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It's a report. Yeah, that's fine. Okay. Good morning, everyone. I've just posted a link to the pack spin cases, these the interactive cases that you can scroll through. But I'm going to start first of all by going through the normal brain just to give you some essential anatomy, because this is relevant to, uh, discussion about what happens during head trauma. Stay here is the normal brain. There's the orbits. This region here is, uh, in the, uh, stupid stellar region. This is above the cribriform plate. So it's the frontal lobe just above the cribriform plate. These are the temporary parietal lobes, and this is the occipital lobe. This is the Quadra Germinal system, which is passed the basal system network. And let's go through this. So here's the frame in Magnum, there's the spinal cord, there's the CSF, and we're going to go from the base right up to the top of these. The massacre muscles, there's the cerebellum, does the medulla oblongata. There's the ponds and the ponds is latin for bridge. And it bridges the medulla oblongata, uh, with the rest of the brain. So that's what it means. Ponds. Cerebellar Hemisphere, Right, left the full fun trickle here is the S F in the pre pond system. Upon times it's coming to the pond. Yeah, there's the temporal lobe. Timber lobe is the Quadra germinal system. There's a super seller system. Just just appear There's the pre pump time system. This area of reduced attenuation Here is the Sylvian fissure I've seen in bed Sylvian Fissure A bit higher er and in the Sylvian Fissure runs the middle cerebral artery first. Uh huh. It's like a third ventricle, so it should be no, uh, wider than that. These are the lateral ventricles. There's the posterior horn of the lateral ventricle. There's the anterior horn of the lateral ventricle. This is the basal ganglia. This is the Lentiform nucleus, which comprises the pew attainment and the global pallidus. And a little down we've got the thalamus. The internal capsule is a network of nerves in the parameter. All tracked that run in this direction. And this is a very, very important past, the brain, because this past, the brain can suffer hypertensive strokes. Um, and in the case of trauma, anything that causes compression of this area will lead to significant parameter all disability as we go higher up these the lateral ventricles. A note. You can see the soul Cy the soles. I contained CSF and they are like valleys between the mountaintops, which are the gyre I This is called the Centrum Semiovale. So this is the white matter. The cortex is the gray matter and the Corona radiator. And there's the coming into the vertex of the skull and we've got frontal lobe and you see very nicely the jar reform pattern of the cerebral cortex. What's the difference between an MRI and a CT? Well, an MRI uses magnetic relative ins and magnetic resonance. Um, does not involve ionizing radiation, but this is a T two weighted image. This is a T one weighted image. The CSF on T two weighted image is high signal the CSF in to see one weighted images is of low signal. Here's a small meningioma, which you can nicely see on the MRI. This is another patient who's got a meningioma this time seen on CT. And this is a para fall sign. Meningioma the fox, uh, giving its name to para fall sign. So it's just to one side or other of the Fox Rim calcification and some mild, um, increased attenuation. When you give contrast in this situation, it would lighter. And we've got some so called vasal genic adama visa genic because it goes up to but doesn't involve the cortex of the brain. Yeah, this next slide is really important. Okay, so here we've got the brain. Here's the cortex. And here is the white matter of the brain. No, the surface just lining the brain. It's called the peer martyr. Okay. And the pier martyr is a very, very thin tissue overlying the cerebral cortex. Just here. Then we've got this layer here, which is the arachnoid, which is, uh, not as thin as the pier martyr, but it's much thinner than the other two layers. Okay. And the space beneath the arachnoid between the arachnoid and the peer martyr is the subarachnoid space. And so, if you were to have a subarachnoid blood, um, infiltration, it's going to involve this area of the brain. But it's also going to go into the salsas. I, which I showed you on the normal brain ct. Okay, because the sole Cy Although they contained vessels, they are also in the subretinal would space. Okay, so a subarachnoid blood, we'll give you this sort of appearance. Now, above and superficial to the arachnoid. We've got the juror, and the juror comprises both the outer and the inner layer. Okay? And the outer layer is stuck down to the inner layer. Except were it splits to form the venous Sinuses. And blood has to get out of the brain as well as getting into the brain. So we do need the venous Sinuses. This is a so called arachnoid granulations because it's the arachnoid layer that almost herniates into this, um, venous Sinus through the inner dural layer. Okay, this is an arachnoid granulations. Now, when you get a subdural bleed bleed, the blood is between the inner layer of the Jura martyr and the arachnoid just here. And when you get an extradural bleed, it's between the skull surface in a table and the outer layer of the Jura martyr. Now the juror martyr is bound to the bone at the sutures. Okay, so, um, when you get an extra dural bleed, it doesn't cross the suture because this combined layer is stuck down at the future. Okay, so it doesn't cross the suits and I'll explain, uh, in a bit more detail in the subsequent slides. This is Grey's Anatomy, which shows very nicely, um, the outer Jura martyr, the energy or a martyr which splits to form these, uh, venous Sinuses. And the subarachnoid layer is between here goes into so it follows that red line basically, wherever the blood vessels go, the, uh, extradural, uh, compartment is a potential space between the outer load up for your amata and the dinner table of the bone. So when you get an extradural hematoma, it's almost always associated with skull fracture. And it's almost always associated with a disruption of a branch artery of the middle meningeal artery. And you get this build up of blood, which pushes the Jura martyr, the subdural space, the arachnoid martyr, the pier martyr and the brain away from the blood. Now you can see here that it can strip the juror martyr off the skull right the way onto the other side, and it's possible to have bilateral extradural hematoma as a subdural hematoma. On the other hand is where you get bridging veins which go through the Jura martyr and towards the arachnoid layer. And if they rupture, as they might do in patient's who've got atrophy. So the brain shrinks and these blood vessels have to stretch to go through that space, it means that they are more susceptible to trauma and elderly. Patient's or patient's with cerebral atrophy, secondary to alcohol are prone to getting subdural. Hemorrhage is now because the juror is still attached to the skill and still attached to the sutures. The blood in the subdural space will cross the suture. And again, I'll show you that in a in a lot more detail. So when you look at the CT of the brain, I've drawn this in. This is where you got the Corona suture. This is where you got the landlord suture. And this red line denotes the juror and the juror condensers in the midline to form the fox. Okay, there's the landlord suture, and you can see these on CT when you look at the bone windows. The Corona suture is very difficult to see in the temporal region, but the landlord suits. You can just see here not to be confused with a fracture. So whenever you look at anything, radiological things that tend to be bilateral, tend to be normal structures. Uh, unless, of course, you've got bilateral pathology, which in itself can happen in trauma. So you just need to watch out for that. Okay, So a little bit higher up there's the Corona lll sutures. You can just barely see the suture on the right. Let the left one is not very easy to see. There's the landlord suture, landlord suture. And when you get an extradural hematoma because the juror is bound at the future, any blurred that occurs between the juror and the skill vault stops at the future. So as it builds up, it produces this biconvex, or lens shape, and it tends not to cross the sutures. So an extradural huh? Hematoma or hemorrhage? Uh, don't forget the Americans. Call it epidural hemorrhage or hematoma. It's often with a skull fracture. It's almost always caused by trauma. I don't think I've ever seen a case where it's not been caused by trauma. Patient's typically have a lucid interval, so they appear to be, uh, fairly compos mentis, and then they tend to go off. Now. Going off just means that they become a bit confused. They lose the, uh, conscious station, uh, conscious, uh, state and the Glasgow coma scale score will plummet. It will go down to about 543. And it's almost always caused by damage to a branch of the middle meningeal artery. So blood accumulate in the biconvex space Strips off the juror from the school, as you can see here, and you get raised intracranial pressure. So here's an example. We've got, uh, and extradural hematoma. It's bounded posteriorly by the Corona suture. And in this schematic diagram, you can see that the juror stops at the suture just here. And the build up of blood in this space, uh, causes the brain to be squashed. Uh, excuse me. And this is associated with hemorrhage in the extradural space is, uh, particularly disturbing for patient's who've got this fracture. Excuse me? I'm just clearing my throat. I beg your pardon. So the fracture causes damage to the middle meningeal artery or one of each one of its branches got an extradural hemorrhage. It squashes the brain over, and it's limited by the brother searchers. So here's an example of an acute extradural hematoma. There's a small, um, cerebral confusion here and it's limited posteriorly by the, uh, Corona suture. Here's another example where the extradural hematoma is between the Corona and the lambdoid sutures just there. And every now and again you can see, uh, an extradural hematoma that crosses the future. Does anyone know in what situation and extradural hematoma can cross the future? Just put your answer in the chat. What situation would cause that hematoma to go beyond the future? And you can use some pressure. Um, more pressure. I suppose that's theoretically possible. But this is a really, really tight bond between the juror and the suture. Uh, multiple multiple impact, as in the same place. Well, the answer is that if you have a fracture through the suture yeah, so somebody's got it right. Uh, Taiwo Well done. So a fracture through the future causes the extradural to cross the suture line. But that's the only situation in which an extradural hematoma will cross the suture. Okay, so well done, Taiwo. And you can see it here. Nice lend shaped. But it's it's breaking the rule of crossing the suture. And this fracture is actually a depressed skull fracture. And it's a really, really dangerous thing, and it is a neurosurgical emergency. Now, before we get onto subdural hemorrhage, I just want to show you, um, in the I just posted that link the pack spin link. If you all open the pack spin links, have a look at number one and we'll go straight for the second Thumbnail over here. Just going to change my Internet. I think my internet's a bit weak at the moment, so I'm just going to change the Internet. Bow with me. Okay, that's much better. So what sort of hematoma is that? Anyone, Uh, extra? Yeah. Extradural rather than subdural. Yeah, well done. And you can see here. There's the Corona suture. There's the landlord suture. And if we put it side by side next to, um, the bone windows, what can we see? What can we see on those bone windows? What's that Sutro to, actually, Yeah, there's a fracture there, isn't there. And there's a fracture there too. There's a fracture there. And what else can you see about the blood in the extra Adderall space? What are these little areas of low attenuation? What's happening? It's gas. So get gas. Yeah, gas has got into the extra general space because of the fracture. So we've actually got a compound fracture. Okay, So gas must have got in through that fracture, so it becomes a compound fracture. Now, can you also see that this extradural hematoma has squashed the lateral ventricle on the right and it's pushing on going on the carbs collision. Sorry. Say that again. Uh, bowing of the corpus pollution? Yeah. So as well as, um, squashing the lateral ventricle, it's pushed it over beyond the midline. Okay. And that's what we call by, uh, call midline shift. So that patient has got raised Intracranial pressure. Okay, Look at the shift and the soul sigh on the right hand side. You don't see them very easily now because they've been squashed by the pressure of the extradural hematoma. Okay. And the salsa on the left. Still relatively normal. So that's one of the signs that this patient has got raised. Intracranial pressure. Now whenever whenever anyone's got an extradural hematoma, they need to have this evacuated really quickly. Okay? Because if you leave this for any length of time, patient's are likely to die very, very quickly. Okay, so it's a It's a really neurosurgical emergency. I'm going to have a look at, um uh, one A. And here's another one extradural hematoma limited by the lambdoid and Corona sutures. Okay, Now, uh, these are often associated with the fracture, so we just need to look for the fracture. Um, and put this on the bone windows. There's 651 images, so it may take a while to load. But have a look at the cases after this lecture at your lecture, Write down what the answers are and just have a really good look at these at these cases. But you don't always see the fracture. There's the there's the fracture in this case. Okay, so I'm going to go back to my PowerPoint presentation, and I'm going to talk about a subdural hemorrhage. So again, the red line represents the juror, and a subdural hemorrhage is where the hemorrhage is deep to the juror. And because the suture and the jurors are stuck together, the alert is free to move across the future because it's deep to the Jura. And this causes a, uh, concave, convex or crescent eric collection of blood. Uh, in the, uh, in the hemicrania Um okay. It's also limited by the fox, which has seen centrally just here and doesn't cross the midline. Don't forget, the juror splits to form the superior sagittal Sinus, which you can see here. So the key to an acute subdural hemorrhage is that it crosses the sutures and it looks concave. Oh, comvax. And that's because, uh, you get bleeding of the bridging veins. So here is a bridging vein which has disrupted it's beneath the juror. And so it's free to move across the suture line, which be somewhere here. It may or may not be associated with a fracture. And what happens is you get this wavy line but as well as, uh, this, um causing, uh, effacement of the sole site in the extradural hematoma. It does it also in the subdural. So, in other words, that that denotes raised intracranial pressure. So the source I are effaced because of this rising intracranial pressure. There's a little bit of midline shift now, unlike an extradural hematoma, the subdural hematoma, the patient's, uh, don't become quite as than, well, quite as quickly. Okay, but it's still a very serious thing that you need to consider and this is my very crude diagram to try and draw what we're seeing here. So the blood goes across the future and it's in a concave to convex for note. Also, that the blow to the patient's head was in the left frontal region. But the subdural hemorrhage is in the right. Uh, parieto parieto occipital region. Okay, now it's called a contra Q injury. And now somebody's asked me how to differentiate fracture and suture line in a child. Um, that's a very, very good question. Uh, sutures tend to be symmetrical. Um, but sutures and fractures can look very similar. So if in doubt, go and ask a radiologist. But always remember, sutures tend to be bilateral and symmetrical fractures tend to be, uh, unilateral. Okay, So what have we got here? We've got a CT brain. We've got a subdural hematoma here. Now, what do you think about midline shift? Has this shifted a lot? Yes. As well as the ventricle. Yeah. So we've got lots and lots of midline shift. That large ventricle has been defaced or squashed. And can you see that the brain, which should be on the left hand side as herniated underneath the folks to the right hand side. This is the patient's right. This is the patient's left. So the left side of the parade has herniated underneath the fox towards the right hand side. And that's called stub fall side herniation. Okay, I'm just going to put that in the chat. Uh, oops. I'll write this again. Sub full sign herniation. Okay. And this means that the patient is at risk of koning do you do to raise it to cranial pressure? Uh, okay. And you can see that there is blood and there is also an area of blackness, which is the CSF type of attenuation. Now, that means that the patient has probably had a chronic subdural, which is acutely bled. Okay. And that's why you can see this, uh, density, which is very similar to CSF. It isn't CSF. It's just, uh it's what we call a a subdural hygroma. So it's basically an old subdural collection. But in the old subdural collection, we've had an acute bleed. Worse, it's still very important to pick up because that patient could be treated with neurosurgery. Now, if we go back to the region of the basal systems we can see that the temporal horn of the lateral ventricle on the right hand side is dilated, and that's a sign of hydrocephalus. And the reason why the patient's got hydrocephalus is because the basal cisterns have been squashed by the pressure above. And if those basil systems get squashed, the aqueduct of Sylvia's get squashed, and that leads to hydrocephalus, so that patient's in real trouble unless they get urgently treated. Um, and the only treatment option here is for a burr hole and evacuation of the subdural hemorrhage. Okay, so it crosses the sutures. There's an acute and chronic element to it now. You can also get very subtle. Subdural hemorrhage is which occur along the fox, and because of the anatomy and because the folks lies medial to the blood, there's the folks. You get a straight line denoting the left side, and the wavy side on the right denotes the side of the subdural hemorrhage. So that may be the only evidence you've got of a some jewel hemorrhage just here, so it's usually due to a traumatic rupture of a bridging vein. The complicating factors are that patient's who have cerebral atrophy due to um, alcoholism or any other cause of cerebral atrophy. Usually the elderly, they're more prone to getting subdural hematomas. The developing hours, two weeks and are concave, convex. And that's because of the anatomy of the juror with respect to the future. So here is an acute subdural hematoma. Again, we've got sub full sign herniation. So the brain below the fox hernia toing to the other side. We've got squashing off the lateral ventricle, and we've got midline shift. Okay, so this just demonstrates how much more sensitive a T one weighted image could be because, uh, this patient has got a subdural hemorrhage, which is about two weeks old. Okay. And at about two weeks old, instead of being high density, the density can be very similar to that of brain. Okay, and it can be quite difficult to pick up. Sometimes you can just see here a hint that this patient's got a subdural collection. Once we give them contrast this, um, it's a bit more noticeable, but it's not until you do the MRI scan that you can see the subdural collection clearly and you can see it's coming down. Uh, separated from the midline of the fox. So this is an extra dural. This is a civic dural, and the other thing I want to tell you about is the rule of two weeks in the first two weeks, blood is dense. The second two weeks, blood is ice a dense, and the third two weeks blood is hypodense. So this is a patient who's got chronic bilateral subdural collections. So here are the subdural collections You're crossing the stooges low density, low density crossing the sutures. And this is a bilateral subdural collection. No, let's go back to the cases. And if we go to number two, open that one up. Uh, so number three I beg your pardon? So this patient has suffered trauma and you can actually see the subdural hemorrhage here. Subdural hemorrhage here. But can you also see blood going in between the gyre I in the sauce? I So this patient has got both subdural and subarachnoid hemorrhage, and I'll come onto the subarachnoid hemorrhage in a second. So subarachnoid blood, uh, the blood goes into the space between the gyri in the selsus. So this is like a crevice in an ice field. Say, if this is the icefield. There's the crevice, and the blood goes into that crevice or the sulcus, and you get this appearance. It's almost like the branches of a tree. Okay, so this is a typical subarachnoid hemorrhage, and a subarachnoid hemorrhage can be caused by trauma or by a rupture of, uh, an aneurysm. So this is where we've got, uh, sorry, that's my dog. I do apologize, And we've got blood in the basal systems Basal cisterns here. And you'll notice also that we've got the temporal horn dilatation in of the lateral ventricles, which means that the patient's got hydrocephalus and the blood is going in. The Sylvian Fissure blood in the third ventricle, blood in the inter hemispheric Fisher blood in the Soviet and Fisher. Here's another example of a subarachnoid hemorrhage which has been caused by an aneurysm. Okay, so it's either due to trauma or due to aneurysm. And the history will tell you which, um, you tend to get hematoma around an aneurysm. Um, so all these patient's need a CT angiogram just to make sure they don't have an aneurysm. But trauma tends to occur. The blood tends to occur above the level of the basal systems. Okay, so this is more subretinal would blood. So let's go on to case number four. Oh, sorry. Case three Bay. Does anyone know were this? Blood is So if I go to the slice above and the slice below, we lose it. So that implies it's spreading across the tentorium and that this is a subdural bleed. Okay, this is a subdural bleed now. I would not expect medical students to know that, and I would not expect junior doctors to know that. But it's the sort of thing that radiologists no. So we can tell you that this is subdural notice that the patient's had the blow on the left side. So they've got left orbital swelling and the contract you injury occurs over here on the opposite side. Okay. And that's very common in trauma contract. You injuries three. See? Take a look at this one. This is just two slides. Subdural hemorrhage. There's an associated fracture, OK, subject because it's crossing the future. Okay, We've also got a bit of a subdural collection on the right hand side as well, which is going up against the fox. But Okay, this is a patient who's got bilateral chronic subdurals. It crosses the sutures lowered attenuation. And there's been a re bleed into that into that subdural space. It was blood gathering posteriorly. So this is called an acute on chronic subdural case three e. This is a chronic subdural, which is causing quite a lot of midline shift. The basement of the actual vegetable and the face mint of the lateral ventricle is a sign that you've got raised intracranial pressure and you've got sub false sign herniation. Uh, with mid large shift. Uh, apologies about that I've got a lot a barking dog. Uh, I do apologize. I'm just gonna put it on mute for a second. Hi, everyone. It's Doctor Sharon Raymond here. In the meantime, if you don't mind filling in the feedback form, it just takes 1.5 to 2 minutes. We really need your feedback. Thank you. So so much apologies about that. I had a barking dog, which I had to, uh, sort it out. Um, so this is a subarachnoid hemorrhage. Case number four where we got blood in the basal systems. How'd you careful lists? Because what happens here is that the blood obstructs the flow of CSF ad causes hydrocephalus, and we've got an interest riebel hematoma, and this could be due to an aneurysm or trauma. In fact, it's more likely to be due to an aneurysm when you get blood around the basil systems. But you can also get it with trauma, so I just just go back to the Power point presentation. So PSA Bratton would blood it tends to go into the salt sigh and the gyre. I, uh these things here with the gray matter of the cortex, is the gray matter of the cortex. So the blood goes in between those spaces, and I just wanted to discuss one other type of injury, and this is the diffuse axonal injury. So this is my very last slide. Um, diffuse axonal injury is where you get a significant deceleration. Uh, so you may be traveling in a car, the car crashes, you decelerate, and there's a deceleration. Were the gray matter and the white matter separate. So you get a sheering of the white matter from the gray matter. So here's the white matter. Here there's the gray matter and the bridging veins between the gray and the white matter bleed because they get shared and this produces potential hemorrhages. So the potential hemorrhages are very subtle and very difficult to see. Okay, very subtle and very difficult to see if you can just see one there. But these patient's do really badly. Because although there's not much to see radiologically, they often have, uh, significant neurological deficit. So they are often in a coma, and they are very poorly indeed. And they do very badly. Sorry. I said that was the last one. This is the last one. Um, he's a depressed skull fracture. So when you get a head injury of this degree, you can actually see there's some subarachnoid blood. There's some interest. Cerebral, consitutional blood. What's this low attenuation here? Here. That's gas. It must be a compound fracture. And the compound fracture is allowing gas to go into the cranial cavity. And we've got lots of hemorrhage inside, and we've got soul Sal effacement so resonant Cranial pressure. This lady was kicked by a horse, uh, with a depressed skull fracture. Now, in spite of all of those changes, um, she did extremely well following surgery. OK, hemorrhage tends to settle down. There's a small subdural collection here. And this patient did very well indeed. Um, so that's that's the end of the lecture. I hope you find the cases on the packs been useful. Um, any questions on any of that? I'd be very happy to, uh, to take any a story about my dog barking. By the way, he's, uh yes, sir. I have heard about the particular spots. What are those? When we see the cities, this, uh, there's a particular, uh, sports like, Is that multiple? Uh, sorry. I can't I can't hear you very well. Can you? Uh, yes. When? When we see this city. Uh, one of the cases I've, uh, seen was a particular, uh, particular beverages. Yeah. Yeah. So it's, uh, either due to, like, multiple aneurysms or, uh, what could be the reasons of many? Okay, in in trauma in the case of trauma, um, this is diffuse external injuries. So it's the separation of the gray matter from the white matter. Okay, Um, and the bridging veins and arteries that link the gray and the white matter, they rupture, and they produce petite little hemorrhages. Potential hemorrhages. Okay. Yes, sir. And although it doesn't look very much radiologically. It is incredibly, uh, damaging to the patient and the patient's, um don't do don't do it all. Well, this is up to the radiologist to pick this up. I'm just showing you the extent of various types of injury to the brain. Um, but as long as you know the difference between extradural subdural and subarachnoid, uh, I think that's the main objective. And I just hope everyone can can understand that somebody said, could you please show us an arachnoid hemorrhage? Well, I don't recognize an arachnoid hemorrhage, because the arachnoid is a bit like a membrane, but I can show you a subarachnoid hemorrhage. Okay, Which of demonstrated, uh, both on the interactive cases and on Power point. So I think Is that what you meant? Uh, do you want me to show you one more time? How are we doing for time, By the way, you've got one minute. One minute. Okay, So the subarachnoid hemorrhage, there's subarachnoid hemorrhage, and there's, uh, an aneurysm which just cause the subarachnoid hemorrhage. There's a different patient subarachnoid hemorrhage. So it's going into the sauce I between the gyri and also random basil systems and it can also go into the ventricles. So you get intraventricular extension. Uh, and it's because the green line represents the arachnoid layer, and it's going Sorry. Actually, the green line is representing the Jura, but the arachnoid layer, which is not actually, um, drawn here, uh, gives you the PSA Bratton would space beneath it, which is where the blood goes. That's what it looks like. I hope that's, uh explained explained it, so thank you very much for your attention. Um, I'm so sorry about my dog barking. Uh, he wants to go out for a walk, and that's exactly what I'm going to do for him now. So I hope I hope everyone stays safe. And, um uh, see you next time. And thanks for your attention. Thank you so much. I'm just going to make one comment. It's, uh, Sharon Doctor Sharon Raymond again. Thank you so much for a fascinating, an informative lecture. As always, Mohammed has written in the chat. Could you teach us how to read MRI An X ray of head injury, step by step, So that will just be hopefully a project for a future lecture will bear that in mind. Of course you have no problem. Thank you.