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Uh Hi, everyone. Um Thank you for joining. I think we'll, we might as well make start now. Um ok, so my name is Mohamed. I'm one of the final years at UCL. I'm currently based at Watford and I'm also presenting alongside drama. Um So I'll be doing the first half on strokes and he'll take over for ct head interpretation. Um So the aim is today, we'll try and we'll try and get wrapped up in about an hour, hour and a bit. So you can enjoy the rest of your evening. Um, c let's make a stop. So for anyone that's new here, this is teaching things, um, we do weekly tutorials normally. I think it's twice a week. Um We, we're all medical students and all that stuff has been reviewed by doctors. So if you just sort of subscribe to the uh uh medical link um as a follower, so you'll be updated whenever we have a new set of teaching sessions. Cool. So let me start on strokes. Um So before we start on strokes, um I say strokes is quite a high yield topic for neuro and it's quite simple to understand as well, uh, as long as you know, a little bit about the neuroanatomy, uh, blood flow to the brain and blood supply and what different areas of the brain do. It's quite easy to localize. So what, where the stroke is and after that management is quite similar, depending on what type of stroke it is and, and sort of investigations as well. Um, so we'll look at strokes and tias how to differentiate them presentations of strokes and their risk factors. Um, the function and blood supply of the brain brainstem and cerebellum, different types of stroke based on location and symptoms treatments and then other differentials to consider as well. Ok. Let's quickly start off with ap, just to see how much neuro ones doing. Ok. Ok. So everyone wants to vote. Yeah. Ok, cool. So, we've got a mixed bag. Um, I think one person's, I think most people either know a little bit or, or they quite, they know quite well. Um, ok, cool. So we'll start with an SBA, um, I'll let everyone read that and then I'll start the poll. So it's basically a 68 year old male, sudden onset weakness on the right side and slurred speech and it's completely resolved within 30 minutes. There's nothing on the CT head. Uh, what's the most appropriate diagnosis? Uh, two. Yeah. Fantastic ti a so it's, it's quite box standard. It's just an intro into our, um, what we're gonna talk about now. So, essentially strokes versus TI A S. Um both of them involve ischemia to the brain. So you get a lack of blood flow for whatever reason. And then the difference is in a stroke, you'll get infarction. So the brain tissue will die as a result of the, the lack of blood flow. But in Ati A, there's no infarction. So it's a temporary lack of blood flow and that gets resolved for whatever reason. And then the, the the brain gets reperfused and the symptoms go completely. Um So in terms of how to differentiate them, normally, tia s last less than an hour and they, they resolve completely, strokes don't resolve. So you'll have residual of neurological deficit in terms of the types of strokes by the sort of etiology, the most common is ischemic strokes. So they cover about 85% of strokes and they normally because of either embolus or a thrombus forming in the blood vessel and that sort of stops blood flow going more distally and it causes symptoms of the brain. The other type of stroke is hemorrhage. So that covers about 15%. And I think these normally have a worse prognosis, but that's stuff like subarachnoid hemorrhages. So if you've got like a an aneurysm that ruptures and it causes a bleed in the brain or you have intra intracerebral hemorrhages. So, bleeding within the brain tissue itself, um the reason why that would be important is because after we look at treatment, there's different treatments depending on what type of stroke it is. Um cool. OK. So in terms of presentations, they're normally quite easy to spot. So it's normally unilateral weakness, sensory loss, you might have difficulty speaking, you might notice difficulties with balance uh or walking, you might also notice some visual uh visual problems and swallowing problems as well. Um We have these assessment tools, I'm not gonna go into um but basically f is a community um assessment tool. So it's for the public to identify a stroke and rosa or rosea. Um that's used in A&E s but essentially they take off points for losing consciousness or sea activity because if you have either of them too, it's unlikely to be a stroke. It's more likely to be something else which we'll, we'll touch on at the end. Ok. Cool. So risk factors. So essentially for ischemic strokes, um It's all the cardiovascular risk factors. So age smoking, high cholesterol diabetes, atrial fibrillation, they will increase the risk of you having a blood clot which will cause ischemia for hemorrhages is slightly different. So it's more likely to be things like hypertension um AVM. So if you've got like an aneurysm, that's likely to rupture if you're on anticoagulation, that also increases your risk of uh bleeding in the brain. And if you've got certain conditions like autosomal dominant polycystic kidney disease, for anyone that of gas, uh renal or gastro um that has an increased risk of having the person has increased risk of aneurysms. So they have an increased risk of subrenal hemorrhages and hence the strokes cool. So we're gonna quickly talk about the function of different areas of the brain. But it's gonna be sort of a very basic overview just just as a context to what we're gonna be speaking about today. Um So we've got the four lobes of the brain, frontal lobe, parietal, occipital and green and temporal lobe in yellow. So essentially the frontal lobe does mainly movement and executive behaviors. So executive function, sorry. So that's normally sort of higher order processing in the brain. Parietal tends to do sensation, occipital does mainly vision and temporal does bits of vision but mainly hearing. OK. So blood supply of the brain, but then I'm going to, I'm going through it quite quick. So if anyone needs me to slow down, if anyone's got any questions, just let me know. OK. So in terms of the blood supply of the brain, we have a structure called the circle of Willis. And I'm guessing everyone's probably heard about this in in sort of neuroanatomy. Um but essentially the circle of Willis is what peruses the cerebral hemispheres. And it's a circle structure because if there's a lack in blood flow to the area of the brain, the idea is that the brain can kind of compensate to a certain amount by sending blood around the collaterals. So it can still maintain some sort of perfusion even if it's not 100%. So what is supplied by is you have the internal carotid that comes up the neck at the front and that turns into the anterior and the middle cerebral arteries in the bra in the brain, then you have the vertebral arteries at the back. They join in the middle to form the basilar artery and then they go further into the brain and they form the posterior cerebral arteries. So you've got anterior cerebral here, middle cerebral here and posterior cerebral here. And then you have the anterior and the posterior communicating arteries and they essentially just form that circle that you can see there. OK. So we're gonna come back to this in a second. I think it's the next slide. Ok. So generally the blood, the blood supply of the hemispheres is split. So the yellow area that you can see. So this is the medial side of the brain, the middle and this is the lateral. So the outside of the brain, the medial side is supplied mainly by the anterior cerebral artery. The lateral outer aspect is the middle cerebral. So that's in pin there and then the back of the brain. So sort of the occipital lobe bottom of the temporal lobe that's supplied by the posterior cerebral. So this this might be a bit of a sort of stretch. But if anyone can remember neuroanatomy lectures in 1st and 2nd year. Um there's an area in the brain called the primary motor cortex. So essentially all the movement sort of stimulus starts there. Now, you could this map here is called a homunculus. And it essentially maps the area of the brain that deals with a certain area of the body. So this here is the m the medial side of the brain. So the middle aspect and then this comes outwards and laterally, Oops, sorry, ok, forward. Ok. So the media aspect deals with sort of the leg, the foot and the higher up you go, goes to the knee, uh thigh trunk and as you come come more laterally, that deals with the upper limb and also the face as well. And the reason why this is important is because if you have disruption of the anterior cerebral artery, as I said here, it supplies the medial aspect of the brain. And on the medial aspect of the brain, you have the lower limb being controlled there. So you're more likely to have lower limb weakness than upper limb weakness. Although lower limb weakness will be more pronounced than the upper limb weakness. But then if you disrupt the middle cerebral artery, which supplies the lateral aspect of the brain, which supplies all this the upper limb and the face, you'll have more weakness in the face and upper limb than the lower limb. Ok? I just wanna make sure that makes sense to everyone because that's quite important to grasp. That's a good, I like that one. Nos efficient. OK. Cool. It, it makes sense to most people. OK. So moving on. So now if you have a stroke or if you have a blockage of the anti cerebral, as I said before, you'll get leg weakness, which is more predominant. The middle cerebral, you'll get arm and face, face weakness, sorry, you'll get aphasia. So you'll have issues speaking and we, we're gonna touch on that later on about the different types of aphasia. You'll have hemispatial neglect, which is where the brain has pro uh it, it has difficulties processing of half of a visual field. Um and then you might also get eye issues. So you'll get homonymous hemianopia, which will come come on to and then the posterior cerebral that mainly deals with just vision. So you'll, you'll notice hone is hemianopia with macular sparing, which again, we will come on to in a minute and as visual processing issues. So generally anterior cerebral, you'll get pronounced leg weakness, middle cerebral, mainly arm and face weakness. And then posterior cerebral, it's sort of just vision. Then you get lacuna strokes and lacuna strokes are a little bit um the most characteristic. So you'll either get just motor loss, just sensory loss or you'll get something called ataxic hemiparesis. Now, the different the way to differentiate these two are like an anterior cerebral stroke, you'll get leg weakness and legs of sensation loss in a Lacuna stroke, it'll be either weakness or it'll be sensory loss. You won't, you won't get both mixed in together. Um And lacuna strokes basically affect these sort of really sort of small arteries that go deep into the brain to get quite a localized deficit, which is why you, you get just motor and just sensory loss rather than bottle combined. Um Ataxic hemiparesis basically means um sort of issues walking as a result of leg weakness. There's also a note here about learning the Bamford stroke classification. But essentially, it goes through what I've spoken about here. I think it's on past med. It does, it does come up with uh quite a bit in past med. Um But yeah, OK. So this is homonymous hemianopia. So if you imagine someone's visual field, this is what they're looking at out of both eyes, homonymous hemianopia affects the black area in these pictures. So essentially, it affects the same side in both eyes. So here is it's the left side of both eyes. And when I said on a posterior cerebral artery stroke, you'd get macular sparing. Essentially, that means this little circle in the middle that still has blood supply. So you can see right in front of you, you just can't see anything left of that. Whereas in a middle cerebral artery stroke, you, you won't get any macular sparing. So you just can't see anything left of the halfway line of your vision. Cool OK, so we got to the SBA. Um OK. Fantastic. It looks at m everyone's great. Um as I mentioned before. So if you go to this one, so anterior cerebral supply is the medial aspect of the brain and the medial aspect of the brain deals more with the lower limb. So in this SBA it says the the weakness is predominantly in his right leg. So lower limb media, left leg, so it's gonna be anterior, cerebral cool. So we've talked about the actual cerebral hemispheres, we're gonna move on to the brainstem now. So a quick overview, the brain, the brainstem is made up of three sort of di different structures. You have the midbrain, which is the more sort of superior aspect, you have the pons which is in the middle and then you have the medulla, which is at the bottom. Now, the thing that's most relevant to our sort of stroke talk today is the cranial nerve nuclear and where they originate from in the brainstem. So in the midbrain, you have cranial nerves three and four, then you for them. So there is it from there in the pons, you have cranial nerves 5 to 8. So this pink structure here. And in the medulla, you have cranial nerves 9 to 12. So down here, just anyone that needs a recap, there's the cranial nerves on the next slide. W we're not gonna go through them just for the purposes of time. But later on, you can, you can come through the slides and sort of map, map them out in terms of the blood supply of the brainstem and cerebellum. You have the S cerebellar artery to the top of the cerebellum, the anterior inferior cerebellar artery or the er, that does the pons and sort of middle part of the cerebellum and then the posterior inferior cerebellar arteries of the peer that does the medulla and the inferior aspect of the cerebellum. Ok. The reason why that's important is because if you get a blockage of, I'm, I'm just gonna call it the icer that's gonna take out the pons. So all of the cranial nerve nuclei within there 5 to 8 as well as a decent chunk of the cerebellum as well. So you'll notice cerebellar issues too, which again, we'll touch on in a minute if you have a blockage in the piker that takes out the medulla as well as the part of the cerebellum behind the medulla. So you'll get cerebellus in that too. Ok. So that's the cranial nerves I was talking about. So the brain stem strokes are quite different from the normal strokes that we talked about before the leg and arm weakness and the problem following. So we have Weber Syndrome, essentially that's a blockage of the posterior cerebral that supplies the midbrain. So if you go back here, the midbrain has cranial nerve three originating from there and also on the back of the midbrain. Around here, you have the corticospinal tracts, which are essentially the tracts that carry motor movements down the spine to the, the respective muscle groups. So, if you have a blockage in the PCA, that takes out that part of the midbrain, you'll have an ipsilateral third nerve palsy. So on the same side, that would be like a eye, the eye that's pointing down and out, and it's also uh the pupil will also be dilated as well. And you'll also have sort of drooping of the eyelid because that's what that deals with. You'll also get contralateral weakness because the corticospinal tract that was behind the midbrain in that area that's also lost its blood supply. So all you need to remember is wes if you have a third nerve palsy as well as weakness, that's gonna indicate a PCA stroke. I'm sorry. Um Then we have lateral pontine and lateral medullary syndrome. And, and these have always confused me because their symptoms, they seem quite random. Um but I'll talk to you how to differentiate them. So lateral pontine syndrome happens when you get blockage of the ICA. So the anterior inferior cerebellar artery that takes out the pons, as I said before and that takes out the cerebellum. So the symptoms you're gonna end up with are so ataxia and nystagmus. So, difficulties walking and eye movements, which is what cerebellum deals with. You're gonna have um sensory loss on the contralateral side of the body and the ipsilateral side of the face because it takes out the spinal thalamic tract, which is what deals with um sensation and pain, sensation. Uh You'll also get Horners on the same side because it takes out the sympathetic trunk and the way to differentiate it is you'll get a facial nerve palsy, which is nerve seven, cranial nerve seven. Sorry, you also get hearing loss, which is cranial nerve eight And that's what's gonna differentiate from the one below. Ok. That's probably a lot of information to take in. But essentially, you just have to sit here, look at the cranial nerves and then map it onto the area of the brain stem that it takes out and just sort of memorize the symptoms from there. So next, we have lateral medullary syndrome. So that's a blockage of the peaker that presents with these three points are the same as the one above. So they'll be the same, the main differentiating thing will be dysphagia. So, cranial nerves nine and 10 deal with um the pharynx and larynx muscles. So, swallowing. So if they're having issues swallowing, it's more, more likely to be lateral medullary syndrome and it's also called Wallenberg Syndrome. So, blockage of the PCA causes Weber Syndrome. Lateral content syndrome is caused by, caused by blockage of the ICA. And you'll see a facial, the palsy which differentiates it from the one below, which is lateral medullary syndrome. Blockage of the PCA and that causes dysphagia. So, issues swallowing. Ok. That makes sense. And then we have the F ba, ok. I think most people got it. Ok. Cool. So basically a 55 year old male, he's got sudden onset right-sided weakness and double vision and examination revealed he has the right sided weakness, left-sided torso, which is drooping, eyelid and the left eye is down and out which artery is most likely affected. So he's got contralateral weakness, but he's got an ipsilateral third nerve palsy. So, eye down and out and uh ptosis. So that's as I said, for that, we, that's a um issue with the posterior cerebral artery. So if we go back here, yeah, IPs lateral third and for the contralateral weakness, ok. Fine. And then I'm just gonna quickly touch on cerebellar strokes. Um Just because I think it's important to understand what the cerebellum does because you need to know like cerebellar exam and stuff fourth year, uh fourth year exams. So if you have an issue with the cerebellum, it causes the these symptoms here. So there's dysdiadokokinesia. So that's where you ca uh the patient can't do rapidly alternating movements. So I've got a picture here of, of what the test normally assesses. So they put their hand on top of the other, bring it up, um turn it around and bring it down and basically repeat that as fast as they can. And if they have cerebellar issues, they won't be able to do that ataxia. So difficulties walking, nystagmus, so issues with eye movement. So when you go to that of periphery, one eye will just start twitching or sometimes both eyes intention, tremor. So uncoordinated arm movements, uh slow speech and then hypertonia. So lack of muscle tone, uh an acronym that Danish. OK. I'm just gonna touch on this and then we'll, we'll, we'll ask any questions um if there's any questions after this because we can move on to management of strokes. So next, we have aphasias. So there's a couple of areas in the brain, one's called Broca's area, which is this orange here and that's in the inferior frontal lobe. And there's an area called Wernicke's area which is a superior temporal lobe. So a bit further back. So essentially brokers is responsible for articulating words in a sentence. So literally the physical physical action of producing the words with the mouth and Wernicke is at the back that's responsible for speech comprehension. So coming, coming up with the words in a sentence that makes sense basically. So if you have, yeah, but both of these are supplied by the middle uh middle cerebral artery, sorry if you have a problem with the Brons area, if that gets infarcted and that's not functioning as it should. The issue you're gonna notice is the person knows what they want to say, but they struggle actually producing the words. So the stuff still makes sense, but they're just really struggling to make, make the to say the sentence out loud. Basically, if you have an issue with Wernicke's area, the person has no issues with actually saying the words, but none of their words make sense. It might just be like a series of random words in a sentence. Um And then we have this link between the two areas called the arch fasciculus. And essentially, that joins the two areas together. And if they have a problem with that, the, the fluency of their words is fine and the comprehension is fine. So it all makes sense, but it's just they can't repeat things back to you and that's called a conduction aphasia. So, problems with broker's area is broker's Aphasia, Wenis area, Wenis, Aphasia. And then if a, if there's an issue with the Q ficus, that's a conduction aphasia. Cool. Ok. So before I start talking about investigation and management, I've rattled through, oh, what's that? Could you go back to the last slide after the SBA? Um There's that one. Yeah, I was gonna say that you more or less you more or less went back through it after you did the Oh, anyway, yeah, that's cool. Um All the slides should be made available and I think there'll be a recording as well if you want to go through it later on. But does that make sense to everyone? Has anyone got any questions on that before we move on to investigation and management. I'll take that as a no. Ok. Cool. Ok. So, so the f say you've got sus suspected stroke, the first thing you're gonna wanna do is you're gonna wanna investigate and that's normally with a noncontrast ct head. Now that's the Raman section. So I'm gonna leave that to him, but essentially Ati A is normally less serious. The reason why is because in Ati A, the neurological texture is completely gone. The reason why you wanna refer them to a stroke specialist is because if they've had Ati A, they've got a very high chance of having either another ti A or, or a stroke within seven days. So if they present to a GP saying I've had like yesterday, my husband noticed that I had issues with my face like my smile wasn't right. And it got better after half an hour and they come to the GP, they need to be referred to be seen within 24 hours by a stroke specialist. That's, that's if so within seven days of the ti A, if it goes past the seven day um boundary, then they, they just need like a one week referral to be seen within a week. Uh The reason why is because after a week, there's a lower chance of the ti a either recurring or a stroke happening. So it's important to refer to a stroke specialist. The other thing is you wanna start antiplatelets. So these guidelines keep changing every couple of years. So I think the current ones now I've tried to double check it with everything I can. So I think it's at the moment it's 300 mg of aspirin initially followed by 75 mg once daily for 21 days. And then clopidogrel, clo clopidogrel gets started by a specialist and that's basically a single dose of 300 mg followed by 75 mg once daily indefinitely. Um They, they come up quite a bit. So II had to memorize that. The other thing you wanna do is you wanna control all the cardiovascular risk factors. So you wanna check their BP, check their uh lipids, um check the HBA1C for diabetes and give sort of general diet and exercise advice. Um Imaging might be done. It's, it's not normally done for Ti Es but it might be done if the stroke specialist decides to. Um and also if they're on anticoagulants, they might decide to do act head um just to check for any, any bleeds. So that's the management of ati A, the treatment for a stroke is, is, is different depending on the type of stroke. So we're going to start off with ischemic stroke. So you have the initial management. If someone's had a stroke, they've just come into A&E the first thing you wanna do is you want to do a A two E, you want to make sure they're stable. So you work through the airway breathing circulation, uh check the blood glucose um as I'm exposing from head to toe just to make sure that there's nothing sort of life-threatening going on at that at that point. Um So the blood glucose, oxygen, temperature and temperature, sorry, and hydration, you want to maintain all of them in their normal sort of um boundaries. The only thing is BP, they might come in with a high BP. And the reason why is because the body is gonna wanna try and increase the BP to increase the perfusion in the brain to try and get past that blockage. Um The reason why you don't want to lower it initially is because if it's an ischemic stroke, if you lower the BP, the area of the brain that's not being perfused is gonna be larger and that's gonna have a worse, worse outcome later on. So initially, you don't want to lower the BP. Also, you might wanna make them mill by mouth because if they have issues swallowing, um, they could aspirate and then, um, if it goes like in pneumonia again, leads to worse outcomes. So you wanna aim for act head within, within one hour. The ct head is either gonna show you if it's a hemorrhage or not. And as long as it's not a hemorrhage, you're gonna go down this sort of stroke management. So there's thrombolysis and thrombectomy, which we're, we're gonna talk about what they are later on. But basically, if they're presented within 4.5 hours of their initial symptoms, so they said the symptoms started like two hours ago, whatever you can offer them both thrombolysis and thrombectomy. If it's happened more than 44.5 hours ago, so 4.5 hours, but less than 24 hours ago, you can offer them thrombectomy, which again, we'll talk about what that is. And if it's any more than 24 hours, it's normally just antiplatelets because at that point, it's too late to try and reverse the blood clot. And the antiplatelets are slightly different for a stroke. So it's aspirin 300 mg for 14 days, followed by cloy uh 75 mg indefinitely. Ok. Cool. So, in terms of what thrombolysis and thrombectomy actually are. So thrombolysis is the mechanical, sorry, the sort of chemical breakdown of a clot. Um, it's normally alter place that's given and it's what's called a tissue plasminogen activator. But without getting too sort of in depth, it activates a thing called plasmin, which basically breaks down the blood clot. So, if this happened within 4.5 hours of the stroke, you'll give this as a medi uh as a medication, it'll go into the blood and break down that blood clot to try and reperfuse the, the brain thrombectomy on the other side. That's like a surgical procedure. So it'll go into like an artery, probably the femoral artery and they'll try and manually fish out the blood clot with, with either sort of suction or sort of breaking that blood clot with a, a catheter. Um, and you could offer that up to 24 hours after the initial symptoms. If you look at the guidelines, it's a bit complicated as they say, like they might do an MRI to see whether there's a chance the brain can get reperfused. Um And if, if it, if there is still salva salvageable tissue, it will do the um a thrombectomy. But just for the sake of keeping it simple, just learn, learn them through lines. Cool. Ok. When did that be? Yeah. Oh, cool. I think most people have got the right answer. So essentially a 70 year old woman, um right-sided weakness, slurred speech. So she's had a stroke symptoms started two hours ago. Ct had said there's no hemorrhage and she's clinically stable. She's al already been given aspirin in the community. What's the next step in management? So, because it's less than 4.5 hours, she's eligible for both uh thrombolysis with PLS and thrombectomy, which most people got. Cool. OK. So hemorrhagic strokes are dealt with a little bit uh more differently. So if we go back to, so the initial management still stays the same. So the A two e maintain the blood glucose, oxygen temperature, uh make a meal by mouth until you screen that swallow BP. Ct all that kind of stuff that all stays the same. They'll do a CT head, they'll see there's a hemorrhage and the main things they want to do is at that point, they'll lower the BP. The reason why is because when it was just, when, if it's an ischemic stroke, you wanna keep it high to perfuse the brain. If it's a hemorrhagic stroke, you wanna lower it. So you're not forcing as much blood out into the brain. Uh And you're gonna, that, that would worsen any sort of neurological deficit. Importantly, if they're on any anticoagulation, you want to reverse anticoagulations. For example, if you're on Warfarin, you'd give them the reversal agent, which is prothrombin complex, concentrate complex, which are aware on that is um or if I need to give the reversal agent for that, um Just because you want to try and get the blood clotting again to decrease the hemorrhage. The most important thing is you want to refer them to neurosurgery. Cos realistically in the end, you can't really do anything for that. You've just gotta wait for the neurosurgeons to come and then they're gonna go in and mechanically fix the, the hemorrhage. Cool. OK. Does that make sense to everyone before I touch this? This is my last slide. Um If anyone's got any questions, give me a shout it out. Take that as a no. OK. So th this final slide just touches on um different other differentials to think of. So we've already talked about how to differentiate between a stroke and Ati Ati A normally resolves with within an hour. There's something called Todd. Todd's paresis or paralysis. Normally, after a seizure, patients can get quite weak. Um it might mimic a stroke in the sense that they'll have like arm weakness and leg weakness. But in the history, there will be some kind of preceding preceding seizure which which makes it known that it's not a stroke, migraine with aura. Um Normally, auras can vary quite a bit. People can have like sensation loss, um they can have visual issues. Uh But again, the big thing is it'll be they'll have a headache before it. And also they might also have a history of migraines as well. And after the migraines over it resolves completely, it won't have any sort of neurological deficit left. We have Bell's palsy. So Bell's palsy is literally just confined to the face. And the important thing is it also takes out the forehead muscles as well. So in a stroke, normally, if they've got face weak, they, they can still raise their eyebrows in Bell's palsy, they can't. Um So that's how to differentiate that multiple sclerosis. Normally, the history is quite characteristic. It's something like a woman in her forties, uh who had like issues with her vision six months ago, which resolved, she might have had like weakness three months ago that resolved. And now she's come back with like one arm that's weak. And the reason why that's multiple sclerosis is because one, the demographic two, the symptoms are disseminated in time and space and the symptoms resolve as well. Um So that's that and then neuropathy, so you can get peripheral nerve damage. So things like diabetes can cause um loss of sensation to your arms or legs. It can cause weakness. Um You could also have trauma that leads to like a foot drop or something. And that's, that's quite specific to the scenario. So you can differentiate that. Also, there's no central symptoms like dysphasia in neuropathies. I think that's my section done. Um So I'm gonna hand over to Rama and if anyone's got any questions, you can let me know someone's got a question in your chat. I've just sort of answer. I don't know if you wanna go, go through that quickly. Oh So basically, um so I said, why didn't you give clo grow at the F ba? Yeah. So basically, it's treatment for ischemic stroke. What normally happens is as soon as the stroke happens, they get given 300 mg of aspirin that's once daily for 14 days, the clopi started after them, 14 days are over. So from the 15th day onwards and if you look at the stem for the SBA, um she was given 300 mg of aspirin in the community already and it is the next best step in management. So you are going to do Thrombolysis and Thrombectomy. The, the copy is only touch after the 15th day. Does that make sense? Just to know these are UK nice guidelines. Um So it may differ if you're from another country or follow a different set of guidelines. But in the UK, this is generally what we do. Should I start presenting so you can take over? Oh, yes, please. Yeah. So I think I just pressed share an entire screen. Uh No. Shut up, shut up. Oh, nice. OK. Can you see that? Yeah. Oh, let me get. Ok. Um OK, sweet. So let's start with the poll just to assess how confident everyone is. Can you see that? Has that run up the pole? Yeah. Yeah. Cool. OK. Quite a strong but generally people can either do spot diagnoses or they're not sure. Uh with CTS. OK. That's fine. So let's start with some rapid just spot five diagnoses. We'll just see what level you guys are at and if you can kind of spot something that sticks out to you on it, easy head. Um So we'll do some pa for that. So this is the first one. Are we looking at a subdural hematoma? Are we looking at brain cancer? Are we looking at HSV causing encephalitis? Are we looking at extradural hematoma or multiple sclerosis? Just let some more responses go and then we'll start going through this quite quickly. OK. We've got quite a split in this one. So more people have put subdural actually, but this is an extradural hematoma. So we will go through this. Um So just remember uh with the CT head, the right side of the photo is the left side of the brain and the left side of the photo is the right side of the brain. So this is a an extra hematoma. Uh It's right side and it's bi it's bulging outwards. Um And this is a very important thing to notice and it helps you differentiate of subdural versus extradural. Um And it's limited by suture lines which means it can't spread throughout the whole brain. OK. Number two, what do you guys think this is encephalitis, a brain cancer called glioblastoma multiform, a subdural hematoma brain cancer called a meningioma or multiple sclerosis. If you guys about 30 seconds to go through this one as well. OK. So a bit of a split as well. But the majority of you are getting the correct answer, which is a Gliobastoma multiform. So this is on the left hand side, it's um in the frontal temporal region. So, towards the frontal lobe and the temporal lobe, um you can see this area around it is edema and this is the tumor itself. OK. Next one, rama you got a question. Um OK, I'll go through that just off this one. So uh three, is this a multiple sclerosis? Is it a chronic subdural hematoma? Is it anit, is it an acute subdural hematoma or is it a meningioma? So you won't really be able to point out suture lines on act. Um But it's something we can talk about when we get two sub juror and extra juror still on the image of question two. And has yours changed the slide or because mine changed, changed to three? I don't know what it is being a bit slow for everyone else. Um The same. Oh dear. I stop Sharia and reha tr it without the pointer. I feel like it's making it slow. Cos I remember the first couple of slides were being a bit slow. Really? Ok. Try that again. Um Can you see the, can you guys see I three now? The, the diagnosis? Ok. Yeah. Yeah. Ok. Nice. All right. I'll only use the pointer when it's relevant then. So um spot diagnosis. Three. OK. I'll let you guys an, I'll give you another 20 seconds or so to answer that then. Sorry about that. Ok. Good. About. Is it? No, I'm still, I'm getting feedback. Oh, no, sorry. It is. It is. Yeah. Ok. Yeah, we've got 11 responses. So, yeah, most of time you're getting the answer. Um So this is left-sided and it's an acute subdural hematoma. So the difference between a chronic and acute subdural hematoma, um you can tell sort of by the color. So an acute subdural hematoma will be hyperdense um which will mean it will be a bit brighter on the CT head again. We'll go through that a bit later and how we differentiate chronic and acute one? OK. Number four, we we've got, is it a multiple sclerosis? Is it a subarachnoid hemorrhage? Is it a me a meningioma or is it encephalitis or a chronic sub rheumato it on image three? OK. This is not working. Um I don't know why it's not updating. Is that, is that working now as I can see image four but not still on question three. OK. I might just do it. I haven't uploaded as a thing. So do you want to try just keeping it off the powerpoint mode and seeing if it's, but then it will be just, that would just be ready. Yeah. Um Do you wanna just present it and then I'll just tell you when to go to the next slide. Yeah, because I've, I haven't uploaded it and then I can upload it in the meantime. I think that's the only thing we can do. Sorry about that guys. OK. Oh We on uh 34. We were on four. Yeah. Uh Can everyone see four now? Yeah. Cool. Yeah, it's, it's, it's still the same poll from before. So if you scroll up in the chart, you should be able to see the same. Yeah. OK. Um Yeah, we've got a good amount of responses. So if you go to the answer, if you mean so yeah, this is subarachnoid hemorrhage. Um You can see hyperattenuation. So the brightness um in the Sylvia assistance, which is sort of the lateral bit. Um That's it. And you can see what we call a starfish stuff. So you can imagine when you do like a, a star jump, you kind of make that you put your arms out like a starfish and that's sort of what you, what you, what you can see on act head. OK. We go, we do one more just for the sake of time. Um Just pull that one quickly. So we're looking at motor neuron disease and acute subdural hematoma, chronic subdural hematoma, Guillain Barre or multiple sclerosis. OK. Should we go move on for me? Yep. So most of you got the right answer. This is a chronic subdural hematoma. So this is on the left side, it's crescent shaped. Um And then you can see this one is darker if you remember the other subdural hematoma we did that was quite light. Um But this is darker in comparison with chronically because over time when the blood stays there, it loses its density. OK. So we skip forward a bit. Let's skip past that. Yeah. So let's go through how a CT scan works. So essentially a CT scan is multiple x-rays hitting your head um at different times and there's like a projector that goes around in a circle around your head and there's like a beam that goes through through your head into the projector and the detector essentially detects how many X rays are picked up. Parts of your brain will absorb more x rays and parts of your brain won't absorb that many X rays. So if one part of your brain absorbs a lot of x rays, it's coded. So that, that appears very bright on an X ray. So your skull, for example, your bones are very, very dense. So they absorb lots of x-rays as a result on a CT head, they are called what we call hyperdense because they absorb lots, the detector doesn't pick up that many X rays and it appears very bright on a CT head. So this is why more denser materials like blood and bones appear brighter on a CT head. And this is measured through a unit. Um a sort of standardized metric unit called a Handfield unit. So the higher a house field unit is, the more dens it is. So the brighter it looks on act head and the less it, the less x-rays are absorbed by the detector, so we can move on to the next slide. So that's just a depiction of that. And as we can see, bone has a household unit of 2, 200 to 3000. Whereas air has a ho household of minus 100 we have lots of different mediums that you'd find in the brain between that. So let's go through some of that. To me, we've got our sort of four main bones, five main bones that make up the, the front of the head or the well part of the skull. So we've got the frontal bone, the spinal groin, the parietal bone, the temporal bone and the occipital bone. And if you look at the junction between the frontal temporal sphenoid and parietal, we've got that region there called the pterion. And if you go to the next slide, we can see that that region is clinically significant. So when we look at extradural hematomas, the region of the pterion is actually very significantly is very significant. This is because there's an artery that runs just behind it called the middle meningeal artery. And the teron is quite fragile. So in cases of trauma, that area can be punctured a lot, a lot more easily than any other part of the skull. And as a result, a middle, a middle meningeal artery rupture is quite common. Um And this is the most common cause of extradural hematoma, move on to the next slide. This is just a refresher of the layer of the scalp. So if you remember, we've got a skin and dense connective tissue at the top aponeurosis under that. And the loose connective tissue and the protium, which is sort of like a membrane that covers the bone and the protium lies above the bone and also underneath the bone as well. We move to the next slide and now we have the jira. So this is sort of quite relevant for a CT head in terms of thinking about your neuranatomy to figure out your clinical diagnoses. So as we went through, we have the scalp at the top, then we have our skull, which is the bone which appears very bright on the CT head and then we have our meningeal layers. So the meninges are the sort of membranes that coat the brain. And there are three different types of the meninges that you need to know about. The first layer is the dura mater, which is split into two layers. One is the parosteal layer, um which sticks to the bone and one is the meningeal layer which sticks to the second layer under which is the arachnoid mater. And then the third layer is the pia mater and the pia mater sticks directly onto the, onto the spinal column and on the brain and between the pia mater and the arachnoid mater, we have the subarachnoid space and I'm sure you guys are quite familiar with subarachnoid hemorrhages. So with a case of a subarachnoid hemorrhage, this is where the blood pools. Um I think we can move on to the next slide and then just to go through something called a bridging vein, bridging vein. So in the subarachnoid space, uh which we went through just before there are some veins that are touch there and those go all the way into the dura. And these are important because if the, if the venous sinuses get blocked, then these can offer a different route of venous drainage. However, they are quite fragile and they get more fragile over time. And also with alcohol use, and it's normally rupturing of these bridging veins that causes subdural hematomas with the next slide. And this is just to remind you of the sub space in a bit more detail. So the subarachnoid space is that sort of green bit on the um on the image. And this is just a reminder of the Arachnoid granulation. So if you look on the right side of the image, there's a little bubble. Um There you are called the Arachnoid granulations and these are out pouchings um that drain into the subarachnoid space. So CSF can float through there from the ventricles in the brain which we will go through goes into the subarachnoid space and then it drains into the, into the venous system and enters the blood circulation expired, please. And this is just a reminder of sort of the anatomy that we see on the CT head. So it's nice and labeled here. I just want you to appreciate the different lobes specifically on this image. So we've got the frontal lobe at the top, it's temporal about the side and the parietal lobe just under that. And then the occipital lobe behind that. And then if you see the thalamus between uh the purple bit just near the middle. Yeah. And if you imagine on the other side, there's the thalamus as well and the space in between those two thalamus that black bit there is the third ventricle on most easy heads underneath that. Underneath that. There you go. All right, next side, please. So this is just to go over the ventricle system quickly. So the ventricles produce the CSF that we've been talking about quite a lot. The cerebrospinal fluid, which is neuroprotective and very important for the brain. So, the ventricles themselves are where are, where the CSF is made and it's made in what we call choroid plexuses, which are different parts of the ventricles. And there are four ventricles. So there's two lateral ventricles, one on the left side of the brain and one on the right side of the brain. And there's a third ventricle and 1/4 ventricle. As we can see in the diagrams. And we can see the lateral ventricle is the largest ventricle and it goes all the way from the occipital lobe. And that's what we call the posterior horn of the lateral ventricle to the frontal temporal region of the brain, which we call the anterior horn of the lateral ventricle. And this is the, this is the ventricle that you'll see the most on a CT head. So it's important, you take note of the lateral ventricle, we move on to the next slide. Yeah. So this is just talking, go back up on the slide. Uh Yeah, So this is talking about how we connect the different ventricles together. Just a quick reminder. So the fore of Monro connects the lateral ventricle to the third ventricle. And then the cerebral aqueduct connects the third ventricle to the fourth ventricle. And then from the fourth ventricle, the CSF can drain into the subarachnoid space through other connections. All right. Next slide and again, this is just us putting it all together. I hope in this picture, you can appreciate the lateral ventricle a bit more. Um And the third ventricle which is between the two different thalamus that we identified in the previous slide. OK. Next slide, please. So how do we actually interpret to interpret a CT head? Um The main thing to do is to have a good structured approach. This is really important because if you get flustered in an exam or in a clinical setting, it's very, it's very easy to follow a nice structured approach. Um And your colleagues will appreciate that a lot also with medical handovers documentation a to it's always very important to follow a structured approach. So there's no confusion um and you can do things as quickly as possible. So how do we actually do this? The first thing you want to do is compare your patient details as with any form of imaging in in the medical field. Um This is just standard. So you look at the patient's name, their date of birth and their hospital number, if they have one. And then you say you would compare to any previous imaging that they have. And then when you're there, you can just call out any obvious diagnosis that you can see. So if you can see an obvious sub VMA, say it, if you see an obvious sub average, just say it, it saves time, it's more efficient and it gets the hard part out of the way after that, you can focus on going through the CT head in a systematic approach because you may miss something. It's not uncommon for a very ill patient to have multiple pathologies on a CT head. For example, an extradural hematoma can also coexist with a subdural hematoma or a patient with a brain tumor, might also have hydrocephalus or they might also have a bleed as well. So going through a structured approach can help you identify multiple things. At the same time. We follow a Pneumonic called blood can be very bad where B stands for bleeding. C stands for CB, stands for Ve Brain, and V stands for Ventricles and B stands for Bone. And we'll go through that in a systematic approach. I think I can present it. Now, you think it uploaded I do that nice. Um uh OK. So let's start with blood. Um Can you see my mouse that's all on the screen? So I can see yours. I don't know how you did that. Mm Wiglet. No, I can't see it. No. Ok. That's fine. I can see you as well. I'm not sure how no idea. Ok, that's fine. So, the first thing we wanna do is talk about blood. Um, so there's four main bleeds you wanna know. So, intracerebral bleeds, which are in the brain themselves and that's normally what we, um call strokes. Um, subdural bleeds, which we've touched them before. Extradural bleeds, which we've touched them before and subarach bleeds, which we also slightly touched them before. So any bleed will compress part of the brain in its skull. The skull acts like a container for the brain. And the problem with the skull is that it can't expand at all. It's a very, very hard bone, that's good because it protects us from the outside. But if something happens on the inside and the brain needs to, the brain needs to expand or there's just more space, the brain can get compressed very, very easily. And there's a certain limit to the amount of pressure that we can have in the brain. And that's called intracranial pressure. Anything that increases pressure in the brain raises the intracranial pressure. And that leads to a certain group of symptoms called um raised intracranial pressure symptoms. So, can anyone suggest in the chat any symptoms of raised intracranial pressure? So, we've got bradycardia, blurred vision, headache, nausea. Yeah, it's all good. Cushing's tried. It's very good. So going through this, we've got Cushing's response. So that's um hypotension with bradycardia. This is a very common sign. We've raised CP. It's very important to recognize in clinical practice. We've got postural headaches, vomiting, nausea, um altered G CS because you can imagine the cranial nerves will be compressed. Um and that can also affect cranial nerve three which can compress, which can then cause visual defects and cause pupil papillary defects um as well. And again, just to reiterate, these are all common um to all causes of anything that would increase the pressure in the brain. So whether that's bleeding, whether that's infection causing inflammation, whether that's tumor, that would all cause raised ICP symptoms. So, going through extradural hematoma. So as we went through earlier, we went through the meningeal layers and we saw how that looked on the CT uh with regards to an extradural hematoma. So, an extradural hematoma specifically is between the dura mater, which is the first layer of the meninges and the skull, the gyro is tightly adhered to the inner surface of the skull, which makes this attachment particularly strong at the suture lines. So as a result, the blood is essentially trapped in that space which makes the bleeding and the blood trapped form a biconvex or bulging outwards shape. And it can also be shaped like a lens. And just to not these, this is an extraaxial bleed. So it's outside of the brain, whereas an intraaxial bleed would be inside of the brain just to go through this quickly. For the sake of time, I'll, I'll run through it very quickly. But the most common cause of an extra hematoma is blunt force trauma. And as we talked about, it's the middle meningeal artery that's affected patients will commonly have a loss of consciousness and then they'll regain consciousness and the pa absolutely fine. And then they'll suddenly deteriorate very quickly after that. And that sudden regain of consciousness is what we call a lucid interval going through what we see on a city head. As I said, we see a biconvex of bulging or a lentiform shape. Um that's normally hypodense which means it's acute and it's a collection of the around the surface of the brain and it's limited by suture lines. So it can't move from that position um of the skull. And then conversely, we've got a subdural hematoma. So again, if we remember our meningeal layers, we have the JRA, we have the Arachnoid and we have the pier. So the subdural hematomas are commonly between the dura layer and the arachnoid layer, the subdural meaning under the dura. And this is to do with the bridging veins that we talked about earlier. So the bridging veins are normally quite fragile and they get more fragile with age and also with alcohol use. And if these rupture, then they can cause subdural hematomas in the space between the dura and the arachnoid layer. But again, this is still outside of the brain and it's not within the brain tissue itself. So we call it an extraaxial bleed. Again. These are commonly caused by low impact injuries, but they don't acutely present all the time. And the subdural bleed can become chronic over time and can present as a chronic subdural hematoma. I'll upload all of these slides because I know there's a lot on them for you to read. Um But generally the main risk factors are old Asian alcohol use and the clinical features are fluctuating consciousness and an increased level of confusion and sleepiness and personality changes over days to weeks. What we find on a CT head is a hyper or hypo depending on whether it's acute or chronic preenter shape collection. So I hope, I hope you can appreciate this is quite like a thin collection of blood that's quite long and present shape like a crescent moon. And it's not limited by the suture lines because it's not the duro layer that's being affected here. It's the space under it. So blood can pool around the brain a lot more. And I hope you notice on this image we'll go through it a bit later, but the ventricles um and the middle of the brain are completely shifted towards the um left hand side. And that's because the, the blood is essentially just packing the brain in and moving it to the other side. So this would present with symptoms of raised intracranial pressure. It would also present with symptoms specific to a subdural hematoma. And on the easy head, we'd be able to see what we call midline shifting, which is where the middle of the brain has moved to one side. We won't go through management today just for time. Um So another type of bleed is a subarachnoid hemorrhage. Um And we'll talk about the systems next, but essentially you see a hyperdense collection in the systems. So we can see labeled on this diagram, the Sylvian systems which are in the temporal region of the image on both sides and in the basal systems which are just just below them. But immediately. And in terms of what causes a subarachnoid hemorrhage, the main cause is again blunt trauma to the skull, but another cause if blunt trauma hasn't happened, um there are quite a few actually, but the main one is a rupture of blood and it sort of essentially dilates first and we call it a berry aneurysm and a barrier aneurysm. As many means talked about earlier can be caused by many things, but kidney problems can be one of them. Uh analysis can be another and coarctation of the aorta can be another one. And in this, in this bleed, like I said, we get bleeding below the subarachnoid below the arachnoid layer into the subarachnoid space. So between the arachnoid layer and the pier layer, in terms of clinical features, the main sort of thing you're seeing sort of questions would be uh a thunder CAPP headache or a headache to the back of the skull where a patient feels like they've been hit at the back of the head with a baseball bat. They also might have meningeal or meningism symptoms. So, again, headache, neck stiffness, photophobia and things like that. And finally, you can have an intracerebral bleed. Um So that's within the brain tissue itself, which we sort of covered earlier with the strokes. And this is more what you'd expect in a stroke. Um We can see in this one, we've got hypodense lesion of blood. Um which means there's been ischemic changes over time. Um which means the area is less dense and not acute, moving on to C. So we talked about B which is blood. Now we're gonna talk about C which is systems. So if you guys remember earlier, we had the subarachnoid space, we have what we call CNS. So that's where the, the subarachnoid space will open up and CSF can flow into that space. And remember that CSF was made in the ventricles and flows into the subarachnoid space. And in that subarachnoid space, we have cisterns which are open pools where CSF can stay um and build up there. So this is just a refresher of the anatomy. Um But I hope you can see the green section is the subarachnoid space. And if you look in certain different areas where there's red writing, we can see the different systems and this is where CSF can pull and build up. You don't need to memorize this at all. It's just to help you appreciate the anatomy going behind um where it can, where fluid can accumulate in the brain. So the main systems you want to think about on act head are shown in that photo, I've gotten gotten from GKI medics. So you wanna comment specifically on the S set system and the Sylvian system, I wouldn't worry too much about the Ambien system, but it's worth memorizing. So the suprasellar system is where your pituitary gland would normally sit sort of in that area in the middle of the brain. And the Sylvian system projects outwards to the temporal region. So remember with the subarach hemorrhage, we get bleeding in that space. So if there's an acute pooling of blood in that area, these areas in the systems will, will appear hyperdense and more bright on the CT head. And it's more commonly a subarachnoid hemorrhage where you'd be thinking of if you see hyperattenuation in the systems themselves. Again, just let me know if there's any questions regarding that. OK. So we've looked at brain, we looked at blood, we've looked at the systems and now we're looking at the brain itself. So what do we want to look out for? There's many, many things that can actually go wrong in the brain. Sometimes it might be an issue with the brain itself or sometimes it might be um as a result of another condition. For example, we have something called midline shifting, which I mentioned earlier where the brain can get pushed to one side, but anything can cause anything raising intracranial pressure can push the brain to one side. So we've got sub jaw hematomas, extra jaw, hematomas, hydrocephalus, even a massive tumor, you can simply just force the brain to go to the other side. There are other things such as masses. So tumors themselves um and sulcal effacement that just means thinning of the brain itself. And then we've got gray matter differentiation, gray white matter differentiation. So normally the brain is made up of two different types of matter, gray matter and white matter. Um if you lose the ability to look at them and differentiate them over time, it suggests generally hypoxia or a loss of blood supply over time. So here we've got evidence of midline shifting. Normally where that Rhine is, is where the brain should lie where the middle of the brain should lie. But this time, it's been completely shifted over to the left hand side. Um as a result of what we can see is an acute subdural hematoma and that it's called midline shifting and it's called, it's called ventricular shifting as well. So just where that arrow is, is where your later, what your, what your lateral ventricle is. And I should normally sit one on the left side and one on the right side. But in this case, it's been completely shifted across. And here we can see what we call so called effacement. So as we're midline shifting, this is not a diagnosis in itself but a symptom of another condition. And this is just decreased ability to differentiate between the gray matter and the white matter. The causes of that are edema tumors, hydrocephalus. So that's why we get too much fluid in the, in the individuals themselves, um bleeding and infections. So let's say you see a mass, let's say you see a bleed, a tumor. How do you comment on it? How do you actually say it to a colleague? So the things I want you to think about are, what side is the pathology on? Is it left sided or right sided? That's the first thing you want to think about. Is there a specific anatomical landmark predominantly covering that area? So, is it, is it in a ventricle? Is it in a lobe? Is it a fronto temporal region? Is it an occipital region? Think about those things and then think if the mass or bleed or whatever it is that you see, is it hyperdense or hypodense? So remember if it's hyperdense, it will appear brighter on the CT head. And if it's hypodense, it will appear darker and hyperdense normally indicates some sort of acute bleed or potentially even a tumor. So for example, if you had a glioblastoma multiform, which we'll cover shortly, you'll see something in, you might see it in the fronto temporal region and you want to comment on the density. So normally it would be hyperdense um itself and then you'll have edema covering it. So these are the tumors we wanna learn. Uh We've got meningiomas, which as you can tell by the name arise from the meninges. So normally on the outer aspect of the brain and this is the glioblastoma multiform we were talking about earlier and you can see around it, it's got an area of edema. So again, if you were to present that to someone, just think about what side is it on left or right side, we can see the glioblastoma multiform is on the left side. Uh It's in the frontotemporal region. It's I would say hypodense and it's got an area of edema surrounding it, which is that sort of ring of fluid around it. So just a quick SBA just to test you guys, I'll run the poll in a second. What do you guys think is the most common form of brain cancer? Is it glioblastoma multiple? Which I feel like I've said about 100 times already. Um A meningioma metas metastases, vestibular trauma or a pilocytic astrocytoma. OK. So we've got about 5050 split. Um Unfortunately, the answer is not glioblastoma multiform is actually a metastases. So brain cancer is secondary to metastases from somewhere else in the body. Be it in the bones, the lungs, the breast, the thyroid or the liver, and the most common form of brain cancer. And this is what we call secondary brain cancer because it's not originated in the brain itself. Uh A glioblastoma multiform is the most common primary tumor in adults. So it's not the most common form of brain cancer. And this is just an example of metastatic brain cancer. And you can see there's multiple hyperdense lesions in both the left side and the right side. And again, if you were to comment on them, just break it down into simple steps and present one at a time. So we've looked at blood, we looked at the systems, we looked at the brain. Now, we can look at the ventricles. So as I said, as we can appreciate, it's normally the lateral ventricles that we're looking at in a ct head. So the pathologies you want to look out for in act hat. Do you see my slides? Um I can see it, it stuck for you guys or is it still, is it moved on? It should be on the page that says ventricles? Yeah, still on the same side. Take over again for it. Um So I don't really know. I want slide 89. You wanna go for it? But I don't know. Can you guys see that now? Yeah. OK. OK. Sorry about that. Um So there's three things you wanna look out for in the ventricle So, bleeding, we call that intraventricular bleeding hydrocephalus. So that's when you get too much t sf um within the ventricles themselves. And remember it was made in the ventricles. Um, but if there's a drainage issue, it can build up in the ventricles and we get what's called a hydrocephalus. And thirdly, it's just calcification. So this is a hyperdense issue that we see in the ventricles and we'll see it later, but this is actually a very normal thing to see in, in elderly patients. Um But you might mistake it for a tumor or a bleed. So it's important to be able to make that differentiation. Ok, go to the next side. So this is an, an example of a an intraventricular bleed. Um It's an intracerebral hemorrhage because it's within the brain. So it's intraaxial, but this is intraventricular more specifically because it's within the ventricles themselves. Go to the next slide and this is what we call a hydrocephalus. So there's three different types of hydrocephalus. You need to know about there's obstructive, non obstructive and normal pressure. So this is an example of a normal pressure, hydrocephalus um won't go into too much detail. But the main thing patients present with is what we call the triad of wacky and wobbly so wet, meaning incontinence where patients they usually have no control of their urine and wet themselves throughout the day. Uh wacky, meaning they have become quite confused and you might notice personality changes in these patients. Um and wobbly, meaning gait disturbance. And what we see on a CT head is a hydrocephalus with ventriculomegaly, which means enlargement of the ventricles in the absence of or out of proportion to sulcal enlargement. So that just means the sulci which are the little infold of the brain don't enlarge in keeping with how big the ventricles are or they don't enlarge at all. And we manage that by draining all that excess CSF out into the peritoneum, which is part of your abdominal cavity. So that's a, that's a, that's an operation or procedure that can be done in a neurosurgery department uh or hospital. Thanks, bye. So this is just an example of calcification of the choroid plexuses. So, if we remember our neuroanatomy, the choroid plexuses where the CSF is made itself, but over time that can become calcified, um and that can be hyperdense. So just make sure that because that can look like a stroke, it can look like an acute bleed or even a tumor. But this is actually a very normal finding in patients. Ok. Next slide, please. So we looked up, we've looked at blood, we've looked at the cysts, we looked at the ventricles and now we looked at the brain and now we're looking at the bone. So it's unlikely you'll have to look at bones on the ct head. Most of the pathologies you'll look at in medical school will want to assess your ability to distinguish between different types of bleeds, um and hydrocephalus. However, it's just important to note this for completion. Um The most common bony abnormality you'll see on acc head is a fracture. Um So we can see on this, on this CT head, on the right hand side, there's a fracture, but it's unlikely you have to present something like this and you can get around it by just saying I cannot see any bony pathologies and that goes with any type of any type of um part of the assessment that you get through. If you don't see anything of note, just say I do not see any um pathologies within the brain. I do not see any pat pathologies within the veles. I do not see any pathologies within the bone and then move on as quickly as you can right next slide, please. So this is all the conditions I think are worth learning for your medical school exams. Um I've split it into sort of bleedings, infections, cancers, ventricle problems and autoimmune problems. Uh And I've also included some relevant MRI stuff um because you may have to interpret some MRI S, it's unlikely you'll ever get an MRI in sort of an OSK setting, but you might get them in S PA S and there are just certain signs you need to know. Um And I've included the imaging finding for them on the right of the table there. We on to the next slide I think we're at the end. Yeah, this is just something for you guys to test yourself with. Um once we release the slides, um or you can screenshot it now if you want. But this is just a little case that I've made um where I want you to in five minutes just present the ct head in the format. We've gone through, going through blood cisterns, ventricles, brain and bone. Um You have your most likely diagnosis based on that and then propose some sort of management plan um based on what you think this patient has, go to the next slide and then skip ahead to the next slide after that. Yeah. And these are just some resources I found useful um have to shout out gee medics because they're very, very helpful. Um The CT head video is good and also the OS resource where they have clinical cases that you can work through um where you can work on presenting it and actually presenting it out loud is where you really learn how to do things yourself because that's when you figure out what your weak spots are. And if you ever ever need to learn a single pathology or you wanna know, know where it goes, just go and type in that condition and then type in that condition and then radio pia. So subdural hematoma raped, ventricular megaly raped and you will see lots and lots of images um of the pathologies you need to learn. All right. Next slide, please. Yeah. Otherwise I think we're done. Thank you guys so much for sticking around. We've got a feedback form if you could fill that out. Um We really appreciate it if you all fill it out because it just makes us know what we're doing, right and what we're not doing, it would only take about a minute to fill out. Um, but otherwise if you have any questions, please let us know and I'll stop the recording now. Um If you are watching the recording, make sure you follow us on metal and during our sessions live because it's more interactive for us. Um But yeah, thank you all so much for coming.