either side and then beneath that, another set of two and then beneath that another larger one. So I've color coded a yellow, green, purple and blue and I'll go back in a second. Once you've had a read of these, there's a tonsils again in the colors I can go back again. So the correct answer is e so the top one is the pharyngeal to cancel, also called the adenoid um or the adenoids. And then below that, you have the tubal tonsils and below that, the palatine tonsils and below that lingual cancel. So these are the names of the tonsils and they form this ring, which is called Wall days ring. Um And it's important because the tonsils having a big role in protection from infections. And that's why people who have a tonsillectomy might experience a higher frequency of infections such as they might have more sore throats and more chest infections and people who still have their tonsils. Okay. So that was the last question. Um Thanks for listening. Hi. Thank you for coming to the original sessions and I've just uploaded the feedback form. So if you can fill them, that would be great. And you will be able to access all the recording and the slides if you can fill them in. And thank you for coming to the revision session. I'm gonna now end the session. Thank you. Oh, there's some questions. Um oops, yeah, I'm just gonna answer them now. Okay. Well, does that answer your question? Hopefully? Okay. Cool. Thank you. Thank you. Bye bye.