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Okay. Good morning, everyone. Sorry about my Internet trouble last time, but hopefully we'll be okay. Now, I've given you a link to a title called Ukraine Medical Students' 1 12, 22. Can everyone see the shared screen just indicating the chat? Yeah, great stuff. OK, so let's have a look at number one. These are all random radiology cases, and I'll go through, uh, the diagnosis in each case. Okay. This patient is presenting with a sudden headache. Would anyone like to have a go at looking at the scan and working out what's going on? Any thoughts? A sagittal, uh, CT scan. It's a It's an actual CT scan. Axle is a is a transverse cut through the body. Yeah. And is that, uh, hematoma and, uh, left upper side. Uh, sorry. Right. Upper side. So this is left. Yeah, this is right. Um, look at the slice numbers. Image number 13 out of 29. So tell me which image number you're referring to? I'm not sure. Are you able to scroll through the images at home? No, actually, because I'm I'm one phone, okay? No problem. No problem. OK, so let me let me walk you through this. So patient's got a headache. So the first thing I think about when I'm a radiologist is what could be a cause of a sudden headache. And a sudden headache could be caused by subarachnoid hemorrhage. It could be caused by an interest. Cerebral hemorrhage. It could be caused by trauma. But you would need a history of trauma and it could be due to say something like meningitis, Uh or, uh, something similar like that. Okay, so some sort of interest cerebral infection. So as we go through the images, I'll just start here. There's the nasal septum. There's the maxillary Antrim. There's the Psychosomatic Arch Just here. There's the Pterygoid lateral pterygoid plate medial pterygoid plate. There's the cerebellum, and there's the fourth ventricle and fourth ventricle has now got a cute blurt inside it. And I know it's acute blood because it has increased density. Okay, and there's blood around the basal cisterns. Okay, so the CSF has now become bloodstained round the Boesel systems around the ambient system and the so called cuatro germinal system, which comes around the back here. So there's the pre pontine system because it's in front of the bonds. And it's just full of this high attenuation material, which is acute blood blood then goes into the Sylvian Fissure on each side because the Sylvian fissure contains CSF. And we've got blood here in the Sofyan fishes in the inter hemispheric fissure. And then we've got blood in the posterior horns of both lateral ventricles. Okay. And don't forget, the CSF does communicate with the ventricles. Now, this is like the branches of a tree. Okay, it's wavy. It conforms to the contours of the gyri and the soul Sigh. So this is a subarachnoid hemorrhage. So in a subarachnoid hemorrhage, most subarachnoid hemorrhages occur from a rupture of an aneurysm, and the aneurysms are usually around the basal systems. First, in the case of trauma, which causes the subarachnoid hemorrhage, the usual site of the hemorrhage is around here. It's above the, um, level of the basal cisterns. Okay, now there's a bit more blood around here, and it looks to be expanded by something. And my hunch would be that this was caused by an aneurysm, maybe of the anterior communicating artery or the anterior cerebral artery, which comes from the circle of Willis. Now, nowadays, um, we can treat these fairly effectively now by doing endovascular coil treatment. So what happens is a neuro radiologist will go into the arterial system of the brain through a puncture site in the femoral artery, and they can deploy a coil to block off this aneurysm to stop it bleeding again. And that can be quite effective. But when I was a medical student, when I was in your position, um, the treatment for a subarachnoid hemorrhage due to an aneurysm was to do a craniotomy, uh, dissect through the brain and then get to the offending aneurysm and clip it off. And it was quite a, uh, an invasive procedure, really. But now, interventional neuroradiology can, uh, stop these aneurysms growing, and you can cause thrombosis of the aneurysm by putting a coil in. So that's the modern day treatment. So this is a very nice demonstration of a subarachnoid hemorrhage. Now, what do you think happens when the blood starts to organize anyone, uh, hazard A guess as to what might be going on in the basil systems. Maybe a day or two down the line? Yeah. Hydrocephalus. Yeah. So why'd you get hydrocephalus? So what Yeah. What happens is you get adhesions growing in the space between the midbrain, the ponds and the rest of the cerebral hemisphere. And eventually you get an organising reaction around the basal systems, and it blocks the flow of blood of sorry of CSF from the third ventricle to the fourth ventricle. Um, therefore, you get hydrocephalus. And does anyone know what the earliest sign of hydrocephalus is? Um, yeah, OK, Headache. Um, they've already got a headache, but the earliest radiological sign, Well, it's dilatations of the temporal horns of both lateral ventricles. Can you see that? Normally on that slice, you wouldn't see the lateral ventricles. So this is the earliest sign of hydrocephalus. Okay, so this patient has already got hydrocephalus following the bleed into the subarachnoid space. They've got hydrocephalus. And I know that because we've got enlargement of the temporal horn to the lateral ventricles. Now, if they've got hydrocephalus, why don't the ventricles here appear to be ballooned? Two reasons. Well, the first is it's very early, okay? And the second is it's got to overcome the pressure that's building up inside the brain. Okay, But the most important sign of hydrocephalus in the early stage is visibility of the temporal horns of both electro ventricles. Okay. Any questions on that? Yes, Doctor. Okay. Yeah, For like you said any reasons, Like, how do we confirm them? Should we do an angiogram? Yeah, that's right. So what happens is the radiologist who is reporting this, um, because they can see blood around the basal systems. They should be on high alert to look for an aneurysm. And then when you get up to the area here, it looks like there might be an aneurysm. Okay. With blood surrounding it. And the patient needs a CT angiogram. So what we do is we then put the patient through the scan er again, we give them contrast, and we do an arterial phase through the brain, and that should light up. Uh, and then the patient goes over to a neuro center, and an interventional neuroradiologist will, uh, do ephemeral arterial puncture. They put a catheter into the arch of the aorta, then into one of the carotid vessels. They then deposit the, um, the catheter through the internal carotid artery into the circle of Willis. Then they put another fine ball catheter, and they follow where the aneurysm is, and then just block it so that it doesn't cause a rebleed. You can't do anything about the blood that's already there. But what you can do is you can stop this aneurysm re bleeding. And that's the mainstay of treatment. Is everyone clear on that? Yeah. Thank you. OK, no problem. So let's have a look at number two now. Number two is a patient with right Alliot faucet pain. OK, bit of anatomy for you. What's this? That's the A sending aorta. There's the descending aorta. Yeah, there's the left. A truth. There's the right atrium. This is gonna be the right ventricular outflow tract, which becomes the right ventricle. There's the liver. There's a small pleural effusion here. Small pleural effusion here. If I put that onto lunk windows, I can see lots of eight electricity cysts at both ling basis. So what that usually means is that there's under ventilation going on in the lung basis, and that could be due to a number of reasons. What's the commonest reason why? Simply might under ventilate the lung basis, pull stop gallstone postop surgery. Yeah, yeah, absolutely. Yeah. Sorry. A miss surgery postoperative surgery? Absolutely. Um, so they are in pain, so they don't breathe in quite as much as they should do. Um, yeah. So, uh, Depression of the C n s. Yeah. Uh, diaphragmatic, uh, injury or attorney? Yeah. Or intra abdominal pathology can cause irritation on the diaphragm or just the pain of any abdominal pathology can cause hyperventilation. Okay, so it's one of those markers that tell you that might be a problem in the abdomen. So I'm going to put this up next to the Corona will slice just here, and we're going to go through. I'll show you some anatomy. There's the portal vein. There's the plastic vein which drains into the ivc, which drains into the right atrium. Who is the RBC? There's the aorta. Can you all see how radiology beautifully demonstrates the anatomy in Living Patient's? Yeah, So we can. We can see anatomy exquisitely because we can see in Axial Corona Low sagittal slice is okay, so let's go down. There's the left liver lobe segments two and three. There's the core debt load, which is Segment one and all the other numbers up to eight. Uh, the right left lobe. There's the descending aorta in the thorax. There's the esophagus. There's the ivc. There's the spleen. There's the stomach. That's the cool bladder. This is a normal goal. Butter, But don't forget. CT can't exclude gallstones. We need an ultrasound for that. There's the right kidney. There's this structure that looks like a wishbone with the adrenal gland. And on the other side there's another wishbone, which is the left adrenal gland, so you can see them here. There's one adrenal gland and they're they're literally just like two leaves. European Doctor. Where's the adrenal gland? Sorry, I was distracted from it. Just here. You can see it there. Yeah, thank you. A bit higher up. You can sit the there's the right kidney. There's the left kidney. Hopefully, you can all do this at home with the, uh, link I've given you. Um, here's the superior muse. Enteric artery. There's the superior music Terek vein. There's the descending aorta. There's the Ivc. And then there's a structure joining the ivc to the left kidney. Does anyone know what that is? It's draining blood from the left kidney to the renal vein. It's the left renal vein. Yeah, and the left renal vein always goes underneath the superior muse enteric artery. Let me explain. So there's the superior mesenteric artery, and there's the left renal vein just there. So there's a lot a renal vein here. Laugh, renal vein. There there's the superior muse. Enteric artery. A little higher. We've got the celiac axis just the since Ilich access goes straight out the sm a or superior mesenteric artery goes down. And then, uh, sorry out and then down like that. So is the superior mesenteric artery. And I always look at the superior mesenteric artery because, um, if it's got thrombus in that can sometimes indicate that the patient has got pain because of mesenteric angina. Okay, so abdominal pain can be quite tricky to figure out, but CT can be very revealing. And it can tell you quite a lot about the patient's, um uh, the cause of the patient's pain. Okay, so as we go down, we can see transfers. Colon, she's here, which is here. Okay, Transverse colon. And this patient's got right. I'll out of foster pain. So we've got the ascending colon here. There's the ascending colon and can you all see a bit of fluid here. The flu is here. And can you see that the fat is of high attenuation? So it's not as pristine as the fat you see else were so mesenteric fat has the same density as fat elsewhere. Okay, but the fat around the tip of the cecum is of high attenuation. And we've now got a fluid collection and the fluid collection has got pockets of gas. If I want to, just make sure it's gas. I put it on two lung windows. And sure enough, there are pockets of gas that's in the bow. But this is outside the bowel. And then I've got something here which is of high attenuation. So let's have them to look at that. So this thing here is here on the Corona low and here on the sagittal. Okay, there says there it is here, and there's the terminal ileum going through the ileocecal valve. So this is the terminal ileum where my arrow is, and that looks okay. It looks a little bit squashed. Maybe, but it otherwise looks okay. So what could possibly cause a fluid collection with gas in around the tip of the cecum with what looks like a stone. Very common, not gallstone alias. Remember, the stone is lying outside of the cecum. It's a very, very common condition. It starts off with umbilical pain radiating to the right Appendix. Appendix? Yeah, it's appendicolith that has obstructed the appendix. The appendix has burst to give an abscess, and the abscess has grown around the Appendicolith. So this is a perforated appendicitis leading to an appendix abscess. Okay, and you can see all this inflammatory change that goes on in the in the abdomen. So So when somebody's got appendicitis, it does give the most intense inflammatory change. And that's why patient's get signs of puritanism. So you put your hand on the patient's to me, you take the hand off and then you get this so called rebound tenderness, and that's because you've got inflammation within the peritoneal cavity. So this patient had appendicitis, and then the only other thing that's important for the radiologist. We obviously look at everything, But once we've seen appendicitis, we look on linguine does just to make sure there's no free gas in the abdomen, and the other thing we look for is any abnormality in the liver because as you saw on Tuesday. Any sepsis in the abdomen can lead to liver abscess is because most sepsis will be drained by the mesenteric veins. Okay, so this is a patient who's got appendicitis. They've got high prostatic changes, uh, in both lower lobes, and they've had a localized perforation. Okay, So in most situations, if not all, move the offending, uh, inflamed appendix and to try to sterilize the area concerned. Okay. Any questions about that case? I hope you can all scroll through these at home. Is everyone finding that straightforward? Yeah. Great stuff. Okay. Yeah. Thank you. Even if you can't do it now, you can do it at a later date, and you've got all the answers. So, uh, these these resources are for you guys and, uh, take full advantage of them. Okay. What have we got? Number three. So I'm going to put these side by side. Let's take a look at the chest X ray first. What does the chest X ray show? So this is a patient who? I don't know whether you can see this. Very well. Let me put onto one screen. We've got gas in the soft tissues here. who's got a thin layer of parietal cloroxed. And this is a case of pneumomediastinum. But can you also see? You can see both sides of the diaphragm just here. Now, this is really, really, really, really subtle. Okay, So my thought as a radiologist is that this patient's probably got pneumoperitoneum, and they've got a new Emmy to start them. So let's have a look at mm. These two here. So you see gas outlining the by road gland just here. And we've got gas outlining the great vessels. The trachea got gas in the subcutaneous tissue. There's the esophagus, beautifully demonstrated by this pneumomediastinum. There's the famous gland, which has been stripped off the mediastinum by the gas. There's the main pulmonary trunk main pulmonary otta on the right palm riata on the left. Left main bronchus left. Upper lobe bronchus left. Lower lobe bronchus Writer below bronchus middle a bronchus. Lower lobe broncos. Sorry. That's the middle layer. Broncos. Rebecca. Pardon. Um, this is the upper lobe broncos, and there's the low low bronchus just here. But all of this gas is dissecting through the mediastinum and it's called a pneumomediastinum. All the gas here. Now you can also see there is gas in the liver and it's branching. Okay, the gas is branching like a tree, so I want somebody to tell me where that gas is. You've got one of two choices. It's either in the biliary tree or the portal. Venous. Yeah, portal Venous system. Well done. So Claudia's got it right. The portal venous system and the reason I know it's definitely in the portal venous system is it's going right out into the periphery just here. And if it was biliary tract gas, it would be more prominent centrally, and we wouldn't really see it in the periphery. So this is definitely portal venous gas, and we've got a whole load of gas going into the wall of the stomach into the peritoneal cavity, which we saw as gas under the diaphragm on the chest X ray. We've got gas in the retroperitoneum, so it's going around the kidney, and there's basically gas pretty much everywhere. So this is retroperitoneal gas. This is gas. In the peritoneal cavity, there's the transverse colon. There is gas in the wall of stomach. There's gas in the retro proscenium, and we've got portal venous gas and it's a It's a very interesting story. This This was a young man who was fit and well, and he I was having an endoscopy. And then he developed certain pain, and that's because he had a distal esophageal perforation. And the gas in the esophagus comes out into the space around the esophagus, in the mediastinum. It also goes into the wall of the esophagus. Okay, so presumably the gas used during endoscopy dissected through the wall of the esophagus and into the wall of the stomach. And whenever you get gas in the mediastinum, it always communicates with the, um the tissues above social emphysema and the tissues below, which is the retroperitoneum. Okay. And one of the other, uh, possibilities is that the second past the Judy Lem was perforated, and that can produce new mo retroperitoneum and pneumoperitoneum. Okay, um, and the only way gas is going to be resolved when it's in the wall of any of the hollow viscera is what can anyone work out? What's happened? Where is the gas gone from the wall of these hollow viscera it's been it's been resolved via the mesenteric veins. And where do the mesenteric veins go into the portal vein of the liver. Yeah. So this patient, in spite of it looking fairly horrendous, did very well. Uh, so he recovered after about two days. Um, but he had quite marked, um, portal venous gas and, uh, PNEUMOMEDIASTINUM and pneumatosis iss. Okay, so that was a complication of endoscopy and it and it sometimes happens. Okay, Number four, I might have to carry these on to another week. Uh, because we're only about a third of the way through. No, never mind, but this is a chest X ray showing a patient who's got, uh, anything. This is a patient who presents with chest pain. Can anyone tell me what's going on here? Left lung? Yeah. What's in the left lung? So here is the left. Main bronchus is obstructive. Yeah, No pneumothorax. So Abdullah's got it right. It's left sided pneumothorax. I'll just show you a bit of anatomy. There's the aortic knuckle. There's the pulmonary trunk down here. Left main pulmonary artery, left ventricle. Right atrium. There's the right hilum. There's the left hilum, and you can see all the lung markings going right out to the periphery. But on the left, side, and I'm gonna zoom this up for you. What can you see? The There is no long markings. Yeah, there's no lung markings here. And that's the cortex of the third rib. There's the upper cortex. There's the lower cortex. There's the cortex of the fourth rib. Uh, okay. And if that's the cortex of the fourth rib, what's that? Is that the pleura? Uh, yeah, it's the visceral pleura of the lung. So it's the lung edge. But the other sign that this is a pneumothorax is that we've got no blood vessels in this space here. So we've got a paucity or absence of blood vessels here. So this patient has got a left sided pneumothorax. Now, can you see how difficult that is to see? But when you see an X ray of a patient who's got left sided chest pain and breathing difficulties, the first thing that should go through your mind is is this a pneumothorax? And then you'll actively start looking for the signs of a pneumothorax, which is the lung edge, okay. And the absence of lung markings in this vicinity and this patient looks as if they've got a normal chest X ray. But in fact, they've got a left. A prickle pneumothorax and new math Oris ease in the erect position will collect in the conclusions. All happy with that. Look, I have a question. Is the patient is a smoker? Because in the Haley, um, I see, like calcific. Uh, please. So these, uh, these high density dots are blood vessels going towards you on the x ray? Okay, these are blood vessels going left and right. But these are blood vessels coming towards you, so they look a bit denser because there's more blood vessel for the x ray to go through before it hits the the plate. Yeah. So that's what those, uh, those are That's completely normal. The patient isn't a smoker, although smoking can be associated with out for eczema, which could be associated with pneumothorax. So this is a spontaneous pneumothorax tends to occur in tall people, males more than females and as a recurrence rate of about 20%. Okay, Bush, You may also get pneumothorax in asthmatics in patient's on ventilators. Patient's who've recently had, uh, chest injury. Okay, all happy with us. You want the link for the X rays here? we go. Okay. Let's have a look at number five. Okay. This is a, uh, an elderly male patient who has complained of abdominal pain and vomiting. Any thoughts? Dilated small bubbles. So Excellent. Okay. And why is it small bell? Because it's placed in the middle of the central. Yeah, it's centrally located, well done. And the diameter is competitively smaller to the large balls. Correct? Yes. So the diameter is no longer than 3.5 centimeters. In fact, it's probably less than 3.5 centimeters. It's probably about 2.5 centimeters. Uh, somebody's mentioned the valve. Really? Con event is so the valve really con event is go right the way across without interruption. Unlike astral folds, which are interrupted by the taenia coli. Okay, so that's another reason why this is a small bell. And the other thing is, I can't see any gas in the large bell. Okay, there's a bit of fecal residue in the rectum, but I can't really see anything that looks like a large bell. Okay, so let's have a look at the CT. Oh, not that one. Um, that one. Now, interestingly, this elderly patient has got gas in the biliary tree I can see here. So unlike the gas in the portal venous system, this guess is in a tube which is a bit, uh, wider in diameter. And it doesn't go right out to the periphery like the portal vein does. So this is in the biliary tree. Now, whenever you see small bowel delectation and gas in the biliary tree, we often think, Could this be gallstone alias? But don't forget in the elderly, quite often they have a very laxed sphincter of oddi and that allows gas into the into biliary tree. Okay, so it may or may not be gallstone Eylea, So we'll River River reserve judgment on that. Okay, so let's have a look see what's going on here. So there's gas in the biliary tree. There's a bit of fluid in the abdomen. This is acidic fluid. It is around the spleen. Also, here is the heart. There's the aorta. There's the stomach. Just here there's a nasogastric tube, which is going from the esophagus into the stomach. And then we've got dilated small bowel, and we can see the valve. Really, Con event is going right the way across the bowel. We've got kidneys either side. Here. We've got small cysts in the kidneys, which is quite normal as you get older, and there's the large bowel, which doesn't have very much gas in it. There's the descending colon, which doesn't have very much gas in it, and we can see a change of caliber of the small bowel. So it's dilated here, and then you can sit swinging round into the groin. And where's the dilated looper bowel? Here. Now what do you think the diagnosis is? What is the cause of this patient's small bowel obstruction? Sit, Permeated? Yeah, it's a hernia. And where's the hernia in Gatlinburg? Uh, it could be in the inguinal. Or it could be. Yeah, it could be ephemeral. Yeah. Okay, now this is a male patient, and femoral hernias tend to be in female patient's ratio of second to one. Now, this is unusual. If this is a femoral hernia for a male, um, and statistically it's more likely to be an inguinal hernia. But I want to just show you something. What is that blood vessel here on the left hand side? Illia. It's the femoral artery, and there's the femoral vein. Yeah. So the vein is medial to the femoral artery. Femoral vein. Femoral artery, femoral artery. Oh, what do you think about that Femoral vein looks normal. Normal shape. Then it looks a bit squashed. Yes, impressed. So why is it squashed? Because there's a bowel loop, because there's a bowel loop in the femoral canal. So the femoral canal is very small, and it conveys the femoral artery, the femoral vein and the femoral nerve. So if you have another structure going through that very narrow canal, what's that going to do to the femoral vein? It's going to squash it, isn't it? So therefore, this is ephemeral hernia, okay? And the other reason why it's a femoral hernia is the vast majority of inguinal hernias will be medial to the pubic tubercle, which is just here. So this is a femoral hernia causing small bowel obstruction. Okay, this is a urinary catheter bag. Okay, But this patient has got a femoral hernia, causes small bowel obstruction, and I'm fairly confident that this is a femoral hernia because it is squashing the femoral vein, which also has to go through this very narrow canal. If it was an inguinal hernia. The femoral vein would look like that. Yeah, um, there isn't a coronal view, unfortunately, and I can't reconstruct it on this, um, image. But I'll tell you what I'll do. I will get you a coronal view for the next time. Okay, Uh, a, uh, sagittal view. So you can see for yourself. Is that okay? I'll make a note of doing that. Absolutely. Okay. No problem. So, uh, is this the sort of teaching you like? Yeah. You can scroll through the images. You can see it clearly. Um, I can go through all the images with you. Is it better than a didactic lecture? It's better this way. Thank you. It's the best we can get. Thank you. Okay, Number six. Let's have a look. So this is a patient who has presented with a coma. Okay, what do you think this might be on the CT scan? Is that a cyst? It's not assist. It's It's actually an ET tube tube. Well, actually, it's a nas. Oh, tricky. Well tube. So it's going through the nose, says tubes going through the nostril, and it's then going into the trachea. Okay, But we're not watching it for that. That's just because the patient is comatose and they've been intubated. So they've got fluid in the maxillary Antrim on the left and on the right. We've got the ponds full theatrical cerebella hemispheres, temporal lobe on the right, lots of gas. So the patient may have sinusitis, um, in those maxillary Sinuses and the patient had an old infarct on the right hand side. And in fact, it's more than just an old infarct. If I look a bit more carefully at this, there's been a craniotomy. So maybe the patient's had some form of surgery on the right hand side, which has left the brain like this. Now most radiologists would have to look at previous films to know what's going on here. Okay, because this all could be post surgical change if, for example, the patient's had a tumor removed or they've had evacuation of a blood clot before. Okay, so there's the craniotomy you can just see here craniotomy. So previous surgery. But on the other side, what have we got? Subdural hematoma. Mia. And is it acute or chronic? A cute cute. It's a cute because it's high density. Yeah, high density. And what's happened to the lateral ventricle on the left hand side? Shifted? Yes, we've got medicine will shift and squashing of that ventricle. So we've got raised intracranial pressure. And here's the fox. It's the brain has herniated underneath the fox, and we call that sub fall sign herniation. Okay? And those basil systems look a little bit more squashed than they would do, indicating that this patient is getting raised intracranial pressure. Okay, so this needs to be evacuated pretty quickly, and you can tell that this is a contra Q injury contract. You comes from the French, which means the other cut. Okay, so I'll just put it into the chapter contract you. There's the blow on the head, and it's caused the subdural hemorrhage here. And the subdural hemorrhage is almost always caused by damage to the bridging veins between the cerebral cortex and, um, the, uh, space above. Okay, in the level of the juror. So the subdural hematoma is often caused by these perforating veins being ruptured. Okay, so, Doctor, Sorry. Yes. Okay. In terms of management like you, should that patient be operated definitely. Right. Well, that that's a very, very, very good question. On the basis of the imaging alone, you would say absolutely. That patient should have that evacuated. They may have a craniotomy and maybe even a craniectomy, where they just relieve the pressure by taking, um, the inner and outer table and a skull flap away. Um, and that would relieve the pressure. Now, that's just on the imaging alone. But a lot of these patient's are very elderly, and the results of surgery are not very good. So the neurosurgeons might argue that, um although it looks as if it's operable, these patient's tend not to do very well. So, yes, you're right. It should be considered for an operation. But sometimes the patient doesn't get the operation. Do you understand what it means? Radiology is fairly clear, Kurt, but clinically, there are more complicating issues. Yeah, Yeah. Thank you, Doctor. It's wrong to subject somebody to an operation that is not going to be very successful. Now, I've gone through six out of 14 cases. Um, but all these cases are very typical of a radiologists night on call. So emergency on call. As a radiologist, we see all of these cases, which means that you do as well. So as junior doctors, you're going to be seeing all of these cases at various times through the evening and through the day and in the middle of the night. So the next time I go through this with you, um, I will start at number seven, and we'll do the last seven. Now, is there another lecture after me? So anyone knows there another lecture after me? Very. Yeah. What? What time is that? Lectured. You know, 10 o'clock is that Should do, actually. Is it 10 o'clock? Yes. And that's the next lecture is at 10 in half an hour. I got time, then to show the Corona like reconstruction of that femoral hernia. Sure, Sure. Okay. I'll do that for you. Just bear with me. I need to find it first. Um, it's on. It's on a different database, but it's worth seeing because you can see these things exquisitely. I hope. I hope you like the cases on packs been gives you an opportunity to scroll through the cases at your own time. Can you all see that? Yes, Doctor. Okay, so this is the same case portal. Venous gas. Uh, sorry. Biliary. tract gas. This is due to a lack sphincter of oddi rather than anything else. Where's the small bowel delectation? And as we go further down, we can see the squashing of that femoral vein because this is a femoral hernia. So it's exactly the same case that I've shown you in Paxman. What I'm going to do now is I'm going to do that. The beach ball of doom. That just means it's thinking about it. Don't worry, I just need to be patient signal. There you go. And can you see this femoral hernia here? So it's in the femoral canal. There's the femoral vein. There's the femoral artery, okay? And it's now going into This is the bowel loop that's coming out because it's obviously smaller and the bowel loop that's going in is this one here. Okay, so the obstruction occurs proximal. Sorry, the Dilatation occurs proximal to the obstruction, which is here, and the loop that comes out is here. And then we've got another looper bowel, which is dilated, so it's absolutely typical of ephemeral hernia, and if you wanted to have a look at it in the sagittal plane, you can do that And so let's get the correct side. There it is. There's the femoral hernia, and there's the point of obstruction. Beautifully demonstrated. Okay, so that's a femoral hernia in, uh, sagittal and Corona. All, um, reconstructions. So I hope you found that useful. And thanks very much for your attention. I hope everything's safe for you in Ukraine today. And, um, please keep safe, and I'll see you next time, which I think is next Thursday. Thank you, Doctor. Thank you, Doctor. Thank you so much. My pleasure. Thank you, everyone for attending and engaging. Please do fill up the feedback form and the next cetera is at 10 a.m. u k. Time. Thank you, guys. Thank you. Thanks so much. Have a nice day.