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I was manning the registration table. I'm the social media officer and I'm the one who's been picking your notification quite a lot. Sorry about that. Um So the before I go on to talk, introduce the next speaker, please, when you got the chance speak to sponsors outside there. And our next speaker is uh Doctor Stuart Currie. He's an academic consultant, neuroradiologist, Basin leads uh he's funded through the leads hospitals, charity to increase um imaging based research, a keen educator. He has very various examiners. Um Teaching rolls through the R C are the BSN are, which is the British Society of Neuro Radiologist and the Royal College of Surgeons. Uh um And he's going to give a talk about the imaging of traumatic brain injury through the rocky bubble. Good. Thanks everyone. It's a great pleasure to be here and thanks very much for the invite. The S R T. This is the outline of the talk, which I'm aiming to be about an hour. Uh We're going to see a lot of traumatic brain injury and work out the pathophysiology behind it um and put it into imaging because that's what we are. We're images we like looking at pictures. Um, and therefore we have to go through this roadmap, the primary and secondary brain injury and pick that up, but we can't do that without this man. Now, I'm looking around the room, I'm looking at the average age and I'm wondering if anyone's actually heard of Rocky Balboa? Let's have a quick show of hands. Does anyone know who Rocky Balboa is? We've got a few over there? Okay. Actually, uh, just half and half then it seems, I think. So. That means let me ask another question. Does anyone have plans tonight to watch all movies of Rocky Balboa? That's a no. Okay. Great. So that means there are going to be huge spoilers here to tell you exactly what happens in these movies. So I wouldn't want to ruin it for anyone. So, who is Rocky? Well, Rocky's this guy, he's a boxer and he has been around for years, over 40 years, been included over eight movies. There's been a recent creed three for which he wasn't invited and we don't know what happened to him. We'll get onto that later, but you can see it started in 1977. Here in the UK has actually launched in 1976 in the US and he's had great success. We're going to start on the first three movies. Rocky one, Rocky to Rocky three. Let's get a Rocky one. So here are Rocky one. The first movie now does anyone know what Rocky did to make money in Rocky one? I'm looking for a friend here. Let's watch these movies recently. They're all. No, no one here. Ok. Well, to put it politely, Mickey Gold Mill up here in the middle was his trainer and he said, Rocky, you're a bump, you're nothing you're gonna match to nothing. You're gonna become nothing. You got nothing. He was really pejorative, really derogatory. And that's because Rocky would just go and fight for about $10 a night. Get beaten up. Sometimes he'd win. And in the morning you go down the docks and he try and earn money by being a loan shark collector. That was his life. He lived in Philadelphia. He lived in a tiny, little flat with nothing. Then we have the lady who's, what's the lady called down here on the bottom left? What's her name? Yes, Pete Agen. What's your name said? Uh, Riffat? So now I've got a friend. So Riffat says this person's Adrian. So do you want to give us an impression of Rocky saying Adrian Riffat, Adrian? That's okay. That's not bad. Does anyone think they can beat Riffat? Uh, call for Adrian anyone in the room? No one yet? Ok. So he Rocky with your Adrian, something like that. That Adrian was a shy retiring type. She worked in a pet stock. She had very little money and she had no confidence and that's because she was being beaten down by her older brother. But Rocky fancied her, but she wouldn't look at Rocky. She would always turn ahead and he would make a point of going in the shop just so he could see her. He didn't want to buy anything. He didn't want to buy a pet. He wanted to see the shy retiring agent. Now, who's the guy? Bottom left? Refract? Okay. So now we've got Apollo Creed. Apollo Creed. Now who is Apollo? Creed? Poly creed was the heavyweight champion of the world. That was him. He was the best. No one could stop him. He'd never been beaten, undisputed champion and he was due to fight, he wanted to fight and defend his championship, but his challenger pulled out. So he was left. What do I do? So his team, his management team and him said that's fine. We'll just challenge anyone. Anyone can come to me. I've beaten the best out down the best. I'm the best. Doesn't matter who's in the ring with me, get whoever you want. And they found Rocky and they said, give him a chance and his trainer said he's all wrong for his man. He's all wrong. He's a southpaw means he leaves with his left. But Apollo with this great confidence that I'll down him in three, get him in the ring. So Rocky went in the ring. He's now dating Adrian. He's full of confidence. And what happened at the end of Rocky one? He loses he doesn't lose. He goes the distance, the Bill Conti song going the distance. He stayed 15 rounds. This is important, 15 rounds, three minutes around. He took an absolute battering but he didn't lose. And what happened? They made a fortune on this movie and Stallone wrote it. They won three Oscars. He was nominated for best Oscar. Now we have to, of course, take that as a pinch because that was Stallone's first movie. Everyone thought he's playing a brilliant beaten up boxer. We've all seen Stallone in subsequent movies and he probably plays that same beating that boxer, but he won that nominee because of success. It led to number two and of course, because he hasn't been beaten. Apollo says, get him back, get him back in the ring. I'll down him in three. I'm the best I'm going to do. And at this time, Adrian has grown. She's got so much more confidence she's living with Rocky. She's married to Rocky. She's pregnant to Rocky's boy. She's left that horrible brother and now she is becoming the champion of the house, but she goes into a coma. There was, there was almost a cry. There she goes into a coma. A Rocky has been in this training for the rematch, has to sit with her night and day and he reads to Adrian as she's in this coma, as Adrian has taught him how to read and she wakes up and you know what she says to him, she says when and the music goes again. Bill Conti's music goes again and Rocky goes out and what happens at the end of number two, he doesn't lose, know, have more confidence he wins. He becomes the heavyweight champion of the world and they make a lot more money, which takes us to number three. Now, number three, Rocky is a multimillionaire. He's living in a massive mansion, he's buying whatever he wants. His trainer, Mickey is living with him, but Mickey's not very well. He's got a weak heart and this guy comes along bottom left. Who's that guy? God, I'm hearing it over there, Mr T, what's your name? Seth Matt. Give us your best Mr T impression. Any television program? A pity. The fool. That was good, man. I like that does ever know the 18. Yeah, Louise, you're saying, what did he say in the 18? You're a format. Yeah, that's right. And he would say I'm not getting on a plane. That was, that was here, wasn't it? That was it. So he's naming this movies. Clubber Lang. And he comes along and he says, you're a people's champion, you just fight paperweight people. There's no real boxing match and he challenges Rocky. Rocky says fine, I'll take you on. But at the time of Rocky going out, his manager suffers a heart attack. He has no heart in the fight and he loses within three rounds and he's lost his heavyweight championship, but then he finds Apollo creed and Apollo comes back and says, I'll train you, I'll train you in a new way. I'll make you faster. I'll make you better. I'll make you more agile and it goes for a rematch and Rocky easily wins, easily gets rid of Mr T. So what we're going to see now after my verbal synopsis is a video synopsis of those movies. And what I really want you to do here is just have a look at how much pounding these boxes are taking this last about 1.5 minutes, right? Is anyone heart pumping there? And that music? That excellent. Is anyone trains with that music? No one. Yes. Once you've tried exam either, but that's what you needed. He said I've reached my peak. That's it. Look at the pounding they got right head injury. That was 1977 the first one. So what's CT around then? Let's have a show of hands. 1977. CT was around. Yes, we've got a few hands. Majority saying no wave of CT around. Then I wasn't even born. Hmm. Anyone know who this guy is? Go and have a guess Hounsfield. He's not sir Godfrey Hounsfield, but he was instrumental with the Godfrey. This is James Ambrose. He was a neuroradiologist in Atkinson Morley, which is on the Georgia Georgia's and he was approached as was many neuroradiologist at the time by this scientists who says I've got this great contraption that's going to allow you to see inside people's skulls and you're no longer have to do Aaron carefully grams to diagnose anything in the head. And that guy was so Godfrey and this was cigar fees, drawing. And all these neurobiologists is what on earth is that? I wouldn't want to, anyone's head going in that. But James Ambrose says, no, no, I'll take a risk on that. That sounds good to me. I've had enough of injecting into people's groins and trying to guess where these tumors are in things. So of course, there it is. The CT came out and it came out in 1971 to 6 years before Rocky. And we can see this first ever CT taken showing the cyst in the right frontal lobe. And now we know it for its ease of access and all these other reasons. But when you see sir Godfrey lying in this washing machine when it first came out and you had patient's there going, is this gonna spin around me? It's my head going to spin and I don't know what's going to happen here. You know, there was, there was a lot of anxiety but still it took off and actually it took off even when we look here. Ok? It wasn't until 2007. That nice came out and said CT should be the gold standard rather than skull radiographs in 2007. Were you born in 2007. Mhm. So technology has improved. We know it's improved. I mean, look at this, we know now what this thing is on the bottom, right? It's quite easily. We can see that is a screw of some sort inside someone's brain taken in elite. We look at this and we go, what is that? You don't want to have a hazard. A guess of what that is inside this person's skill. It's tricky. We don't know what that is. You're looking for the slices. This is a single image. Okay. I'll give you the bone windows. Okay. Now, no, it's metallic but we still don't know what it is. But now we can do three D Ricans and we go, it's another screw. What is it with people in leeds and look at this. What do you think made this happen? Shout a bit louder. A hammer. That's right. A hammer. Look, here's the hammer whack. So now he's got this picture of leads of this crazed man going around with his belt and he's got his hammer and he's got his nails and he's doing a lot of damage. Uh But of course we still get this. What causes this? A gunshot wound? Yeah, I mean, look, we can see it. There's the bullet going all the way through. We don't tend to see this much in clinical practice because of course, these people are dead. They're probably dead at the time. But we said, I haven't got that from my collection. Uh Let's get that scan done uh as quickly as possible for people to ask questions. Um So, of course, with all this technology that's coming around, it's tricky for us guys, tricky for you. You know, you get polytrauma as of thousands of thousands of images now that you have to look through. So we have to utilize it. We can do this, we can have a look at the person here. We can spin it around. We can see quite clearly on the soft tissue windows of this three D reconstruction that they're sat on the CT, they've got the strap around the head and then what we can do is we can just retract a little bit by windowing. Now, you can see that depressed skull on this person. We now can put in our visual interpretation and see exactly how this impact has happened. And then when we go to the bone windows itself, we can see exactly that horrible, horrible compressed depressive communicated fracture. And we can do more, we can do three D planers. We can actually make some more blood type of windows to see exactly where that hematoma is. There's so much more an offer and we've got to utilize that. Now, I tell you there's a fracture on this skull. Ct you're scrambling to find out exactly where that fracture is. But you use what we have now and say, well, there's a soft tissue hematoma over the frontal bone. Let's have a look there on bone windows, okay. There's the fracture. It's so much easier than trying to look on that actual slice and get it there. So technology has improved and it continues to improve. We're now in the age of ai and outsourcing companies are now adopting these algorithms such as a doc, which is a little additional point to help the radiologist that says, I think there's blood on this ct here it is. What do you think, Mr and Mrs radiologist? And we have to say yes or no to agree to that and sometimes they're wrong, but most of the time that bang on it and it's getting much, much, much better. So what have we seen in these first three Rocky movies where you saw Rocky took an absolute hammering, he gave some back. But where are we on our journey through the head injury? Well, he certainly had a primary head injury most of its extracranial and he had a lot of bruising, a lot of soft tissue bruising, particularly over the orbits. Uh He may have had a skull fracture but where does that count on the scale of traumatic head injury? Where do we think Rocky was? He was still standing up? I was going to say he's still coherent but he was still talking. That's Rocky. What is it G C S? He was walking around, he was usually everything. It's 15 isn't it? So we're skowron him here as a mild traumatic brain injury. But note on this table, even when we go to moderate and severe traumatic brain injury, you can still have a normal imaging. And therefore most of it is based on that G C S. And most of the research coming out is saying if your G C S is 13 or lower, then your mortality rate is much, much more substantial. And so the Australians don't measure it here. They would say actually a mild traumatic brain injury is something that's 14 or 15 G C S. They consider uh 13 to be part of the moderate severity. And you're all familiar with the nice guidelines that have come in all though. I'm sure no one ever pays attention to that apart from the requesting junior that says according to nice guidelines and then it gets done. Yeah, sir, we're on our scale. Primary secretary brain injury. We've looked at extracranial. What about this intracranial component? When we go inside the skull? We've got to think well, is this inside the brain itself or is this extra axial? So it's inside the skull but outside the brain. And when we think about inside the brain itself, these two main conditions, contusions and a few sex title injury. And when we go in there, these three familiar bits of blood, the extradural, the subdural, the subarachnoid when we get to secretary, which we're gonna talk on later. We'll see how all of these things are going to impact the brain, leading to brain herniation, leading to vascular insult, leading to in function and hemorrhage. But to do that, we have to go to number four. Now what happens in number four? Who's the big guy there? Huge, isn't it? Who is he that for? You're dying to say something here. He's Drago, he's Ivan Drago. So this is Dolph Lundgren playing Ivan Drago and Ivan Drago is a Russian and this was said in the Cold War. So the Americans have to outdo the Russians, Russians trying to outdo the Americans. But what the Americans have up their sleeve is that they consider the Russians to be dope fiends to do anything. The Russians just take drugs. So what we have now is a Russian challenger who comes to the US and says, I'm the best. I've been trained on these amazing athletic equipment. Nothing to do with drugs and I want to take on your champion, Rocky. But what actually happens is Apollo comes back. We all have Apollo because he's the best heel down him in three. He's no, he's not under speed anymore because he's been by Rocky and he is in retirement, but he still thinks he's great and he says, don't worry about this. Bum. He's a chump. I'll take him in the ring, I'll beat him Rocky and then after that, you can have it, but I'm gonna make an exhibition fight. So what we're going to do now is we're gonna join a video of that exhibition fight. So we've got Ivan Drago in the ring with Apollo Creek and this is just round too. This is it. And what Apollo has said. So Rocky is no matter what, no matter what, don't throw in that town, no matter what. Yeah, it's on for round two dancing around the lights appear to be still a little rowley hands up, hands up and now it is the Washington standing there, the Russian trying to intimidate free and the tries to step in and he's told, yes, I've never seen a bottle tape so much. Okay. Okay. Yeah. Yeah, there is no. So Luke Pandemonium, what you can do it, what it means really job. What's the stretcher? Somebody said first what started out freed appears to be in very serious condition you guys done. So you can see the Oscar pose at the end. They're both going for best actor. They're looking at each other. Now, what was anyone's favorite part of that video clip? Another thing that really struck anyone on that particular video clip. There were two for me. One that Apollo Creed was taking an absolute beating and he was, was that he was on the ropes, his eyes were shut. He shouldn't have been able to communicate a tool. But somehow he sees Rocky pick up the white towel and turns around to him just as strong as opposed to in the face is no, don't throw it because of course, that's lunacy. It can't happen. And the second is the doctor that's there who says, oh, creed appears to be in very serious trouble. That's me out. I can't really do anything. Um, thanks very much. We'd all love that role. But that was the role of the doctor back then. This was 19 eighties. There's no paramedics in there. There's no doctors there, there's no oxygen. There, people begin pounded, starvation of oxygen to the brain and no medical help whatsoever. So, what do we think could be happening now? To Apollo creed. He's on the floor. He's having a seizure. He's in serious trouble. What's happening inside the skull? What can we come up with? Don't be shy. He's probably gonna bleed. That's right. He's probably got a bleed. That's right. So if we look at that bleed, he may have an extradural hematoma. He may have very commonly associated with skull fractures. We like to think of them as lemons uh because of their shape or maybe that's just me. Um I don't always have to be associated with skill fractures, but there's a high percentage, 95% or so. And we could do our three D Ricans and create some great pictures. They don't have to be just unilateral, they could be bilateral, some associated with fracture. The other one not associated with fracture were told they don't cross suture line So how do we explain this extradural hematoma? What's happened here? I made a bill. It might, it might be multiple extradural. So one on either side, yeah, any other explanation correct if there's a fracture there, particularly that fracture takes out the superior social sinus. And actually what we have is a venous bleed into the extradural space and surgeon then rushes in and takes it out. But this is on the surface, this is extradural. So it's on the surface of the Europe at Pacman enj overlying the brain. So what fruit would I associate with a subdural? A banana? Yeah, it looks like a banana just like we saw before. So these crescentic high densities of urals. So these will be underneath the juror and therefore sat on top of the leptomeninges covering the brain. And the surgeons go in pierce the juror doing the burr hole usually drainage here. We've got a true craniectomy and you can see it lying on top of the brain that you would take off, but it's not going into the sole site. It's not going into the sole site because that is where the pia mater sits below the arachnoid mater in the sub arachnoid space. And that's why we can see the sub arachnoid blood in the sole side in the sylvian fissure is. And you're all used to seeing this type of pattern of blood multifocal, sometimes with the subdural, sometimes with the subarachnoid at the time apart. From blood. Anything else as a general? Not here. We're talking about rocky anymore. What else could be found in the setting of trauma and the spaces if it's not fluid, what would you say? So it could be a real and we get this thing called the Mount Fuji signs. I think this is a terrible sign. We have some great signs in radiology, truly great signs. But look at that. That's Mount Fuji and that is our sign of tension, pneumocephalus pressing down on the frontal lobes. So this is where we have to have the Star Wars fans who said, I agree, Stuart, get rid of that Mount Fuji sign. This is now the Millennium Falcon sign and that is so much better. It just rings true. But if that's in the subdural space and here's pneumocephalus in the subarachnoid space doing exactly what the blood was doing following the salts. I following the PM eight. Er that's in the extraction space. Let's go into the brain itself. Let's have a look at these two things contusions and then the D A I and what I want you to do here is watch the next video. It doesn't matter if you watch the top or the bottom and we'll repeat it, but just watch what's happening to this dummy. Uh huh. So what we've seen is that car is traveling, it has to stop that kinetic energy has to go, it hits the wall. But the dummy moves forward and the dummy either hits the airbag or hits straight into the windscreen. And as that skull hits the windscreen, the brain is still moving inside the skull. So the brain hits the skull and that's what's causing the contusion. And of course, when we look at where that brain is gonna be, it's gonna hit the familial structures, it's gonna hit the inside of the frontal bones. It's gonna hit the petrus ridges. It's gonna hit the sphenoid bones as it ricochets back. It's gonna drag along the Kristic alley in the anterior cranial fossa going to cause more damage. It's going to come back against the petrus ridges and the top of the mastoids and cause more damage. So that's where we should be looking for our contusional injury. As we can see here, lower frontal lobes, bilaterally, temporal lobes, bilaterally, particularly just above those mastoids as it ricochets back. And we can see the damage it causes on the pathology sample where we have true gliosis iss and volume loss. I found this interesting this statement here. A punch by a professional boxer has been estimated to generate the same force and impact as being hit by 6 kg bowling ball rolling at 20 miles an hour. Now, as an academic, I want some of that research, I mean, goodness me, that is tremendous isn't, I don't know how I get that funding money to sit in front of a panel. And so I just want to go bowling and I just want to do a bit of boxing. That would be awesome. But it is true. You know, is that the same in reality of being hit by that steroid induced Russian in Rocky Four. So Apollo creed would have been going through these forces linear acceleration. His head is going back and forth, but it's also rotating as it's doing it and then he gets a shock as he hits the canvas and he gets that really impact deceleration. He's had all of that thrown at him. And it's those things that not only lead to the damage we've seen here, particularly with the subdural hematoma is that box is high, likely to get, but also the diffuse axonal injury, the diffuse swelling of the brain, the loss of the normal souls I receive and these bits of particular hemorrhage we see generally at the gray white matter junction. Why do we do that? Because grey matter is generally filled with cell bodies, neuronal bodies, the axons leave and go into the white matter and the shearing rotational forces are cleaving the cell body from the axon. Now, we can't see that on imaging were completely reliant on the little vessels that run with that to burst and it's that vessel bursting that gives us these microhemorrhages. And then we can see the diffuse external injury here. We've got a person that's had a traumatic brain injury and we've got complete loss of soul side and that's all we can really say. But the best assist is telling us on the intensive care unit, they're not waking up, they're not doing as they're meant to do. So, what can we offer as images? What can we say? Bad luck. That's all we've got. Well, we have a bit more now, don't we? We have the MRI. So what sequence did you go for to look for blood on MRI? You could try flare, flare is particularly good for acute subarachnoid hemorrhage. But we tend to go for the new susceptibility wage imaging which is a gradient echo based gradient echo where the magnet doesn't like the heavy metal, it doesn't like iron and it gives us a black signal because it doesn't. So the blood shows up. And now we've got the diffuse axonal imaging pattern that we didn't see on CT here, we can see the pathology sample of all those holes of the neuronal degeneration left by that egg zonal will layer into generation. Great places to look for subtle diffuse axonal injury is the corpus callosum and the forex. These will give you subtle hemorrhages and give you clues to where that few sex only injury is happening. But you've also got to be cognizant of the reald diffuse brain swelling where all the systems are down, all the soul side down. If you have a look at this slide, go to the bottom. Right first, this is the susceptibility weighted image which shows all that black. So this is blood, this is a diffuse axonal injury to the corpus callosum. Let's work our way through those imaging. Next to that on the left bottom is a standard T two star graded echo still showing the blood but not as much. We've got this very powerful three D S WI sequence. Now, if we go to the bottom left, this is our diffusion weighted imaging of A B 1000 bottom left. And next to it, on the right is an ABC apparent diffusion coefficient map that still shows as abnormality. But it's saying the water molecules aren't moving very well. That's what we can tell from there. But we go to the top, right. That's essential T one showing a Dema within the corpus callosum. We can see that on the flare and T to as high signal. Now, if we go to the CT CT was there, the CT was showing the corpus callosum is low sick, the low density it was there already. We could have suggested that on our CT reports knowing where diffuse axonal injury happens. So we're now at this situation where Apollo creed is on the canvas. We've suggested he may have extra actual blood. We've suggested he could have diffuse axonal injury, diffuse brain swelling that still doesn't explain particularly why he's about to die. So we have to go to this secondary head injury where the primary head injury is the initial insult there it is bang, it's done. The secondary is coming after that initial impact where we're looking at brain swelling, herniation and vascular insult. And we have to go to this Professor Munro and what he said was in a normal state. We should only have three things in the skull. We should have a brain, we should have some blood and we should have some CSF that's it, treat it like a closed box. But if you introduce anything else into that closed box, the pressure has to change and things has to give. So if we introduce blood into that closed box, what happens is generally the blood shrinks first, venous sinuses shrink. CSF tends to reduce the ventricles, compensate by becoming smaller. But then if this blood is growing, the brain has to move spaces, it has to move. So it might move from the supratentorial compartment typically down into the posterior fossa. And by doing that, it creates this herniation and the most common herniations, we will see our sub Paulson herniation where one cerebral hemisphere moves under the falx to the other side. And you'd be they're measuring a degree of shift. I no doubt on your CTS or descending trans tentorial herniation where the cerebrum, typically, the uncus followed by the parahippocampal gyri go down through the tentorium, insura and press on the brain step. So let's have a look. Here's subfalcine herniation, the subdural hematoma, subarachnoid hemorrhage causing that shift to the right, that's to the left. Sorry. Here, we've got a great example of descending transtentorial herniation. And the reason why it's a great example, just look at the temporal horn of the right lateral ventricle here. That's not going to be there. It's going to be here. This is descending trans tentorial herniation. The youngest has gone first. It's pulling with it, the parahippocampal gyrus and then it's pressing on the brain stem and what sits there, the third nerves, the third nerves are coming out of the mid brain. And that's why we're here. Things such as the people's are blown. They've lost the oculomotor function as you get descending transtentorial herniation that could put pressure on the cerebellum and then you get your tonsil herniation. Another example, now we're seeing the tonsil herniation with subarachnoid hemorrhage at the foramen magnum. But we have something else on here. Now, as we have brain shifting, the brain presses against vasculature. What's it gonna press against with sub Dalcin herniation? What's the vessel that's gonna press against? That's right. The anterior cerebral artery is gonna press against the A C A. So we've got to look for A C A territory, infarction. What vessel is bound to be affected as the uncles is going down as the parahippocampal gyrus is coming down. What vessel comes around the mid brain going back with the PCA? So we should be looking at the PCA territory and say is there in function, we should be doing that as part of our routine. So here sub Pahlsson herniation, descending, transtentorial herniation has early hydrocephalus. All due to that subdural. They've had that taken out. But what do we have left PCA infarct on the left? A say infarct on the left all caused by that pressure effect with the brain herniation. So, could anything save Apollo? Creed. What do we think if Apollo was boxing nowadays? What could save him? I know craniotomy. That's about it. Cranials me now, what's this person being left with? Yes, they've had the cranial to me. Yes, they're still alive. We can see the contusional insult they've had to the brain just above those mastoids as we've said. But they've got this infarct here a piece, a infarct involving the visual cortex because of the brain herniation. They had similarly on this one. You think diffuse brain swelling, there's extra actual blood. They've had a craniotomy. What life have they got? The whole right? Cerebral hemisphere has infarcted because of the brain herniation and the pressure upon with arterial structures. And you can see the contusions above the mastoid on the left. Okay. Let's think outside direct trauma to the head now and think in the setting of any trauma, what other damage can the brain receive? Okay. Is that clear? So, I'm not talking about direct head trauma. I'm talking about trauma somewhere else in the body, but the brain's still being affected and to do that we'll have a look at this very short video. So here's Rocky, we're going to pick up Rocky. Now, what's happened here is he's just lost Mickey in Rocky three and he's angry. So he's thrown away his helmet. Never a good thing to do when you're about to go on a bike. But he's angry. He's riding angrily and he leaves for Adelphia and he comes in here. He's got to say hello to Adrian is Adrian there. Hello, Adrian Francis's biking. So what's rocky just done? Then? What's likely to have happened there? He gets brought into any on his polytrauma board taken up by a helicopter comes down has his full polytrauma. See tears are all used to. Now he's on the ICU and intensive. This is saying he's really not behavior very well doc, yeah, he's not behaving as I would expect for someone with these type of injuries. And you've told me a CT brain, it just shows a bit of swelling. What else could happen? Anyone have any ideas? Well, this was his M R and here we have this flare on the left and we have susceptibility weight imaging right in there, middle left. And then we have diffusion weighted imaging on the far right. And we can see all this particular restricted diffusion on there. We can see all this high T two signal on the flare. And we've got all these dark, very, very, very tiny bits of dark on the susceptibility, weight imaging. And he's in, he's not responsive G C S is seven. What do we think is going on? Say again, diffuse sex of injuries a good thought. But it's not in this case. And it will be the radiologist that tells them what's happened because the radiologist says I still have all his imaging. Let's have a look at his imaging. Ah, that's Rockies leg. So, what are we thinking? Now? He's got fat embolism, fat embolisms traveled up. It's gone through the pulmonary artery vision system. It's in the venous system is clogged. A load of the vessels, venous structures in his brain has led to that typical appearances of fat embolism. So as we move along, what do we look for in chronic traumatic brain injury? This is really important. We had an M D T in recent years where the neurologist brought scans similar to this and said we can't find a reason for this person having so many in fuck's. And the new radiologist said that's because they're not, this is prior traumatic brain injury. And this 32 year old had undergone hundreds of thousands of pounds worth of tests to see why he was having infarct because it was misdiagnosed by someone else. These are the classic appearances, you know, now the pattern of traumatic brain injury, frontal lobes, temporal lobes anteriorly, posteriorly around the mastoids, it then loses volume atrophy, it undergoes some sort of repair gliosis. So summary, so far, we've said first ct 1971 we've said things have really changed. We can got a stack of imaging now to look at, but we can use what's available to us to spot the best we can. We can think about fruit. We're all getting a bit hungry. We may have to get to MRI particularly to look for the diffuse axonal injury. We can think about other causes of encephalitis, the related to trauma including the fat emboli. We must be cognizant of what the effects of that primary trauma will be in terms of brain herniation. But we don't just say brain herniation. We follow in our reports to say whether there is infarction or there is not infarction because we're clinical radiologist, we know what's going to happen to this person if they are not going under neurosurgery treatment. And we're going to look for that chronic pattern. We're not going to misdiagnose infarcts particularly in the young. So we can see in Rocky 12 and three, it was mainly up their primary head injury, extracranial, maybe some facial fractures. We've done Rocky Four and we've said creed is dead, probably covered all those things. Oh, Rocky five considered the worst movie. It took the least money so much. So it had so many complaints that Balboa said I'm going to make 1/6. So what happens Iraqi five? But Rocky Five happens straight after Rocky four. Rocky four, Rockies been over to Russia he's fought Dolph Lundgren, Ivan Drago and he's beaten him and he's come back and he's found out that his brother in law has lost all his money because he signed over power of attorney to a hapless accountant. And that accountant has taken it all invested it poorly and all the money's got. So Rocky has to go back, leave his mansion, it goes back to Philadelphia. It goes to the same old house just about, he takes his wife and now he has a kid who's around about 11 or 12 called Robert. So here's an accountant that came through leads, uh, 10 years ago. And I like to think of his Rockies accountant because he's lost the champs money and he was having a really bad day and he took a rock and he just pounded his skull. That was the history. He just pounded a skull to make this big hole in his frontal bones and he was still alive. So he then took a stick and he put a stick through the hole and you can see the contusions there that's been caused. I don't think that really happened to Rocky's accountant. So now that Rocky is down on his money, he says I need to go back fighting, I need to need to get back fighting. So he goes to see some doctors and let's have a look and see what happens at this. It may be a lag on this, but let's see, what happens because of the continuous violent blows to the head. You developed a condition particular to boxers called cave in septum pellicula, which is a hole in the membrane separating the ventricles. The brain surface neurons in this area have also been traumatized. Excuse me. Doctor simply stated, Mr Balboa, it means that you've suffered some damage to the brain. How long until he recovers the effects of the reverse? You know, you have to retire. I don't want to retire. He doesn't want to retire. He don't want to live at that part of Philadelphia. He's used to the good things in life. What do we spot there on the imaging? What on earth is that? What is that? 1990 is the Americans? Well, what I like about it is you're going to the top and you go, well, that's patient confidentiality. That's good. I can't see anything there. That's saying that's Mr Balboa's head. But where is the cave um set to pollution? Um They've given us an actual slice nowhere near where we need to look. The satchels of Parasagittal and the Corona Als. And then they put a lot of color on it and then they've given it a sort of graphic representation and then they tell us it's a cave um septum pellicula. Um I don't know how many times that was take, you know, they had to get a second doctor to go. Uh He can't pronounce uh Lucidum. So I'm just going to say there's just been trauma. This is what we're talking about the cave. Um septum pollution. Um This opening filled with CSF between the lateral ventricles opening up of the septum. And why is this important? Because all these people produced research at this time and said the cave, um septum pollution um is associated with chronic chronic traumatic encephalopathy boxes that have this should no longer box, which is why Rocky said I can't fight. And it's thought to be these fit forces that we've seen before. The sheer forces the rotational forces that open up little gaps and create this new CSF space. Little micro cheers caused by repetitive head injury. So what we found then is Rocky becomes a trainer. He takes up the um sports arena that was left by Mickey Gold Mill who died and he starts training Tommy Gun, Tommy Gunn this young up and coming champ and he takes event as a, as a son. But then Tommy gets a bit restless and said I should be the champion now. And Rocky says, calm down, you'll get there in the end. But let's do some fighting until this guy comes along on Tommy guns shoulder and he's George Washington Duke. And what he does is he proclaims and that's pretty much his acting. I have to proclaim whatever I say. And he's taking off this guy who's Don King at the time. He was a massive boxing promoter and in the end of the movie, what happens is Rocky and Tommy Fallout because George Washington Duke tries to get Tommy and Rocky in the ring together and Rocky says no. So instead they have a street fight, they have a street fight outside of Rocky's house, the streets of Philadelphia. And what happens at the end, Rocky wins and still own thought. That's the perfect ending. How long he was? But he thought, how can I get back? Luckily, this neurologist in Australia said, I've looked at all the evidence and there's no association between boxing, repetitive head trauma and the cave in septum pollution. Um So what does that mean for Rocky? He can fight again? He gets his license back and he's back this time though. He has a very, very young Mason. The line Dixon undisputed heavyweight champion of the world. Rocky is now 60 mesa is 30 and the reason to get in the ring is because an A I machine said if Rocky at the height of his power was to fight Mason, now Rocky would win and for some reason that upset Mason. So he says to Balboa, get in the ring and Barbara says, sure. And what happens at the end? Rocky doesn't win but he goes the distance and he leaves happy in the knowledge that he's actually fought to this person half his age and didn't get knocked out. So let's have a little recap where we are with Rocky. A proclamation. You're 60. Uh, the guys are nearing the end. But what we have to do now is touch on this the last five minutes. So, is rocky at risk of developing chronic traumatic encephalopathy. You're shaking your head vigorously there, sir. He'll say he's bound to do it. Is he, he's bound to. Let's have a look at the evidence, repetitive head trauma and it's been believed for decades. Let's have a look at these decades. How long 19 twenties it was first reported. Actually, if we look at this timeline, let me put some circles around. It's quite a big graph. 1928 Martin first said there's something going on here with boxes undergoing cognitive decline. 1977 the phrase of dementia poor logistica was phrased. That's prognosis, meaning fist. So this is the punch drunk person, repetitive head trauma. We see more developments and then finally we get a consensus with criteria in 2015. There is concussive blows, certainly, but it's these sub concussive blows, but the patient still feels fine but they've had repetitive head injury. We don't just see it in boxing. What other sports have we been seeing? Rugby, ice hockey, ice hockey is a funny one for me because, you know, they shouldn't have head trauma, but of course, they all get into fights, take off their helmets and start hitting each other. So it sort of falls down to boxing. But you're absolutely right. American film was a big one, they're paying out billions of dollars. And outside of sport, we've also got to remember the abuse women and men suffer at home comes under the same umbrella and people that are serving in wars come under the same umbrella with the blows that they have uh from the explosions. So what we see is if you take a head injury, normally one would have a recovery phase before they may get hit again. But particularly here in rugby, in boxing, they don't have that recovery phase. In fact, they have that vulnerability phase where the next head injury comes. There is no recovery. We've seen it in recent years with Alan Shearer getting on an MRI scan because of the guy on the top. Right? That's Jeff Fast. All. And his daughter said, I think he's died of chronic traumatic encephalopathy. He played for West Brom and England and then there's Willie Stewart on the bottom, right? He's the leading expert in the UK on chronic traumatic encephalopathy. He's a neuropathologist in Glasgow who received a large grant from the F A to look into the effects of heading football on chronic traumatic encephalopathy. So we know it's happening in football players as well. But what is it? Chronic traumatic encephalopathy is a towel opathy. It involves the deposition of Tau. Tau is a protein. There are six Aisa forms, these are crucial proteins that help stabilize microtubulin, particularly in neurons. And it's thought that these repeated head injuries cause some disassociation with these tiny proteins and they start aggregating, forming neurofibrillary tangles. Other two opathy is you'll be familiar with Alzheimer's disease. You may have heard of frontal temporal dementia. You may have heard of progressive supernuclear palsy. This is all falling under the same umbrella but it has a different pattern of distribution. So at first in these first four stages, in stage one, it accumulates deep inside the sole side, perry vascular spaces, predominant in the frontal lobes. Then it becomes much more widespread until you can see stage four where red indicates the deposition of towel, it's all over and it's still going into the entorhinal cortex which is in the medial temporal lobes. And we can see why it has an effect on cognition on memory, on function. But note here as a structural imager, we can use MRI and our best to diagnose CT or help to diagnose CT is looking for that cave um septum collusive um looking for increased ventricular dimensions because of underlying brain atrophy. And these patient's also get this pigmentation of the substantia nigra and something called the locus ceruleus which is down in the ponds, but we can't diagnose CT CT is only diagnosed postmortem. But do we have imaging biomarkers? This is probably our best. Here's a pet trace er and you're going to hear some great talks on nuclear medicine shortly and this is uh Flowertown Sapir and this should be depositing exactly where those uh towel deposits are and showing up. So here we can see much, much more red on the left compared to the normal control on the right. But it's still not brilliant because it all depends on how those neurofibrillary tangles are depositing to whether we get through binding. So the last few slides, how does all that affect Rocky? Well, just because you've had repetitive head injury doesn't mean you're going to get CT, doesn't there are other things, boxes, career. He's had a career over 41 years and his pre fights before we took it up. Well, we know that Adrian taught him to read. So he's in that bracket of having a low educational quality co morbidities. He's lived through lymphoma. Genetic factors can't answer that one. But really, is he going to develop CT no chance? In fact, they're working on another movie because it brings in so much money. So Rocky will be fine. Not all people with repetitive head injury will champion. You've been a great audience. We've covered. This has been really great having the interaction. It's been great being invited here. Thank you so much. Uh It's a captivating talk by a doctor Currie. Um I think he's managed to captivate the audience quite really well. Um We're actually running a little bit behind time so we won't have time for questions. But if you have any questions, feel free to approach doctor Currie after this and ask away