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I will start minute or two I ever on. So welcome back to the second part of this new radiology webinar series, where over the next weeks to months will cover the approaches in common cases. In the most common radiology emerging modalities. You'll come across when you work in a hospital on my name's Kept Hanging on one of the trainees in South Yorkshire in the UK If you miss last week's introduction to Radiology than don't Worry will be a loaded to the mind of the website in the near future. So tonight I've got Doctor Cooler, who's one of the radiology registrars, and Sheffield, who will be took her, who would be teaching about CT, have interpretation. So this will cover a logical approach, and we'll also discuss some cases. A swell. There is a trap box. So when there is some audiences direction, please feel free to be involved by typing in on some will be able to see what you've written. Uh, please make sure you stay until the end because then you'll get a link to fill in some feedback so you can collect that all important certificate for your port. Four years on down some I'll 102 years. That's right. Yeah. Great Thanksgiving. So, yeah, I'm I'm Sam, um, one of the radiology train Easier. And Sheffield in the UK on several us to talk about CT head interpretation on just a bit about about scanning on dermatology itself. So just a brief outline what we'll go through today so we'll start out with just some. I have some objectives that we're going to go through to. Anatomy's and common conditions bit on. Had interpretation go through some cases at the end. You know, a brief took John betting and reporting. So by the end of the tour, hopefully your bill to I didn't fast minutes of a colon marked on CT head Describe some components of the meninges meningitis layers describes past the territory. That's magic. There is the brain identify through last for their vents on to see if he had depression into friendships with some of the beaches of hemorrhagic skin. Looks good, system background. So head trauma is the leading cause of death in people under 30 years of age. It's a very common cause of mortality is more common in males to three times more than females they may be related to some of these permanent factors, which are motor vehicle accident, sound, assault to leading cause and in the elderly of those you you've worked in a hospital setting or already appreciate that presentable. No morality patients come through with falls and interest to the head, requiring a CT has come to just anatomy to start up with. So see, they asked me at the brain and school is composed from the outside school. Bones on underlying suitors join the bones together, they follow the passage of the lobes, which named similar to suitors and bone mass. Um, that will come on to be interesting and then below school. And we have your and your muscle layer. It's the main bones that we can see here on the CT. On what? On the CT. Reconstruction of the skull. Let's see the frontal bone just at the front has at the back. We have been settled bone, have temporal bone, and inside we'll head on the left and right, and at the top you have to parietal bones, although we're tend to to it, it's just the parietal bone is a single entity, and these both these bones are joined by various suitors, which seem basically in the middle of these bone spaces. So we have our own or suture, which joints frontal there, too bright a bone Santa suit you, which joins the left and right sides of the price of it. And then we have a lot of dried soup. Just switch to an occipital bone to the process that is a squamous suited, which it joins the temporal boat to the parietal bonus. But, um, there are several of these but piece of the major ones to start up with. That's a basic level, and then the brain again. It's probably most of us all know. So it has three main compartments started with cerebrum or alternatively, known as a super tentorium. Bring Stan and the cerebellum. Also, uh, otherwise known is an impotent Oh, really? So these subdivided into their respects. Exceptions to the tentorium refers to the tentorium cerebella I, and this is just a side on Saturday with you of the brain, and you can see there's a 10 Torrey, um, cerebral I, which would divide our brain parenchyma from the cerebellum. I be super tentorial off the tentorium and infratentorial below the Sentoryu. And then we have the brain stem. Just composed three major structures, which is the mid brain, the bones in the middle. Okay, and and then the lobes of the brain. So the legs of the brain are again named after the bones that overlies Um so at the front, you have the frontal lobe. Then we have the parietal lobe, more posteriorly. Then we have a temporal lobe. That's sort of infralateral on the back. We have our except to lives as a broad statement. Well, no, the brain is more complex than this in reality, but generally the frontal lobe associate it personality contrast ically practice lobe with sensory motor sensation around your motor function temporal lobes with speech and memory on except a look with vision. And obviously there is a lot more complexity. But that's began a good basic understanding of what? The function of these separate lives. Uh huh. And then we have our brain stem. As you briefly mentioned composers, our mid brain at the top, our pants, which is the full care aspect in the middle and then on medulla. And each of these layers essentially be brain stem itself wasn't as a whole is our origin point for cranial nerve six. By the cranial nerves exit and go to their respective areas where they have their function. So three in the street for will exit the mid brain and go towards the eye where they have there various functions on movement. In my muscles, the bones cream this like to wait in the middle of a cream that's 90 12 as well as the respiratory and swallow centers should have to manage your layers, which we have starting from the skin at the very outside aspect. And then we have the brain on the in a very small space. In between that we have various layers starting up with school and school is composed of three different layers in itself and not the day goes on. They they are the outer table. On begin a table which are two areas. Two aspects it of the essentially counselors bone, and then we have a spongy layer in the middle, which is known as the diploic space. Below that we have are you're a matter which is in the blue, and this is actually two separate layers duramax that so often we learn your matter is one layer, but actually there's two sort of sub layers. One is not a periosteal outer layer on once in a meningeal a and then compared to your, um, onset, believe that we have our arachnoid matter in the gray. And these also have little outpouchings, which we concede here, which can intrude into the general space. And these are new nose Rockwood Granulations on. These are important because when we see these are CT head scan, sometimes that can mimic small areas of thrombus. But actually, sometimes these are all. All they are is just little arachnoid crime elations. So it's important not to miss take these apology and then believe that yeah, p amounts it. Severe matter is the innermost layer of just overlying the brain parenchyma. And as you can see, the difference here is that it's able to follow the sole side off the brain as well. So it's the only layer that follows. The invagination is a brain. So see, it's scalloping along the so called pattern, and it's the only lab that does that cause opposed to the more flat out of players. Now just vascular anatomy. So diagram asshole. This is representing our circle of Willis, So cycle it well. This is essentially composing of anterior circulation, which is fine from a parotid arteries. These two large arteries in the right on that side supply put on the anterior circulation to the front of the brain and are posterior circulation, which is from the basilar artery, which supplies prominently the brain stem cerebellum on the back of the brain so that occipital loops when these, the puzzle artery of the back, is composed of two little arteries of charge in on this diagram, but they fused together to form clots is our our tree up the back. They give off small perforating arteries to the points in the brain stem, and they have various arteries to the cerebellum and is to dividing posterior cerebral arteries, which going to supply both except to lose at the front of the brain. We have to carotid arteries on the right outside, which divide dominantly to give our anterior ST Martins goes towards front of the brain. It's a plane from two lobes on the middle cerebral arteries, which are the biggest branches of our into his arteries, and this is quite on the temporal lobes and the lateral aspect of the frontal parietal lobes, so the largest territory supply predominantly by the middle Cerebral Artery. We also have a pharmacologic branch, which comes off just before the bike vacation of the anterior middle cerebral arteries. And then we also have the connection between our interior, your circulation first air circulation, which is no posterior communicating artery. And this is what makes it a circle of Willis, essentially without the posterior communicating. Actually, there would be no continuity of flow and these role into related that for because of this communication with the anticipation of posterior circulation. And these full, as we've mentioned, supply very spectacular territories, so you can see the anterior through blocked resupplying the front of the brain and the car immediate. So sign the middle cerebral artery. Large lateral expects the frontal parietal lobes last the temporal lobe, and then the acceptable lobes are supplied by the mysterious big watchers. So just the basics on CT scanning. It's a CT scanning first thing to remember when CT scanning is performed. Is that the patients lying down and we're looking at the patient, head to toes the patient's lacked is actually our right on the screen, and so everything is reversed. So what we see in a zone image from the right side of our spring is actually the patients like side. And similarly, what we see on the right side of the screen will be the patient's left side, and I first so image on CT used to be acquired on image. As you can see in a while, they would be a single detective place behind patients and actually being be fired through patient patients. Head at the area that needs to be imaged and then essentially, the detector and be X ray being would move one by one around the head, and this could take up to a now our in the old days. Nowadays we have what's lost seen is Depo. You may have seen scanners within our regular departments where there's a single ring of detectors and the X ray beam congest movin once with motion around them because the disaster is already there around the patient, and then it could be acquired in a matter of seconds. Where do you suppose it used to be? A lot longer? We also sent to acquire the X ray in a you know, particular plane to the old bits is different to an MRI scan where we can scan directly across the brain by tangles. We tend to do this because we want to try and avoid radiation does to the eyes as the eyes. Uh, very sensitive to radiation on the main complication from radiation to the eyes is is cataract. So we try to avoid the eyes, you know, scanning from Therefore, we try and scan this angle and therefore the brain may not appear the same one CT or MRI because of the way that they been scanned. And that's why it could be some differences in the parents is, despite being same patients head. So CT is based on how it feels scale. And this is the measurement of unit measurement that we used to essentially assess a CT scan. So what we have is a hounsfield scale. So hospital scale essentially, how much and X ray beam can absorb into a tissue. So our dentist issues, for example, our bones absorbs lots of extra tissue, so it has a very high number into the thousands of this arbitrary scale. Where is there, but X rays straight through, and they don't get absorbed by any passes. The body have a very low number in minus 1000 and everything else in between has burying amounts of absorption. So soft tissue water, in fact, and in fact, we tend to say that water is the level of zero, so it's in the middle. So something bright as just bone will appear very bright because it's absorbed a lot of that tray where something like because it's not absorbing any, actually disappears black. Because there's no X ray. That's material that's been a block. Everything else is in between and somewhere shaded, grown in the middle now because our eyes can only see approximately 50 shades of gray scale. At one point, we have to narrow our window to only 50 shades or or so. So when we put it on a soft tissue window, you can see here. This is a standard brain CT scan. We put on a soft tissue so we can see the gray and white matter quite nicely. But what we see both backs is basically everything about this bones line becomes white. I eat the bone and everything below becomes black, so everything from water to air is black. So the lateral ventricles that you're here containing our CSE fluid becomes black. If we then want to view the bone, for example, we have to shift our scale Oh, to that level. And that's what we call the bone one day. The problem with that is that whilst we see the bone nice and clearly now, everything below that now becomes blocked out because it's below the line and it's the same thing we're looking at CD. It belongs food shift. They scaled down to the bottom where they had the air window, and it would black out all soft tissue. But we'd see the long is going nicely and so we should be scales Dynamic clears. We're looking through the scans to look at the various aspects of tissue on the bone separately to assess the whole head, uh, entity. So in the UK, we have various indications for CT and that those have you worked in the hospitals will be very aware of these guidelines by Nice, the governing body have made it quite clear of which scans can indicate a seat which patients presenting with certain symptoms. Comten Decatur CT Head scan. They include dropping in GCS suspected school fractures, base of school fractures, focal neurology, multiple episodes of vomiting. And these old will indicate a CD had that ship performed within an hour if the patient presents with other so non urgent symptoms, such as if they are on warfarin and think I had a fall winter otherwise well before they had a history of bleeding or clotting disorders, they had some amnesia. Then they still indicate a CT add, but that's not as urgent. And they can help out with an eight hours what we say but doesn't need to be done within the hour, which the indications on the left require CT to be done on reported within an hour, whereas the indications of the right could potentially wait till eight hours. Although we like to get them done, of course, the soon as possible. So on a CT head scan, we can see various structures which will just come through person basic anatomy again. So when we see a CT scan so again, the right hand side of the image is patients left and the left hand side of the images. Patients right because the patients lying down the bottom of the images, back of the patients, head facing up. So you talk with the images patients front of the head. So we have our frontal lobes at the top of the image upset a little bottom. And then we have a very stretches to these dark areas here, so much we seen on both sides, or a lateral ventricles thescore divided into frontal horns and occipital homes. At the back. These container street responding fluid the other vegetables in the brain of the bench from fourth ventricle. But you see, I'm different slices in terms of covering. Then we have very suspects again. It might be difficult to see, but this is actually a structure which say it's adjacent to be frontal horn of the lateral ventricle. Noon is Acorda nucleus, and this is part of the deep brain matter adjacent to that. We have begins very hard on the ship. See a lot of CT scans to necessarily see this very clearly takes a lot of time. But there's a slight bit of difference in the shade of grey here, slightly darker, and this is known as the internal capsule which has an anterior limb, and it comes around on. If you correlate it with being actively textbooks, you'll see there's internal Capsule, which has an anterior limb coming around to is you knew where was abandoned, and it comes down around to a posterial limb with the internal capsule. Often one mistake that's easily interpreted as potential hemorrhage or blood on the CT scan is that these bright areas here now these are just normal calcified corporate plexus. These are often mistaken for bits of blood within the ventricles, but actually these are just normal physiological structures that produce CSF with in the lateral ventricular system. Just normal is not for structures and don't need any further management. And but he's not to be interpreted wrongly. Assemblage usually shouldn't be. I think we ought to somatuline fold your head so blood on the head can be appearing differently, depending on how old it is. So acute blood is bright on a CT head, so you see it is a hyperdense structure because it's it's more dense than the adjacent brain. After approximately a week, it becomes the same. Density is the brain, so you can see it gets very hard to differentiate a line between the brain and the blood, and that's when we called ice it. And it's and that could be the most important, the most difficult one. To try and see. If there's not very much blood, you might not see very much, so it's very difficult to sometimes see these. So you have to look for the other signs, like mass effect on any changes to the sole cycle pattern to detect these. And then after approximately two or more weeks, the blood becomes low density or hypodense, And so it's a lot lower or darker in the adjacent brain and that all you can see that he's now chronic on these are not active bleeding. But they have matured a now chronic, and it's It's hard to say whether these are two weeks old. Some patients will walk around with these four years and not realize if they're not causing any significant problems, so we don't know how old he is. Maybe if that just low density. The only difference is that very hyperacute blood can appear dark because it's flu intensity. So if there's very hyperacute before it's clotted, it will appear the same density is fluid like CSF because it hasn't clotted here. It's only when it clots. It appears bright name clean out some trauma, so trauma that you can see on a CT scan could be out in primary care office. This is what we see initially. So if this was, somebody had an injury directly to the head. When we hit on the head, for example, the injuries that we see on a CT at that particular time would be his injuries to the stop fractures to the school and then the intracranial bleeding. If later on in a couple of hours or two hours time, we'd see secondary effects. So we may see. But they're effects after, for example, hypoxic, ischemic injury, swelling or edema. So not that doesn't necessarily occur straight away. So it's only a few hours later that we may see that which then causes raised in training pressure if they're open school fractures, for example, that maybe secondary infection and meningitis or abscesses, which we may not see till into wrong. But it's important to be aware of peace. The memory care doctor. I miss essentially the principal within the brain. That's the brain is a box basically containing three major components of brain tissue. CSF on blood. All containment picks structure, which is your school, and these three have to have a balance. And normal people have a balance of all three, predominantly with brain with bit of CSF bit of blood. If there's a cube leading, then it means the blood will increase. But that there is a limited space. So because the two components have to compensate will give away for that, Blood says it means that the brain tissue will be compressed if there's more blood. Similarly, if there's hydrocodone, build CSF on the brain that can cause the brain tissue to be squashed. Or if we have brain tumors or brain swelling, we can compress blood and CSF, which means that we might get compression of that vessels and needs to stroke. So essentially, this is a principal. When your resurgence work, where if there's an acute bleed, they decompress the school, and that allows the blood to be able to evacuate the fixed space, and it allows the brain to be able to be compressed into that space that is relatively fixed. So coming back to our meningeal layers that became, but we addressed failure. So come on, two So times bleeding. Okay, so the first type of bleeding is between the school and the jury matter on the outer area still drool matter, and this is extradural average. So this is often seen as a calm back structure or lentiform structure on these, Basically, because of the way it's just beneath the bone, it adheres to the suture lines that the bones, if you use that, so if it will adhere to the satisfied suture. So we're passed from right to left because the Saturday also drip you remember back to initial diagram. We had such a drooling across the brain, separated into right and left parietal compartments so it tends to stay on one side. It tends to not be able to cross the front because of our Coronas future, and it will also prevent it from going to the back of the brain by the lambdoid suitors. So we can see that on this diagram, where we have blood kiwi in an extra general space because it's nice and convex in order Lenti form, shape. And then we have our position of our Corona suitors which would be coming across the front of the brain preventing this area blood crossing into this frontal space. There we have it. The back. We have blood in two spaces here, so these are two separate areas of bleeding. But they're essentially prevented from crossing into one of the space by this fusion of suture here, which is the alarm nodes suit too, which we also see on the inside. And then this effect this area of blood is prevented from crossing to the right side by the sagittal suture Cross the midline. This is how it can tell it's an extra dural hemorrhage. This is different to subdural hemorrhage, which is between our jury matter our arachnoid matter between the blue and the grace bases. So this often appears as a more konkey shape or lentiform. True. So you can case she able present shape on this is this has a difference. Meth mechanism off separation to the seizures which was the extra dural. So in subdural hemorrhage, the prevention across is seen by it is performed by the dural layer are two major a layers in the brain. Our our fault cerebral, that toward tentorium cerebella so I'll fax serebriakov one's Proscar midline. It's divides are right and left hemispheres, so in blood generally tends to accumulate. You'll see it coming across in a subdural location of be present shape, but they won't be able to cross the midline. It may go into the midline space. It may start to collect along the midline, but it won't cross over into the other side. Similarly, the Tentorium cerebella I will mean that if you're not social hemorrhage in the super tentorial layer, it generally won't cross into implement. Oh really, or vice versa. May up blood around cerebellum, but it generally then won't cross into the brain parenchyma above it because it's it's material layer. Well, then can go down the further space to come onto ah, subarachnoid space. So as we say this so earlier, this is between the arachnoid space and the pile layer. So because the P L. A. ER is able to go into the invagination to also colitis our brain so in the blood. But we haven't Cuba lead in the subarachnoid space, so we tend to get this picture of two more so called continent of bleeding, which is dispersed throughout brain invagination in it. More SoCal in General Patton. Then we see in a subdural extradural, which tends to stay on the outside, these Congar into our small fish is within the brain a lot easier. The main two methods off subarachnoid hemorrhage most commonly used to have trauma. But the other very common mechanism of subarachnoid hemorrhage is aneurysm rupture, which we conceive in the brain very, quite commonly as well. Often we can tell the aneurysm where it's originating from from where the blood pools. There tends to be, most commonly the anterior communicating arteries, so connecting the to anterior cerebral arteries. The posterior communicating are true. True saw on our circle of Willis diagram on the basilar artery tip, which is also another place for aneurysms too commonly develop. It's interesting breed summary. Yeah, extra general lens like hemorrhage or more present shaped concave subdural average arm or subarachnoid invaginated hemorrhage. And we also can get actual injury to the brain itself. Brain has injured parenchymal intracranial bleeding, where we will see more of a circular pattern of injury or contusion directly to the brain so it will appear much more focal on. Essentially, it's almost like a bruise. Is that the area of the brain now scheming stroke? No so scheming stroke we'll just briefly cover. So when we have a screaming stroke, it tends to follow in arterial territory. This is an example of an anterior cerebral artery infarct. So we saw the type of earlier where we saw where the interest real artery circulation is supplying. It supplies the anterior aspect of pull it closely, so it's mostly with para median space. We tend to see competitive the normal wrong side of patients have a nice soul, sensible sign here. This also iron based due to the cortical swelling. We have lots of great white matter differentiation to the gray and white matter. I separated, been observed it on a picture here. Well, see, the central white matter is a dark gray. Then the out of grey matter and the white matter is on. Essentially are transmitting fibers. Gray matter is on. It essentially are initiating fibers that we used to initiate a particular action of the white matter, then transports those fibers and we lose that differentiation here due to be a demon from involved in on also the because they conform to an arterial territory we tend to get a tickle wedge shape have been part from because it's a a territory. So basically, the middle cerebral artery won't be involved with mysterious reblocked to people. So, quite honestly, it here's to that. Sometimes you can get multiple arteries being affected, and you might have a bigger the anterior on middle. Cerebral arteries were happen had had strong vessel stroke. Then you make it a larger area, but you can generally tell terrier stroke has been affected, given the arterial distribution. School fractures. So with school fractures, we have depressed skull fractures. What? We have normal school lunches. Classes start to depressed. All righteous we can see because of the outer table is quite heavy structure. You may just guess I'm being honest. Quite severe School for actually may get depression of the school, which may that interfere with the Sinuses running around the outside of school. One common pitfall, again with school practice, is how do we tell difference between a skull fracture and it's suture. Suitors tend to be symmetrical on both sides. You can see this picture here so can see suitors on both sides, and we know the expect locations about Corona. Suitors are not suitors now. There are all the menu of suitors well in the school, but generally you'll see symmetry on both sides. Sometimes we can see asymmetry the suit just so if we have a fracture that goes through the suit, it can sometimes widen the suits rub along side. So here on this bottom picture, you can see that there's widening of the left side of the Lamictal future compared to the normal right side. And that's because it's the fracture is passing through that school that school suture and therefore call this diet Stasis or whitening of the suitor. And it's particularly common in the London suture occipital bone fractures. Yeah, so there's some important features now. Interpretation. So the major things that we want to cover when we're looking at heads a mass effect midline shift on hydrocephalus so must effect. We have when we have blood for any structure such a a mass lesion that may cause the brain to be shifted. And so the key problem with that is that conceal diagram on that right is that we have herniation the brain on herniation of the brain in various directions gonna care so we can get an issue the brain across from right to left, which is known as somebody outside service because we know the fuck Serebriakov is running down the middle. This is so about sciences. It's beneath the fox cerebral and this going left to right all right to left. Similarly, if we can have trans contrary also is called variant, Skull said. Through the school, we can get transtentorial so that interim cerebella I below tentorium if we have a massive fact, that's these. The key things to look out for because if we squashed the brain parenchyma it can lead to compression off the brain. Stem in the brain stem is important for our respiratory center on, If we can have a respiratory center, we can't breathe and therefore we will essentially have a fatality from that. So it's important to look for any features of massive fact what we call Tony, which is what they're the cerebellum in cerebella tonsils and Branston start to descend into the a spinal canal. Then the second major. A special account for is hydrocephalus, which is the buildup of See It's a fluid again within what prevent from system and this again going back to Monroe carried up trying this can well, any increase in a little fluid. This is in this case, it's fluid will increase the amounts, decrease the amount of space available for the brain, and therefore it will cause further deterioration. Further impact on the vessels. Really further impact ischemic stroke, maybe to further impacts, um, cognitive function on mass effect, which can be to the radiation. So systemic approaches to interpretation is interpreting CD had. So there are two or they have listed two methods here, um on these are two of many, so one method can be an outside to inside approach. So starting in school, going into the jury, next thing good brain, and then setting the metric ALS, the basil systems and soft tissues A different method. If you like acronyms or previous a shins, you can try. Blood can be very bad, so you can start looking for any blood to look for any bright hyperdense fluid within the brain. Then you can look assistance. Then we look at the brain itself. So looking for any great white matter differentiation lost or any and my sleeve, then we come up with the ventricles. Is there any hydrocodone, Lis? Then we can look. And the bones? Is there any fracture, or are there any lesions of the boat? So for those who may be undergoing any exams, this quick Osti style station. So what we want to do is huge. Confirming patient details, presenting an image. So you would say this isn't CT and up feels. So these images taken an axial planes is head down off the various patients. Then you're going to comment on the this abnormality. So you would say, in this case, the obvious Obvious is we looked at this one earlier in area Hypoattenuating left frontal lobe with respect compression. Well, the left lateral ventricle. Yeah, stress for exams. So some of some cases there. Okay, so I'm just going to scroll through a few cases on If anyone's the typing what they think on the track box on, then feel free to do so. Um Oh, see if you can beat me to it, and I'll give you a few seconds and then, if not so, just presenting the answers. So this is a case of a patient with two days history of left arm on a ms from, you know, P a. So just going to scroll through the CT scan on If we have any answers, we could just type them in to the box. So just go through the image a few times and see what's anything could be seen. Yeah, So what I would be thinking if I saw a history of two days left monomers 10 million appear so you can tell a lot from this history already. So two days means that the patient has had symptoms for not just a very cute period time. It's a reasonable amount of time. So any changes that may have occurred would be more obvious. Now, after two days, then they would be They added two hours the left side. So a good history can be very useful to add into by the side because it means that knowing the brain, we interrogate the opposite side generally because of the way that the track fibers tend to be orientated on the opposite side. So now left one of us for me anopia. So it's visual symptoms. So we're now going to be localizing our attention on the right side on the visual cortex thing except alone. And we know it's two days old, so we think that changes a going to be quite established at this point. So in direct attention here, straight away to the right, except a lobe well can see, if reason this image a nice circle pattern on the lifestyle and you can see the nice Fisher on the right. That's this area of low density cortical swelling, most of so kind loss of gray white matter differentiation. It's in a quite well defined region, and so this is consistent with a little right sided posterior cerebral artery territory in part. And it would fit with the clinical symptoms of the changes that we can see so you can see an area low density here at the top of the brain. So this is just something that we see very commonly in people. Potato patients who are particularly older on this is something that we can just say that is small vessel disease or chronic small vessel ischemia. And this is just a long standing. Essentially, it's like atherosclerosis off the peripheral vascular system. So, um, over time, particularly patients who call ask you the disease will have these low density changes, and they tend to be within the white matter. They don't resemble a stroke because they don't have. Loss is great white differentiation. There's no cortical swelling. There's no wedge shaped pattern, and therefore, and it's only involving the white matter. So it's very consistent with small vessel disease rather than an acute stroke, which we can see goes away to the cortex, the next one. So you have elderly, confused, increasing falls. So come through this image against anyone has any ideas, feel free to type in the way but otherwise are, scroll through them a few times and then, okay, three ounces you can't. It's very common presentation. Who this particular history and patient population so immediately going through that scan, we can see that there are some changes on both sides of the brain, so you can see that there are bilateral present shaped. It spans all the way across from front to back, bypassing the suture lines of alarmed with incredible suitors. But do it does not bypass the midline of the bunks. They're on both sides, and they are mixed density. The left side is larger. There's considerable mass effect with the face man took this whole sign, and compression brain on the right is less less so, and so these are consistent with bilateral subdural hematoma. This the density is mixed. It's not quite bright. It's not quiet, very. It's not quite dark. And so this patient may have had an acute on chronic subdural hemotomas that's developed after maybe a recurrent for a lot of patients will often have chronic subdural collections long term. But then it may be recurrent falls that they acutely bleed and make those collections larger. That men cause them to go to hospital. But many patients come function if they have small subdural collections. Still, case of the next one we got case decompression surgery previously for left sided subdural hematoma in in the past. Again just go through these images. So you see, there's been a whole going back to the decompression that we said earlier helps Teo evacuate that excess blood. Allow the brain, too. Expand out and then immediately you can see on the right. That's this Robert on Sutent. It's dominantly right sided collection of hematoma that again, present shaped does not cross the midline, but it doesn't cross the Crohn on Mondays futures, but there's also the low lower down. Expect this higher density here so we could do this. Croup acute on chronic subdural hematoma or acute or an acute on sub acute hematoma. This is probably a stuff acute human. I have a torn because I so dense it's similar density to the brain, so it's probably an acute on sub acute on the left side. Now is the chronic residual sexually mature because it's hypodense for low density. So you've got almost all three phases of that. So I really miss him on this can in the queue face the sub acute phase and then the chronic phase in the left side. Okay, it's the next case left sided in attention. So again, with the history, it folks ourselves on the right side because the left sided symptoms. So this kind of just going to go down a few times and for the egalite amongst you you'll see here. I'm just reason this friend, if you compare the left side of the patient to there right, you'll notice that there is dark region here. Now you've seen within the right side of patients posterior parietal blue bordering on there except alone. Loss of gray White matter differentiation is you can see next to the side. The blend between the dark gray was like, Really, it's now just start. Great. That's, um, so called a face mint. You lose some of your soul sign, and again this is consistent with an early infarct, and this is not really in the past that we've seen previously where that mean a lot darker. This is more subtle, but again, we can see that this is a thing for given. It's what shaped pattern, then the various features that we mentioned just again in keeping with the right sided with Syria Tekturna in front and then the next day. So this is evolution of the same involves. We can see how that's changed and how much easier it is to be able to. You said Nothing thought. Now, once there's been even a day, and that's why it's important to be able to pick up these changes early. To be able to establish I be therapy. Nowadays we can do in endovascular treaters as well. Certain cases to help remove there's clots causing the street. Here's a case of sudden onset. Worst headache. So history probably should give it away. But it's just a few slices that showed this passenger blood. This is quite central. This, um, focal blubber put here that's become IRA and see the blood seeping into the various soul side of the brain. Now, given this distribution, as we mentioned earlier, this is where the anterior cerebral arteries would be passing through frontal lobes. Connecting them would be an opportunity for you to get communicating artery aneurysm. So we can do CT angiogram to assess for any underlying aneurysms and what we can see here. Well, concede our right and left anterior cerebral arteries in between. Is this blob small block here? That is an aneurysm responsible for that subarachnoid hemorrhage. And often they can be very small, but they can be treated both in an endovascular approach. Will neurosurgical approach. So now going back to trauma again? Cyclist Car. So going through the images so you can see immediately There is, um, blood on the left. Onda also put in front on the right, and this patient has got all three distributions of hemorrhage from last camera. Save calls Atlanta for looking extradural hematoma. on the left side, up front on the right. There is right sided sexual humor, too. And the blood doesn't always have to play. There's not enough of the blood. It won't necessarily gold way around and present shape. It is just a small amount of what it may just start coming around like this and stop. But then you also noticed some further blood in within the salts I off the brain as well. And that again is in keeping with subarachnoid blood. So often, in case of drama particular. Here you can see this whole side got blood within them. In trauma cases, you may get multiple areas of bleeding just because the drama has just rattled everything than the brain. So you'll get a lot the various Pathans of bleeding. And then if we looked at the bone window, we would see that there is That's cool. Front trouble left side contribute to that left side and extradural hematoma. So this was not a different case. This is a patient with known lung cancer. So what behavior scrolling through this few slices here so we can see that there is abnormality within both frontal lobes. Then we can see some areas of high density which looked like they are defined, if it on this draw a ring around and these were keeping with metastases, so these are different, too. That's what the differential for this parents could be potentially stroke. So you could say, given that there's a lot of dark material around the outside of the brain, which is a demon, this is a different type of a demon to a demon that we see in stroke. In stroke, we tend to get walk or cytotoxic anemia, which is where we, a demon, will affect the gray matter as well as the white matter, where, as this type of edema, which we tend to see in metastases or any inflammatory or infective process is is called basal cardiogenic a demon. And this isn't a Dema that essentially spares the grey matter and test only involve the white matter, and this is due to that that is, in ischemia. You get different titles breakdown of the of the best vascular walls, and therefore the edema can infiltrate grey matter in a different way. To what you would see. An infection. Yeah, cancer. And so you can see here that there's rats Experiment the outer grey matter where the demons seen, she turns. Get this almost scalloping type of appearance, which is characteristic of a cardiogenic, a demon, and you tend to see these in. I have an infection or neoplastic processes. And given the history of lung cancer, the differential for these could be that it could be abscesses with depression issue raised, white cell count fever these could be abscesses, and often we need to do an MRI, sometimes to differentiate between the two. But given that look, cancer history and absence of any inflammatory marking grazed a country Marcus, these are likely to represent lung metastases, the next patient back again to trauma, since the underlying theme found on the floor confused. So going through the head scan few times to receive this bilateral so true collections, which appear chronic. So they're very low densities that dark. So we know that they've seen president for a while, and there's new bright material to to suggest acute temperate within them. But what we do see is in the a lot of ventricles, some acumen, identity material and room with patients lying down. So this isn't the dependent aspect. So the this one layer and this is a cute interventricular itch. And sometimes in cases of low, low impact of lost you trauma that can be just a small amounts of so intraventricular hemorrhage that just shows his amount small. Now this compliant to the ventricles, and you may not see his house more. So it's important to always assess the ventricular system not just the hydrocephalus but in case it drawn a for any potential blood as well. Next one, this patient was punched, so we see left sided identity. It's scalloping in appearance, and it's going within the soul site, the brain. So comparing it to the previous subarachnoid hemorrhage as this is a case of subarachnoid hemorrhage, this is more compliant. It'll inside, and there's a clinic. Street drama is unlikely to be an aneurysm, so then we can leave it at that. We don't need to do an underlying CT angiogram, which we may do for if we suspected and then you vision, for example. But it's important. That's why it is important, too. Got a quick history, please, just against, um, spot examples. So again is an example subarachnoid hemorrhage, which is quite central invaginated muscle side on both sides. Another example off a present shape subdural, which is not only not only go across the side, but also you can see it coming across. The folks at the back here just prevent it from going across to the left side by the factory bright. But it means that the blood can still collect in the midline along the folks, but it just can't pass over it. And it's consult causing considerable amount of mass effect. Which is another thing that we need to remember to mention when the report from our radiology side again, this is another bit bleeding. So, uh, again, so cold blood performing to a Silverado right pattern? Well, we'll sit out on the left side. Certainly is present shakes bit of high density in keeping with a subdural human tumor. This is super general answer peroxide hemorrhage on this particular image. So we have again nice lens shaped welcome that shapes hemotomas. It's not passing the lambdoid suitors at the back or Kroger suitors at the front. This is in keeping with an extra little hemorrhage. Have here a load and stick chronic subdural hemorrhage with a mild amount must faxable basements. And again, this is a little getting chronic. That's the age, this type of injuries and of a common person that we see. So this could be where there's a left sided extradural in the summers were already familiar with. Now what we see on the right side is actually a small relative around injury, and this is what we call contact injury. This is where the brain, because it's in a fixed liquid box, it's able to float around the CSF. And so when we get an injury, too, the left side the brain will slush around in the CSF been essentially, it will get smashed against the opposite side within off the school, so we'll see. Injury on the opposite side of the brain's been moved and rattle and it's gone. It's gone off to hit the other side of the school with the impact, and so often we get this intraparenchymal, which is a nice round bit of blood within the brain tissue itself, where the brain's been injured against by by hitting school on the opposite side. Sometimes we may only see the contract root injury, so Kupinski res if if any of you familiar with French means on the same side as the impact contribution mint opposite side, too. So this sometimes the opposite side of the the only side of the injury and the normal side of impact maybe normal. So it's important to understand the mechanisms of injury to be able to work out where bleeding may careful. This one is in the case of an extra dural hematuria. But what we see in the middle is a small amount of low density. And this was going back to our initial few slides, where we mentioned that hyper acute blood convey low density, so low density can be similar to CSF and therefore, if we got active bleeding. So if it's bleeding at the time of scanning, then we may see the small amounts of a low density within the identity. And this is just the representative in hyperacute extra jewelry metal. Again, that's a nice case of bilateral extradural hemotomas. And because there's been injury to run to the brain, we have bleeding in both compartments, but they are able to cross each other because of a sagittal suit checked that runs in the midline, so we'll get this by frontal call backs pairs. We may get mixtures of subdural cube blood in a chronic hematoma. So hospital layering because active cube blood is more dense than watery old blood. Then we'll have the deeper accu blood will appear lower or dependence, and you'll get this layering. In fact. Well, you may see an acute on chronic came a timer. This is often a very tough case to two detect particularly there's not much office. So what can see here is that there's almost no so called platinum the left. There's a little bit of midline shift, but actually we can't see any definitive layer of blood. What? This is a nice it dense subdural hematoma, and the only way we can pick this up is by the secondary effect. By seeing the massive vet by seeing the circle of basement, we can actually see the differentiating line of blood because it's the same. Density is brain. It's often these artists cases is particularly, there's not much respect. Also the basement, the's company most difficult to detect. It's just finishing off towards the end now, so just betting critical in so most counts, we have a CT on non contrast cans. So mostly it's of drama, hemorrhage or stroke will be able to just do without contrast. Look for the basic signs. Then we make us do MRI in full for the differentiation, particularly case that stroke. So indications to do contrast we may use for tumors in the U setting infection. 15. The abscesses, any settings of masculinity. It's what we may see. Any advice for the abnormalities. And as we've seen already with the aneurysms, we can use CT angiograms in the arterial face where we put the contrast and scan when the contrast is running through the arteries to detect any aneurysms or any large vessel occlusion. In cases stroke, you can see a clock looking lesson. And then we also look for being a Sinus from mostly serious there, a clot in the being, a Sinuses that can also see on it CT venogram so they would be indicated for contrast. Otherwise, most things we can see on a non contrast plain ct of the head and just sometimes looking at reports. So those of you, maybe on the war's looking at reports, absolutely make it confused with the technology that we use sometimes on department. Sometimes many things could be the same thing. So some phrases, such as chronic small vessel disease, which essentially, like we mentioned it's almost like arthrosclerosis is that peripheral vascular system it could be described in the reports is mature scheme. It change with the chronic white matter, ischemic change or disease supratentorial white matter small vessel ischemia, periventricular small vessel ischemic disease. But all these key thing is that there are not acute findings. They are just findings that are associated with aging or general background follow. Gee, they don't require any immediate action. If there is an acute stroke, they should or will be described past an acute stroke in the report. So if you see the word small vessel disease, small vessel ischemic disease don't necessarily be worried by that look for the words acute on that will be deciding whether it's in a few to put on June and also involutional change again. That's referring to an age appropriate to see that report and age appropriate shrinking of the brain. So obviously, as we get older, our brain slightly will get slightly smaller with all of us, and it's not necessarily excessive for a judge, Um, so this amount that's appropriate if we see that with generalized cerebral atrophy often that can be used interchangeably with involutional change. However, technically, it shouldn't be, because atrophy implies pathological plus is loss of brain parenchyma. But often reports will often mentioned generalized three black coffee, but they're referring to and more appropriate age expected rated of program grant, um, a loss. And again, it's not anything to be concerned about unless they specifically mentioned a disproportionate focal atrophy of a particular lobe or pattern of lobes. And that's when it may require further investigation. But generalized body probably wouldn't require any further investigations. And again, if it's not reported on, it's likely not to be a significant panics. They're not. All ports will have findings mentioning the school, for example, on a stroke. CT had to that, but we'll all have looked at the heads on schools completely on. So if the report is necessarily mention, it doesn't mean this not been looked at. It probably is that there's nothing necessarily of acute on that finding all wrong, significantly pathological, so you don't need to worry about. So in some right good news is that he had for violent inpatient medicine. He had trauma quite efficiently. The diagnosis will lead to better outcomes again. For those working on the ward spell. To recognize these quickly can help you to them. Just pick up the phone up quicker. If we haven't reported, this can quiet then. But if you've seen a bleed, you could pick up the phone neurosurgery and get a patient referred earlier. And then they can have potentially any management performed earlier as well be and the good thing mental of any associative fractures on the bone window. Look for any complications of a demon midline shift radiation. And also you can see the different ages of blood products with subacute or chronic presentation. If nothing else, from extra girls look like lemons, kinds of generals look like this. Okay, so but it's the after presentation. Thank you very much. Yeah, and any questions hung around for Yeah, thank you very much for that. Some. That was fantastic. I learned about this evening that olive oil when I go into my neck ship. Um, there are lots of things popping up in the chat. There's a couple questions on the, um today. Spends that story. I actually see any questions I can read. Smell to you. So, um, one is, uh So how do you differentiate between spectric A calcification and orange? Yeah. So, uh, calcification. So it'll goes down to our parents. Build units, scale s o constipation. Typically a similar to bone. Uh, calcium is upstate. Bone is made of calcium. So custom were very, very bright. And what we can use on CT, we can use tools to measure the house bill. Units of our of anything that we see so we will be able to put a little marker on. It would tell us a hounsfield unit on two counts. The calcification would be very brighter in the thousands. Blood would be blood similar to soft tissue. So be yeah, somewhere around 50 to 70. So objectively tell there's another question. So when requesting a CT, do we specifically need to ask a contrast or non contrast, depending on indication? Or would this be chairs? And by the radiologists? Generally, the radiologist will choose, uh, protocol it appropriately on. On some occasions, it may be useful to be able to. It's suggested on No, not already adjusts will be familiar with neuroimaging, uh, so that may not necessarily think about doing the extra contrast can absolutely happened, nestled on much neuroimaging do with the past the body, for example. And so it can be useful to suggest it if you if you have. If you have a thought in your mind of a college, it may be best seen. On contrast, there's nothing wrong with suggesting it, but generally will will first call it. With contrast, it would require it. Yeah, so, uh, so everyone has been watching. You shall get feedback going to email through to you within the next 5 10 minutes. Also, um, but also paste into the chat box below Swimming's Do that now. So once you feel on the feedback, you should get it if it gets into your email. So next Wednesday evening, eight PM so that'll be this time. Next week, Dr Marie will be presenting a stricture approach. Common cases in pitfalls off chest X ray and invitations on the link to register for that is in the chat boxes. The middle one, and I'll go to the metal events for that, so don't forget to sign up for that so you don't miss out on that last link will take you to the mindedly websites where you can sign up for a while. The radiology webinars on. Then you just need to put in your email and then you'll get notifications of went to attend booze. There's been a few people asking for the slides, and if it's recorded, so these this does get recorded. Um, it just needs to be downloaded from metal because they're quite long presentations. They take quite a long time download, but they will be uploaded to the mind that we both sites in the near future. Um, just Well, I've been talking some. There's one last question. Uh, what information do you get from the doctor when requesting skin? Yep. So that's a good question. Um, so, um, useful thing to know is thesis. I'd, if there's any neurology, very helpfully would help to guide, are approached the scan interpretation. Absolutely look everything, but obviously can't guide and influence our our focus. We know what besides the neurology on thedy're Asian of symptoms is also useful thing. Actually, neurology findings because up to sleep there, think about brain injury. It's all functional anatomy, which can correlate it to a specific localized area after. So if you have a good neurology exam, visit findings can actually help direct our interactive approach to that on. So anything, any people, neurology. Outside of that, the pathology, uh, duration Any particular past medical histories always got a history of cancer. That's quite a born to let us know about. For example, any previous strokes. Example. Uh, second medical history. He's almost. We'll give you 30 seconds, just in case anyone has any last minute burning questions. Just again. Don't forget to fill in the feedback that's on. That's all the links that you need to do next. I just above in the chatbots. So the feedback for this session that's how you'll get your certificates on do next week's chest. Sexually Webinar link is also up there, so don't get to sign up to that on also, how to sign up to a liter Webinars. That mindedly does all right. I think that's all the questions. Thanks so much. Okay, take a lot