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right, everyone, welcome. Teo are finally the session for today. So we're doing a neurology part too, on, uh, which is gonna be put on by President rib aunt. And he's got a big, big lecture for you guys. Amazing questions. Really concise and important learning points. So please stay tuned for that as usual. You know, we have small introduction introducing our sponsors and setting up a few ground rules. So these are our sponsors s a medical protection society. They're great organization to help medical students and junior doctors kind of navigate through the legalities they might encounter. Um, they also. And if you sign up for free, there's a chance you could win a, uh, remember exact amount correctly 183 183. There we go. Uh, watcher. So please do sign up Onda. This quest met. Got a great question. Bank use the code on skis. He 20% to get 20% off. And also and you, medical Defense Union, which is also another, um, medical kind of protection organization To help medical students and journey doctors kind of navigate through those legalities. And as always, we are happy to be supported by mental on, um, using platform, bringing together healthcare professionals from around the world. And we were lucky to be supported by them and off certificate function and recordings and slide to be uploaded on medal for you to access. Um, so and also please on, I think Vincent or Allan one of them will be putting it on the chapter. Please follow all our social. We've got a new, uh, Oscar see community on Facebook. It's a really great space for you guys to come up with your questions on gone a weekly basis. Someone from our team will be releasing questions for you guys to get a little tea, sir, as to what the session will be for that week to please, do, um, follow us on our community and please try to engage is much as you can on with. We're happy to answer any questions you guys have regarding research exams or any any even welfare. Okay. And these are a few of the ground rules. Please keep your microphone camera on mute on DNA. Sure to ask questions you guys have any doubts on, but we'll be happy to provide an answer and please doing get to the poor. It's really important, important function that we're trying to provide you guys. So please do try to do that. And these don't grow on drawn the slides or anything like that. Be any Be respectful on the chat, this session will be recorded, and we'll be releasing feedback form. So it's the middle of dissection, and the slides will be You'll be able to access to slide on middle upon completion off the feedback form. And that goes for the recording as well. Okay. And if you have any questions, please email us at OSTEO Outlook or skis. A gym, a doc, um, on. Make sure remove us from your spam or junk to receive our by week newsletter every two weeks. And please do, um, make sure the sheriff's on your social on, but just keep up to date with Allah. Upcoming events. Um and, yeah, enjoy this session. I know it's gonna be a really good one. So positive to rebound now. Cool. Um, thanks. Moving? Uh, yeah. We have some really, really good topics today. We're gonna cover the remainder off, uh, last Tuesday, topics that we haven't covered. So thanks. Moving for the introduction Final CCS. You guys know, um and today is neurology. Part to the session would take about 1.5 hours, and it covers stuff like stroke hemorrhagic and a schematic meningitis headaches, which are really, really important to know for our finals. Cool. Let's start off with the first question. Now, if someone could lunchable please no call, I'll give about 50 seconds for you guys too. Would for the answer here, please engage into questions It helped to your learning and everyone's learning learning us Well, so, um, let's see. About 40 seconds, right? Called Let's let's pause it there. So majority of you have gone for 53% of you have gone for a d uh, being middle cerebral artery. So, as as we usually do, let's try to break down this question. Ah, 46 year old male presents to the emergency department with right sided weakness. The moment you noticed right sided weakness and thinking about a unilateral cause in the brain itself, it needs to be higher up or in the brain stem that you're thinking about. So you're thinking about is giving hemorrhages, strokes, aneurysms on and and dissections to um so that being said, he has headaches, so it kind of narrows it done. It has to be in the brain. Um, and he has partially drooped eyelids. So what does this partially true eyelids signify? It means that as some sort of toast is going on and doses can occur either in seventh facial nerve policies or bonus syndrome. So these are the two causes of Tosis, and it doesn't say anywhere that there is a coordinated facial droop as well. So that's only a single a drop of the eyelids. So it's probably a bonus syndrome here. Then he mentions that it came on when he was dancing. So there is caused because he was exercising during during when it came on and has a past medical history of hypertension. So all the symptoms are pointing towards this thing called carotids artery dissection. Now, the way that this this this works character trait, a section is that it kind of trapped as daily. Often you go in tomorrow in the carotids are tree which compresses on the sympathetic drunk. And we'll go through what Honus syndrome is at the end of the presentation, when you're kind of comparing a facial nerve palsy in and hole in a syndrome. But this is just a present Asian. So when you see partially drooped islands, you need to kind of think and try to investigate What exactly is going on here? Yes, right side of weakness Hemiparesis, which is also known as hemiparesis headache. If those are the sole incidental findings, it would probably a meal to be a middle cerebral artery infarct, because that's the most epidemiologically common infection. But with a bonus syndrome, the answer is character doctor that did that make sense? So strokes itself are classified into it ischemic and hemorrhagic stroke ischemic being a hypoxic nature of stroke them 10 Minutes is a clot and aneurysm that's causing a block in oxygen being supply to the brain and hemorrhagic a magic meaning that does it bleed acute or chronic bleed that's causing this so called localized focal neurological symptoms. So when talking about so let's talk about ischemic stroke first, followed by a hemorrhagic stroke. Ischemic strokes can be caused by clot. A dissection when there's a hyperperfusion in the brain is a classification system for the schematic category of strokes, and it's called the Oxford Bamford stroke a classification, and unfortunately, it is something that needs to be memorized. A total anterior circulation stroke and to break down this words and your circulation strokes includes the anterior cerebral artery, the middle cerebral artery, the atomic artery, the anterior carotid artery, a stress as well as the internal carotid artery. Everything is listed in the next slide. Um, so does an anterior. Uh, those are the anterior circulation, and it needs to be consistent with these three features. Homonymous hemianopia unilateral weakness off the face, arms, legs and cerebral dysfunction usually usually this artery, which is slurred speech. Now, if there are two of these three symptoms, it is classified as a partial partial and the circulation stroke now lacuna stroke. What lacuna stroke means is that it's basically when a single artery, a single perforating artery, is occluded. It could be supplying. Either the internal absolutely could be supplying theme or motor motor functionalities. Or it could be supplying even the cerebellum. And that's why it can be only one of these because it's a single artery, so it could be a pure century stroke. A pure motor motor stroke appeared a century or motor a stroke. Or it could be eight x a taxi and hemiparesis, which is more of cerebella signs. And finally, a posterior circulation. Stroke is usually inclusive off the posterior cerebral artery. It could cause a cradle of palsy contralateral century and motor motor paresis or bilateral motor or sensory polices. Conjugated I movement a policy because the eyes are involved in the posterior circulation through cerebella dysfunction are isolated homeowners tendinopathy anterior or posterior inferior. Cerebral arteries are severe. Cerebral arteries are infected. It also includes the, uh what do prolactin. So that's why this could be infected. Now, let's we want to The second question. If you guys could launch the pool and you're just looking at the check trainable of three also can cause produces, um, and down on a deviation. Yes, that's right. Oculomotor enough supplying the Levitra probably bureau and deed. Um, muscles of the eye. Uh, Alan, I I don't think I don't think the fullest launched his Oh, it's large things. Sorry. I say, if you could just Yeah, because just boat on that one. Yeah, well, I think let's stop it there. Majority of you are getting this, uh, this question right. And the right answer is a CT head. Um, yeah, And so when When a person comes into the the emergency department department and suspecting a stroke, you need to do without a hemorrhagic stroke first before you give anticoagulants. And so a city had must be done initially. For those who put from back to me, that would be the right answer if a city had this artery done. Because this this seems to be an anterior circulation through our least a partial anterior, uh, circulation stroke. Can anyone tell me What? What artery do you think it's affected in this in this trip? The chart. And he says that the weakness in his legs are worse than the weakness in his arms. So weakness in the legs being worse than the weakness in his arms is a anti restorable artery stroke. Um, that's just because of the proportional supply off blood. The legs are supplied by the the motor cortex that's supporting the legs are supplied by the anterior cerebral artery, whereas the upper body, as well as the face and the hands are are surprised by the middle cerebral artery. Cool. So this is the management of a suspected ischemic stroke. Firstly, you do a CT head. That's the most important. Now, if I could just employee you guys to just ignore this bit for for a while now this is more of a posterior circulation shop management, and just look at these three for now, at least so initially. If it's less than 4.5 hours, you offer thrombolysis in the in the name of and the drugs to offer. Thrombolysis Instructor kind is a swell as all the place I usually all the places the one that they used because because of the acute nature off it, you immediately send club breakers to break the clock so that the symptoms are relieved as they're still possible. Possible salvageable tissue there. Now, if it's less than six hours but more than 4.5 hours, you go for it from back to me. If it's a confirmed STD, uh, proximal anteria circulation stroke. And these are all the arteries that I mentioned earlier. That is a that defines a proximal anterior cervical, a Shinsho on a CT or MRI angiogram. So from back to me is where the neuro radiologist put a wire through all the way into the brain by the femoral artery and removes the clot and just it just pulls it out. Uh, and so that's what it's from back to me is now. If it's between, the range is off 6 to 24 hours. A thrombectomy is indicated. If it's a confirmed proximal anterior circulation stroke seen on a CT or MRI angiogram, and there's potential for salvage off tissue, that means that the ischemia slowly spreading still. And so if you remove the clot, there is a chance that brain tissue can be spared. However, if there is no chance, meaning that ischemia has done its damage and it's done its maximal damage already, there's no indication for Thrombectomy because that's not much. The trump back to me will help the the the risks off the train back to me that was bleeding out and etcetera, I'll create the benefits. So that's why. And it's only indicated, um, and that's potential salvage Now for posterior circulation strong, it's slightly different. It said that it's similar guidelines, but the guidelines kind of very quite unspecific, according to Nice, which where we review all our guidelines from this nice guidelines by the way, for a post post. Your circulation's dropped. It says that less than 4.5 hours from back to me, thermal isis is indicated. But anything more than 4.5 hours. Somebody, uh, from back to me is indicated at least 24 hours. And the key point of note is there 24 hours before the onset of the symptoms, the person needs to have been okay. That's a key thing for thrombolysis and from back to me to repeat that again 24 hours before the stroke onset of stroke. The person needs to be all right for the doctor to proceed with that from back to me or thrombolysis, depending on the time. I hope that makes sense. And one more thing I wanted to add is posterior circulation through it's posterior cerebral artery as well as a basal artery. Cool. Now, once you treatment for the stroke is done, you want to start them on some prophylaxis or preventive medications immediately. You would start aspirin, and that lasts for two weeks. Now. If Trumbull Isis has happened, um, which is all the place you'd start the aspirin about 24 to 48 hours after the trouble. I systems happen just because you don't want to know the mark with anticoagulants and and the platelets. So you start this aspirin for two weeks, and then after this two weeks, you'd switch them over your clopidogrel. So after two weeks, switched him over to clopidogrel and this last forever because it's just a preventive measure. But since they have had a stroke, that there's a chance that they could have another stroke. A swell, um, one of the questions that's coming is what What do you mean by them? Be okay, All right, it's still that means that they're they haven't had any other symptoms or any other conditions, um, in the 24 hours or any symptoms, basically in the 24 hours prior to the stroke happening. Cool know if clopidogrel is indicated for whatsoever reasons, whether they're allergic or whether they can tolerate it. Aspirin plus diaper, Amador is given. It's a combined okay medication, aspirin plus time diaper mellow. It's given separately, but it's this sort of Methodist Methodist given, And if aspirin is not tolerated and you give modified release diaper middle past the final sort of outcome now for cardiovascular preventing prevention. Because many of ischemic strokes are caused by a cardiovascular risk, hypertension and everything. They could have a cardiovascular comorbidities that have developed or haven't developed yet, so you need to consider giving them a statin as well. Primary prevention is 20 mg certain, and for secondary prevention, it's 80 mg of statin that you give. So let's move on to the next question. No, uh, from back to me can be done in older patients as well. Lady, um, just because it as long as it has potential to salvage brain tissue. Um, because many, many of the times strokes are seen in older patients rather than the younger patients, it obviously depends on your core morbidities and how much you can save and how, how their life impact, how how big of a life impact might have on them. Also, that is considered in making this decision when it comes of guidelines. This is offered to everyone cause you can't be biased because of age. Cool. Let's stop it. The majority of you guys have gone for on immediate CT head on a second. Cancer is a city had within one hour, so the right answer here is actually a city had within eight hours on The reason for this is it is a guidelines question, and it is something that we need to know. Uh, but a 70 year old man, the first risk factor is 70. So he's good that the the guideline says that anyone over 65 years old who has a non traumatic mechanism off a head injury so he clearly does not have a traumatic mechanism of head injury. His GCS is 15 for the past three hours. So the guidelines is that an immediate city had is indicated for people with a GCS off less than 15 for more than two hours or less than 13 on presentation on. All these guidelines are in the next few slides, and also he has a past medical history off 1 mg disease. And this is what prompts a CD had within eight hours. No other focal neurological deficit. It's observed, so it doesn't have to be to urgent, but it needs to be urgent enough that you're reviewing the person for anything that has happened. So now we move on to hemorrhage. They're three different types of memory ages. There are other types of hemorrhages also, which I'll go through in just a bit. Actually, you're a hemorrhage. As you can see, here is a contact lemon shipped feature that doesn't cross the suture line between the frontal and parietal bone. It stays within the suture line, and it's cause off the rupture off the middle men in July artery, and they tend to present with a sort of loose it interval. When it comes to medical questions, they fall down, they get up the move around for a bit and suddenly for the fall back down again. That's what it lose. It Interval is no. A subdural hematoma or a hemorrhage is a crescent shaped hemorrhage that crosses it's suture lines. It's cause off eruption, the bridging veins. It couldn't be a chronic or an acute onset acute onset being dramatic mainly and a chronic, one said, being because the person is aged or person is a avid alcohol consumer because their brain shrinks when you drink a lot of alcohol for a large amount of period of time. Now can anyone tell me what exactly this city had shows? Because I've chosen this specifically for a reason, I'll give you a clue. There's a different in color. There's a hypodense region and a hyperdense region. Yes, that's right. So acute on chronic. This is an acute on chronic and that usually that usually happens when there is a trauma associated with. It's an elderly person getting ahead. Uh oh. Are, uh, yeah, basically elderly person hitting the head so they've already had a sort of hemorrhage has been collecting up, and the final kind of impact has caused it to rupture even more? No, as you can see, uh, look, if you compare this brain and there's rain here, you can. You can really see the suture lines, but down here, you can see so you can see that it's not a very healthy brain. It's it's kind of shrinking already. So it's It's not really it's not a young breanna that that's what they call it. And you can see here that there is a bit off midline shift because it's not a straight line who, um, the the next type of, uh, hemorrhage that we can talk we're going to talk about. It's a subdirectory hemorrhage, and that's basically caused by a rupture of the aneurysm, which is the most common cause for bonus point. Anyone in the child? Can you guys name, uh, what is the most common aneurysm rupture that caused us to stop type of severity? Or which location is it based in? Uh, yeah, it's a very early in the aneurysm, but yeah, that's right. So it's it's the most likely cause is in the anterior communicating artery. I think it's about 35% a step it immunological statistic for anterior community communicating artery rupture on. That's just because the blood is pooling all around the circle of Willis. Here, Uh, As you can see, it's just pulling the blood vessels because it's kind of taught under the subject matter. And finally, the last kind of hemorrhage did we talk about is a inter interested rebroke hemorrhage, which doesn't really come across in this particular few categories. And intracerebral hemorrhage could be any any bleeding to the brain stem into the basal ganglia into the in this case into the ventricles, which could cause hydrocodone, which we will talk about in a bit also, huh? So the management off these hemorrhages can vary from presentation presented in a swell but actually Urals are married to manage with craniotomy with excavation. If the person presents with consistent increased intracranial pressure, a craniectomy can be done for a necktie. Me and craniotomy. The difference is that the bone flap is removed and put into the stomach. The reason why it's put into the peritoneum of the stomach fat is because it has good vasculature, and it can keep the kind of bone well nourished and well supplied. Now subdural is usually excavated by a behold do behold PSA done and and they had, um, and it's just excavated just like that. Uh, if that still doesn't work, then this bottle's can be converted into a craniotomy. A behold is done for both an acute and chronic severe. Oh, it depends on the collection or the density of collection as well. And finally, a separate subarachnoid can be done by a clipping or coiling. As you can imagine, the berry aneurysm has burst, so you need to stop the bleeding by the putting a coil into the region or just clipping it so putting a coil into the region would be by a neuro neuro radiologist. So again it goes through the femoral artery all the way up and just put a coil so that no blood can flow into the very aneurysm, whereas a clipping is done by a craniotomy. Because I mean it's coming from externally and just clipping it again extradural is could have a watch and wait. That's why the severity could have a watch and read. Um, but it's not very, very common that you do this because you want to remove. And, um, it usually depends on the age in this factor. Also, uh, no, it's America night. The usual presentation is a the worst headache off their life. Or you could present trauma. So that's something that has come up in the past, and you need to be careful. Just because it's trauma doesn't always mean this extra zero. Look at the clinical signs on See what's happening and, yeah, so the next management would be so this. So if a person presents with a sort of a brain injury or a brain brain insult, this is the This is the so called guidelines that we need to follow on. This is what the question was based on. An immediate CT scan is done. If GCSE less than 13 on arrival or Jesus less than 15 2 hours. Post incident. If you remember Old guy, he was just 15 3 hours post incident, so he didn't quite me. This criteria give that a sign of a base of skull fracture, which is just a sort of blood vessels being ruptured underneath your eyes or behind your years. That's what Hand assign BRANDEIS and battle Sinus focal. Neurological deficits If that's motor weakness or century weakness. Something like that, or more than one vomiting episodes. Now a CD head in eight hours is indicated in people over 65 any clotting or bleeding disorders. And if you remember, this guy had one village brands disease suspected trauma mechanism, which this guy didn't have more than 30 minutes of retrograde amnesia immediately before the incident. That just means that he doesn't remember 30 minutes before the incident. And if he doesn't remember this him, he, he or she doesn't remember this. It's a city had within eight hours. And these are the nice guidelines, right? Let's move on to the next question. Now, then, yeah, just to add into Megan's Point Thehyperfix region. The lighter region is the acute part of the hemorrhage was the darker region is the The Hypodense region is the chronic aspect of the hemorrhage. That's right, but just a caveat to that is that the moment it starts bleeding, it hasn't clotted in the blood, and so it still remains high, potent. So it remains dark until the blood has clotted in a cute face, and then it becomes hyperdense and then slowly progresses to hypodense back again. So that's the so called progression off it. So if you see a hyper hypodense region, it could either be a chronic or it could be a just blood situation. It's usually not a just usually not a situation where the person has just let because there is travel time and stuff by ambulance that comes into play. But it's just a heads up. And, um, so So the criteria was that anyone who hasn't had a head trauma so that was the criteria, and Edward G. C. Is kind of patient. We sent him. It's variable from patient patient JCs 10. If that's your normal functional Jesus, then it could be sent home with a character care package. Um, package of care. Sorry, but usually they're not. Um, you tried to send them home a GCS 15 or 14 less case that they're confused. Then you can, as long as they have, people could care for them. Right? So majority of the people have gone for C, which is the right answer here. Now, Um, what we're looking for here is called Equina syndrome, and this person has lost his in a door, and he has pain radiating to the bilaterally. This is a classic sign of cardiac wanna. He works as a brick layer also, so it's quite stress stressful, but it's physically demanding for him. And he has a past history of prostate cancer. Now, the generally the nice guidelines are the gold gold standard. Uh, gold standard is a MRI lumbosacral. We try, try to do it. Quite a bit of extensive research on this, and for some reason, it says MRI lumbosacral, But with his history of prostate cancer, it could be met. So you need to do MRI because whole spine, but generally for for a cardiac wanna syndrome. Oh, So the answer is emery whole spine because the compression could not only be in the cord equina cardiac wanna is the lower motor neuron part when the spinal canal just ends at L1, which is also commonly ask questions, but yeah, so it could be slightly higher up. Also, if you suspect kind of the upper motor neuron spring too cool. So Dante's see here. So quarter equina is a medical emergency. The patient needs to be on the operating did operating table within eight hours off the presentation. If it's suspected cardiac whiner, it presents with back pain, sciatica, loss of blood and bowel functions and saddle menace Anesthesia. Saddle antiseizure just basically means anesthesia and the S one s two s three s four region. Um, that's just that's just the saddle region. So you do a PR examination to check whether their sphincter tone is all right a post void bladder scan to see if they have any real reason it's in in urine exam. It is going to kind of cause the the team around it t be suppressed MRI, lumbosacral or whole spine. Whole spine is the one that's indicated. And finally a diskectomy, which is just the removal of this this. And as you can see, there's a huge compression on the spinal cord is almost complete Compression of the spinal cord here. Right. Let's go on to the next question. Um, how did the friendship, Metastatic. Sorry. Can someone launched the pool? Please call. It's launched. Um right. So how would you difference? You have metastatic, uh, cancer and cardiac wanna so called A Quite as you could see in the previous feature that that that picture showed a MRI t two because the CSF was bright. And you can see that the disk appears dark and it does it. It has an obvious herniation there. No, with a metastatic cancer, you notice that there is a calcification or kind of blobs on the on the spine itself. Uh, and so, yes, on on the on the spine itself, And it would be slightly more brighter than than a disk. So that's what you'd see in in a sort of compression. Um, so if not operating within eight hours, you have a kind of a mobility risk. You have a chance that the neurological deficits could have a complete or permanent damage cost. And so that's why the kind of guide line is that you, uh you operate within eight hours. Okay, let's end up all right there. Uh, and majority of the people have gone for a 49% of the people with a split between a n. C. Being the next next two answers. No majority of you guys have gotten it right and identify that this is a case off normal pressure. Hydrocephalus. Now the three signs and symptoms to note is that their shares wobbly, wacky and wet. And that's how I remember it. So she's walking. Probably abnormal, good, wacky. She's been forgetting stuff recently and wet because she's had blood and continents. And this is the classic. Try it. It's called the Adams or the Hakim's trial off normal pressure Hydrocephalus harder. Keflex is basically a increased amount of CSF being produced in the ventricles in the circulating went circulating ventricular system, and it could be caused by two different reasons communicating or noncommunicating reasons. And as it says by the name itself, communicating just means that there is a consistent flow with no obstruction. Where is noncommunicating means that there is an obstruction in the hydro communicating hydrocephalus could be caused by an imbalance between the CSF production in the, uh in the core I tissues, whereas a, uh, known communicating could be because of instruction, human subarachnoid hemorrhage or aqueduct stenosis or calcification. Normal pressure Hydrocephalus generally presents, with the ventricles being really large on a CT scan without any with the particular three symptoms that I mentioned. So as I mentioned your normal pressure hydrocephalus Adam Adam Czar became Striant dementia, income incontinent and abnormal gait. Uh, it's, uh so it's wacky. Incontinence red and abnormal gets wobbly. Three W's. So the investigation for hydrocephalus is a CD head, obviously, because you want to make sure that there's no other pathology there an MRI, which is not that done really that often, or a lumbar puncture. Now the lumbar puncture is contraindicated in constructive hydrocephalus just because you could occur. And if you guys are in our our ski community, you would have seen a recent question on calling being there. Uh uh, if it Corning happens, the most most common almost likely cranial love to be affected. His cranial of three a sweep Oh, still in our chat. Um, cool. So the treatment for, uh, hydrocephalus is basically trying to remove as much CSF. It's possible to kind of normalize the normalize the pressure there in the ventricles so initially acute situation. It's an external ventricular drain, which is just taking out fluids from the ventricles. It's kept it the same level off the patient so that it match in the volume or the pressure is achieved. Now, in the long term kind of scenario, you do a ventricular peritoneal shunt or a lumbar peritoneal ocean. That just means that you insert a sort of a tube into the ventricle and make it go all the way down to the peritoneum, where the peritoneal as a swell as the gastrointestinal tract absorbs this so called CSF and put it back into a snooty it's and put it back into circulation eventually, UH, not directly, but hopefully the appropriate amount. And this this kind of relieves the pressure. A lumbar peritoneal shunt is not usually done unless it's indicated in certain specific rations just from the number region and go straight into the peritoneum. It's really risky procedure because the spinal cord could be damaged, right? Let's go on to the next question. Here we have, I think, 11 questions today. Cool. Let's stop it there. Uh, and majority So it's It's a really, really close bit, and I was watching The numbers go up and down. It's a split between B and C, which is under your coat syndrome and, uh, Brown say, God Central, 41% going for the record and 39% going for Brown Cicotte syndrome. Um, now, the correct answer here is actually anti record syndrome, and we're gonna talk about all the different types of court syndromes that can occur in the spinal cord. Now, in this question, it says that this person has lost his temper pain in temperature bilaterally. So that's the spinal Salam IQ pathway that he's lost. And if it's a bilateral spinothalamic part pathway, it needs to be on the sides. I'll show you a picture off the cord itself, so it makes more sense, and motor functions also lost. So given that the spinal column it and the motor card syndromes are being lost, I'll show you why. It's an idea Court syndrome. But another risk factor for this that I wanted to make clear was a ruptured aortic aneurysm. So surgery for aortic aneurysm and that type of surgery usually causes a are not usually, but it could cause a disruption in the and your spinal artery. So it causes ischemia to that bit off the cord, causing an anti record syndrome. And it's it's quite specific to of an anti your coat syndrome because it affects the anterior spinal artery. So court syndromes. So that's dorsal coat syndrome. And anterior continue on this on the slide Dorsal coat syndrome. Just basically. So for references purposes, this is a kind of a mirror image. So the dorsal call column is there on this side as well. The motor tracks are there on this side as well, obviously supplying It's the lateral contractor, depending on which side which which track did this. But for for diagrammatic purposes, we have just highlighted one side one, Um, and thanks to marry for drawing it. Drawing, Adopt, Um, yeah, so a dorsal coat syndrome if you if you kind of dissect the name dorsal means behind. So it's affecting the behind part off the spinal cord, which is also known as the dorsal column. Um, and so it also can, um, affect the fine Dutschke reception and vibration sense is so you notice a bilateral loss off fine touch and Proprioception, mainly now a anterior called syndrome, which means that it's affecting this whole region. As you can see in this diagram here, it's affecting this whole region. It's affecting the lateral cortic spinal ventral cord spinal, which is both motor tracks. A so all ST spinal spinal column IQ, which is the lateral and mental spinothalamic tracks. Now it's spinal tract telling me tracks control the light, light, touch, pain and temperature, and the motor tracks control the smaller functions. So if there's a, uh, bilateral bilateral motor function loss s or less pain and temperature, you notice you think of an anti record syndrome at the century. Century level usually starts 222 levels below the lesion, and that's keep on 23 levels, actually below the region. And that's a key point. That's because off the dermatomal distribution, they say this is the spinal cord, and this is the body. It kind of goes on a diversion pattern rather than a convergence or a straight pattern, and that's why it's a kind of it goes two levels of the region. If that makes sense, and then the next two are brown secret syndrome. as well as a central cord syndrome. Now Bronte Coat syndrome, as we have all learned in medical issue heavy section of his spinal cord. It affects the corticospinal, which is the motor track spinothalamic and dorsal column on one side only. But because the spinal column it crosses over after the spinal cord ends or below that not in the middle of level. It affects the contralateral side off pain and temperature. Various. It's the lateral side or find touch, broke reception and motor function. No, I hope that makes sense now. A central coat syndrome is slightly different because it's it's a bit hard to understand. It's usually seen in this condition called syringomyelia, and I had the the kind of I was quite fortunate to see a patient with syringomyelia. Unfortunately, um, so the patient seeing, um, earlier is defined as a sort of a cyst in the spinal cord. So what exactly happens if you notice this diagram being a spinal cord? If you see the middle black dot here, the CSF actually goes through the middle of the spinal cord, opposed to what many people think it goes around the spinal cord. It goes in the middle of the spinal cord and bates the smaller car. And that's how it works. So considering the fact that this middle it goes to the middle of the spinal cord, this syringomyelia usually happens in this condition, called a chiari malformation. That's basically a small amount of brain tissue coming and obstructing this spinal cord. Now, if that obstruction is present, that's going to be a high pressure in. The CSF are in the spinal cord itself. And so this high pressure because of the pulse, it'll nature off the spinal cord is going to cause a expansion in this central canal. Now, if this central canal is consistently expanding, with the pressure being higher at the entrance rather than below, so that's right forms this type of shape. It's going to affect the survival region more than the lower bits because this is a cervical desist e Jurassic. This is the lumber, and this is the sacred region, and it goes outwards like that for almost every tract here. And so that's right affect the cervical region more dandy, more than the number or thoracic region. And so if you notice the key words that you see an exam is a shape like distribution. It's usually in the sea. 81 more, uh, see 81 dormant dermatomes and mind Tums That's just supplying to spit. And this bit here. I don't know if you guys can see, but the pinky finger and the side of the biceps or the medial side of the biceps. Um, and it depends. It really depends on how much this this sort of CSF collection has expanded. So if it is a bigger expansion, it could affect the thoracic region or the lumbar region. And that's why it really depends on how much it's expanded. Um, so, as I mentioned, larger lesions can affect the spinal tap. Lamictal also column and motor motor loss is also and usually survival is the one that's predominately precipitated because off this so called cherry malformation, right, So let's go into the next question. Now. I hope that made sense. If you guys have any questions, please put in the chart. I'd be more than happy to onto So you come to the topic off had aches. Now Head exists is quite a quite a huge topic, to be honest. Yeah, right. Let's stop it there. So majority of you guys have gone for B, which is high dose prednisolone. But the right answer here is actually IV methylprednisolone. Now let's break down this question. As usual, you understand what exactly it's asking for. So this 33 year old female is presenting with unilateral loss of vision and pain in her forehead. So both are unilateral, and she has a past history of polymyalgia rhuematica. She was recently admitted with disseminated intravascular coagulation due to sepsis. Know the condition that we're thinking about here is giant cell arthritis, because off the temporal kind of pain and the union lateral nature off it as well as the loss of vision and because there's a loss of vision the moment you see that the optical of visual symptoms, you need to go for a more potent and more stronger cortical steroid, which is IV methylprednisolone. And the reason why you go for me I'd be made out methylprednisolone is because high dose prednisolone it's not able to penetrate or kind of disseminated itself enough. You need to be able. You need to find a cortical steroid that's actually able to affect our reach. The eyes which is quite hard, so you need to give as high as possible IV methylprednisolone now. So let's talk about headaches. And, um, actually, before that, does anyone know why I put the icy recently? Admitted you to the I see you two Subsys. Anyone know the significance? It's just a extra point that I put in. There is no relation to the so called giant cell arthritis. No, that's fine. Okay, So gentle arthritis, the SARS raised and in the I see also the SARS race. So you need to kind of a certain what is causing the years are rays. Whether it's the d, I see all the all the, all the joints arthritis. Although it's going to be really, really tough to kind of differentiate that. Yes, sir. That's the cause. Okay, cool joints. Arthritis is a unilateral headache. That's usually in the temporal region. You notice a pulsating temporal artery as well as the usual classic picture is that when a person is called being their hair, they find pain there. Um and you'd be able to see a tender, palpable temporal artery. Visual. December Visual disturbances are not always that, but if they're present, you need to give IV methylprednisolone and you notice a raised inflammatory markers, especially yes, are now. The gold standard is temporal artery biopsy. But if you are suspecting it, and if you know that that's the so called symptoms and and that's the presentation, you straight give high dose prednisolone or IV methylprednisolone, without doing a temporal artery biopsy. Because that takes ages to do, and it's hard to get the clearance and the justification. Um, yeah. So the reason why I put Polymyalgia rhuematica here and the initials quite quite vocal about it. It's because he's doing a rheumatology session and he's covered polymyalgia rhuematica on the only I'm gonna go over briefly, but they're so called an overlap between gentle arthritis and polymyalgia rhuematica because off both of them being inflammatory conditions. So polymyalgia rhuematica you notice muscle stiffness in proximity. Approximately muscles in the morning lethargy and rxa and night sweats and raised yes, are also because that's inflammation. Just a reminder that creating kindness and mgs are normal because it's not a myopathy, and you give prednisolone for polymyalgia rhuematica. And if you see a condition, this type of presentation and you see that people that this person has muscle stiffness in proximal regions, A little achy threat. You must be thinking of the polymyalgia rhuematica just because there's a huge association between the two. Um, cool, right? So let's go on to the next question here. This is still on the topic of headaches, and one of the question says, Would you do IV steroids followed by temporal artery biopsy. So you do IV steroids. You wouldn't exactly need a temporal artery biopsy if the symptoms are solved by the IV. Steroids. Uh, if that makes sense, because IV steroids curing the inflammation just points more to the diagnosis off joints. Arthritis? Yes, she is slightly young, but there's no set age range dead. A gentle arthritis can have. It could happen in anyone with a past family history of inflammatory conditions. Uh, or it could sometimes happen sporadically as well, Right? So let's stop it. They're 28 year old female presents with unilateral headaches. She mentions that it affects her day to day, and it she needs to lie down in a dark room to relieve the symptoms so it happens more than 18 times a month. So we're thinking off chronic migraine here because of the dark room features, as well as it happening more than 18 times a month as well. Is it being unilateral? So in terms off a chronic migraine, uh, the first line treatment is actually sumatriptan. But considering the fact that she's pregnant, you need to give propranolol because so much return is highly teratogenic. So the prophylaxis medicine as majority of you guys have gotten this propranolol now cluster headaches and migraines. And so let's let's talk about Crestor headaches and migraines. Good migrants for a bit. Cluster headache. Headaches come under the category off a subset off tried germinal autonomic cuff algia. Um, and it's it's said to happen once or twice a day. People. It's not actually the timing's because that's what helps you distinguishing exams. It usually occurs in between about 15 minutes and an hour. You know this agitation read. I like cremation literally and post nasal drip with nasal stiffness. Are you on rare occasions? Is you notice my assistant OSIs. It's basically they just feel really, really bad with with sputum coming out and not sputum come out but nasal drip and stuff like that, and the moment you see the one nasal drip thinking about cluster headache. The acute management of this is 100% oxygen in non re re breathing mosques. Apparently, it helps with their their breathing as well as, uh, narrowing. Reducing symptoms or a mask are a sub cut or nasal drip by a mask. Cool. There are a few medications that contraindicated in cluster headaches. You cannot give paracetamol and said's opioids or goat or or a triptan that's really important to remember. And prophylaxis for cluster headaches is verapamil that's really, really usually used for migraines and clusters headaches. More likely than not even this for Flex is called acupuncture. 10 sessions of acupuncture is quite recommended by the nice guidelines, but that really isn't isn't followed in clinical practice just because it's hard to get this sort of acupuncture appointments and stuff like that. I was just having a child with a consultant based on that, and they don't usually do it in clinical Ah, practice. Uh, so a migraine is classified as it's throbbing headache with nausea, photophobia with or without aura. And if a migrant is indicated with aura, it's always important to remember that it cannot be prescribed the C o c p. That's one of the UK Mac four guideline. It's a contraindications. Usually people experiencing a migraine going to a dark room after attacks or during attacks to kind of quiet it down, and they they tend to lie down. That's their mode of relieving your migraine attacks. In terms of acute management, you give your Ultram tens or insides or or a trip plans together and paracetamol for the pain. In young people you give nasal, drip tense and, uh, prophylaxis You could give a permit or propranolol uh, who? And there are a few things that, uh, I think I mentioned earlier that assuming trip done is prophylaxis. It's a mental impairment. Um, yeah. Um, so they're few things that can precipitate migraine, and it is chocolate hangovers, orgasms, cheese, contraception or a contraceptions lie in alcohol travel. So it's It's in the morning chocolate right there. A red wine and Citrus fruits also precipitated. Anyone know the amino acid that is common in in cheese and alcohol? That and chocolate is real dark chocolate, specifically, that precipitates this migraine attacks. Yep, that's right. So someone is this message. It's actually tyramine. So these things. Contents. This this products actually contain tyramine supposed to tryptophan, which is a precursor off serotonin. Tyramine is the one that these these few things contain that kind of precipitated greens. So we move onto tension, headaches and medication. Overuse, headaches, tension, headaches is different from the previous previous, fewer unilateral tension. Headaches is bilateral. It's like a tight band around the head with non positive and low intensity. It can be caused by smoking, stress, anxiety, caffeine and fatigue On and and chronic. It's defined as more than 15 episodes per month, and one ti point for your skis ask, is that you guys do? One key point to keep asking them is that whether they have a headache diary because they need, you need to have an official record off when the experience of comedy times they're experiencing. And it's really important in this patient's for tension headaches, the treatment is aspirin, paracetamol, an Ancid and prophylactic prophylaxis. Also is 10 sessions of acupuncture. As I mentioned earlier, it's not really done in clinical practice. Um, right, in terms of medication overuse, headache, um, they you need to usually do codeine regular medications. Opioids are triptans and you need to stop medications. The usual medication that you need to do is codeine. You need to stop this recording because it usually causes increased amount of headaches. So I always think about when a person is having headache. Could I be on high amount of medications? And finally, you need to hydrate. Let's talk about tried trigeminal neuralgia and I hit a swell They said the last two headaches that we're gonna be talking about today. Trigeminal neuralgia is basically a pain in the trigeminal distribution off the off the face. So as you can remember, this maxillary mandibular opthalmic divisions off the trigeminal nerve. B one b two b me. Three and in that region, if you notice a high intensity pain across their face, even buy the smallest touch or the smallest sensory cause. Even with the blowing off wind, you could suspect it being a trigeminal neuralgia. Now, the exact clinical diagnosis or the clinical reason for trigeminal neuralgia is not really known. Some say it's because of compression of the trigeminal nerve at a certain location where it and just the the the orbit already ordered the face in a particular canal. But it's hard to hard to say, to be honest. Um, so it's by the trigeminal distribution. It's a walk by the smallest tactile effects, but the common drug to use is carbamazepine as well as gabapentin. And sometimes you could do decompressive surgery, which is just to relieve the pressure in that particular compression region. A. So let's steer tactic. Radio surgery. Um, yeah. Um, now the classic presentation of my age. Idiopathic intracranial hypertension is an obese female in her about mid twenties and thirties. Um, something precipitate, precipitating factors. Good closet CRCP steroids set recycling lithium That's recycling. That recycling being the most assessed one in examinations, doxycycline on and stuff. Um, so what do you notice in my eye is popular edema, headaches and blurred vision? Just imagine that there's an increased amount off intercranial intracranial pressure. It's causing a sort of, uh, the CSF to leak out from everywhere, including the optic nerve. And that's why you get papilledema and blood vision. So the treatment for this is weight loss. Being the first conservative management acetazolamide which wrist relieve the pressure and repeat lumbar puncture as you're relieving the pressure now, in this case because lumbar punctures can be therapeutic and there's no obstruction there. So you need to do a CT head to make sure there's no obstruction, which could possibly result in Corning. Then only can you indicate a lumbar puncture. Now, big optic nerve fenestration is there for treatment resistant idiopathic intracranial hypertension. That's just small cuts in the optic nerve to kind of relieve the pressure to let that see CSF out. And finally, you could do a a BP or elevation. 15 years ago, everyone was getting a be patient. But now it's only indicated for those with serious amount of disease, because patients are very, very prone to obstructions, which I really, really hard to rectify. Right? Let's go on to the ninth question. Now we have three more questions left, right? Let's end up all right, er so majority of you have it's actually a really recall equal split. It's between 80 and see, 36% for C and 37% for eight, right, So the the majority of you have gone for a, which is back to your old cause. Now, let's bring this question done again, as we all do for whole question. So next deafness Photophobia and a fever is the classic. Three. Try it for meningitis. So you're thinking about meningitis here on. He's recently returned from a trip from eight East Asia after a business business trip. Now lumber puncture is done and these type of appearances, yes, see, So the appearance here it's yellowish. Okay, on the poly poly marks are normal the moment the polymorphism normal polyp moms are like neutrophils and mainly neutrophils as neutrophils comprise off majority of our immune cells, so neutrophils are normal. That means it can really be a back to your old cause because neutrophils are normal now. If it's lymphocytes, it could be a viral cause to be closest or fun guy. This can't be normal because it's yellowish, right? So it has to be these three now, now that it's yellowish. Virus doesn't doesn't usually cause a yellowish appearance because it's not a cellular organism, so we can rule out virus right there. So based on the protein and glucose, we need to decide between people closest and fungi. Now the protein is high, which is seen in both tuberculosis and fungi. But the glucose is low, which is more likely seen in people closest as compared to fund I, comparatively, in Cuba closest a glucose will be even lower than it is in fungal. I think I might have a normal, more slightly low glucose. Uh, and it's really dependent on what type? A fun guy and the type of interaction and the type of availability they have. So the right answer here is actually tuberculosis. And this is example this kind of, um, seen by the the fact that he has returned from a trip from East Asia, which is epidemiologically more likely for tuberculosis. Tuberculosis to happen. Um, so the cause is of meningitis. This is something that we definitely need to know in terms of, uh, categories that I recommended. You find a sort of a way to memorize these so called causes of meningitis. Um, because sometimes they could ask what is the most common cause of meningitis in new bonds? And you need to go straight to droop B streptococcus. No, I wouldn't I wouldn't go and read out everything. I let you guys see this in your own time. Uh, this is a lumbar puncture on This is the sort of table a cheat sheet for for the lumbar punctures and stuff. Just a quick note is that fun guy is decreased or it could be normal. A swell, but it's due closest is decreased even more than fungal. So fun guy has. Would would that would most like most likely than not have slightly more glucose compared to your closest right. And this is the management style. So the management Scott style can be divided according to the age group or the type off bug that is present in the CSF. So the lesson in three months, As you can see, there's a common team of effort tax. I mean being the common, and it has to be IV. So less than three months you give every day for taxi mean and amoxicillin. Uh, from three months to 50 years you'd give IV catheter aksam in on more than 50 years. You give, I rechecked. I mean, I'd be careful text me and Marcelin, and this is based on the email immunological status off the person, and that's why they give the sort of empirical treatment. Um, the reason why it's more based on their age rather than the the cause is because you want to give an empirical treatment. You don't know what's causing it. So you just try to wipe out all different types of bacteria could cause it. And most of the bacteria of wiped out by care for taxes and amoxicillin Enough. It's pneumococcal. We give IV catheter accident HIV, you give IV care for tax. I mean, it's well, meningea is the one difference that you give IV benzylpenicillin and careful, doctor mean Or can Pradaxa mean And for history, listeria You give me amoxicillin or gentamicin? No, together with this. What do you know? Notice in many your cocoa septicemia is that you notice a purplish nonblanching rush. So the moment you notice a purple or pink nonblanching rash, nonblanching just means if you roll a glass over it, it doesn't change in color. Um, you're suspecting meningea cockle septicemia and you start them on IV benzylpenicillin on or we can for taxi me. And for people who have had contacts with people who have meningitis in the past seven days, you give her oral ciprofloxacin and ask them to isolate us. Well, just because you don't want them spreading the meningitis all around, you also asked them for their vaccination status give you can give ciprofloxacin or if em person, but the main one that's given a Cipro. Um, and you'd give dexamethasone for selected variants, especially pneumococcal meningitis, where ah, hearing loss could be a sequel. E. And you want to prevent or reduce the chances of hearing loss. And so you give immunosuppressive drugs so that the vestibular No best of luck. Okay, enough isn't affected, right? Let's go into the 20th question. We have just a few more slides left, so we'll learn on hanging around, right? So let's stop that pulls there. Majority of the guys have gone for B, which is Karen a Sinus. Trumbo's is as this is the right answer. CBT is the right answer here on the classic presentation of Karen, a Sinus thrombosis which I will explain the path assist for pathophysiology to you in the next light is high fever headaches. And you would notice this thing called prognosis, which is the bulging out off the right eye and evidence off partial sensory loss, which is kind of facial nerve. See quickly, and you notice confusion as well, as well as perennial enough. Six. The cranial nerve six dysfunction, which is why he's getting a double vision on horizontal. Great guess if you can imagine creatinine of six supplies the lateral rectus. And so you notice a horizontal double vision. Right? So cavernous Sinus thromboses. What exactly is it about the cabinet? Sinus sits behind the ice on it. So it's just like this. As you can see here, this is the pituitary gland, and it's just the selector kicker that sits here. It's a lot of becoming stuck ish. Saddle looks like this. Um, yeah. So the key the way to remember all the structures in a in the cabinet Sinus unilaterally is by the pneumonic or Tom Cat or being the um oculomotor d from Tom Cat being the trochlea enough, the autonomic nerve maxillary in a m o Tom and then cat again. So that's the lateral side of things. The medial side of things. That's the internal character Carotid artery, artery. So see a being the Abdus since no and the trochlear number again. Some reason it just just put it again to fill in the morning, to be honest. But it's autumn Cat now, Kevin, a Sinus Tom bosses presents with headaches swollen eyes. Just notice prognosis, which is basically the bulging out of ice. This needs to be distinguished from the bathroom. Ammonic, uh, exact example. Loss. I do not a pronounce it, to be honest, seen in Grave's disease, Um, Ophthalmoplegia, which is just a double vision and pain. A bit of pain on movement of ice progression. So it's usually progresses from a orbital or a periorbital cellulitis. Periorbital are brittle, cellulitis being the more rarer kind of progression. Or it could be from an infection in the three nights or Ethmoid Sinus, also known as sinusitis. So what do you do? Here is a memory contrast off the cavernous Sinus, which is this whole region here, and you want to give them IV antibiotics with unfractionated heparin or low molecular weight heparin. And this is because you don't want to You want to prevent any sort of clots in this region that could potentially cause it's steaming damage to this type of cranial nerves on could cause a block, Um, in the carotid arteries. Uh, yeah, that's cabinets and, uh, thrombosis. It also presents with changes in your personality. Such a confusion kind of aggressive behavior and stuff like that, which I haven't really read it or not. But it's a presentation, right? 11, which is the last question. Uh, we do have. So I I didn't create a question for the next topic. So we have just two more topics to cover, and we're done with today's session. This is a bit off mean question because it's it's asking the so called management plan for this particular, uh, condition. So once you guys are done with the, uh, Paul's, could you put in a check what exactly you're thinking about? What is the condition that you're thinking about? You never got This is all tallness Cool. Let's end up all right there. And could you guys put in the chart? What what condition you guys are thinking about here. So the pool says, um, bees. The majority answer with second, a third, the actually close split? Um, yeah, that's right. So you're thinking about Ramsay Hunt syndrome on? We'll go through. What exactly? That is the next question. Next few slides. Sorry. So, um, the presentation here is pronounced pain in her idea, which is pretty regular Regular pain, which is playing in the year drooping off the right side of her face, which is fresh. Ulnar palsy. Vertigo Tentative, which is affecting the vestibular popular now. And the CD had has ruled out a stroke because this could be a stroke presentation for a while, you know, So the medication here is actually or acyclovir and or a cortical steroids. And that's the indication for Ramsay Hunt syndrome. Now what exactly is Grams E. Ramsey hunting? Rub? Let's go over here first. So Ramsey and Syndrome is actually the reactivation off very Salazar virus in the seventh cranial nerve. So that is the reactivation of varicella zoster zoster virus can happen in two different nerves, that trigeminal of see and five and seventh cranial nerve, which is C and seven. So we'll see. And seven you get a regular plate pain, patient policy, vertigo in tinnitus and a rash around the year, which is called vesicular. Basically, just meet it contains a bit of fluids, and the treatment for that is oral acyclovir and oral corticosteroids. No hobbies. Austin filmmakers is a sort of I condition that I a nose condition that you get with the activation off. Very Salazar stove iris in the trigeminal know now we keep on to remember with both of these conditions is that if the patient has been recently diagnosed with HIV or goes on immunosuppressive drugs, this could be something that's reactivated because off the lack of community oppression that's happening. So what you notice is a rash around the high ice or on the tip of the nose side of the nose as well and is known as agendas. Sign. You give your own acyclovir for 7 to 10 days within 72 hours, and if that's a sort of ocular involvement, as you can see, this a dendritic approach here which does not have vesicles. So there's a another condition, which will cover an ophthalmology where these dendrites have vesicles less is herpes zoster ophthalmicus, which doesn't have vesicles. And so, if that's ocular involvement, you want to go for an urgent ocular ocular opthalmic revere. Sorry, cool. So let's talk about wholeness syndrome and facial a policy, as we talked about in the first question that we did so hold a syndrome and facial nerve palsy. The key thing to differentiate from this it's only syndrome is due to a compression of the sympathetic brunch, but his facial nerve palsy as it stays in, the name is cranial know seven compression or something affecting reading of seven right or no syndrome as we talked about. It's the sympathetic brunch. It has three different locations that it can happen. The first location is the central location, which is from the brain duty sort of anterior, um, anterior region off the cord. Uh, it's called the anterior horn cells. Could be it could be on your home, since it could be other regions as well. So that's the so called first order neuron. The second order neuron is this sort of think bit here that comes from the spinal cord and goes into the canal is there, and the third order neuron is from the ganglion all the way into the different parts off the face or different regions that it supplies Now. Obviously, if there's a compression in different parts or different order neurons, different symptoms are going to be noticed. And let's try to explain the sort of symptoms that we see based on the different type of neurons that we observe. So let's go on with central first. So for the central neuron, it's caused by strokes, syringomyelia, multiple sclerosis and a tumor. So it's more off a central course, which is in the brain or the spinal cord, and it it causes. And hydros is of the face, arms and legs, and hydros is means the lack of sweating. So because the main first neuron is being affected, everything downstream is also affected. That's right, causes and 100 hydrocil off everything below. And this should be unilateral. Actually, it won't be bilateral, so it'll because on addresses of everything now, if it affects this second order neuron here, which is the preganglionic you're on, you know, distantly and hydros is in the face because it's already started, branched out and it's going towards the face so on. Hydro says only the face. Now third order you're on, which is the postganglionic you're on, you notice. Know and hydros. It's because all the branches have already split. So let's it as a branch point to the ice. That's a that's a branch going to the maxilla, maxillary, mandibular or ophthalmic division. Um, you notice that it's already being split, so you can't really pinpoint one particular region with us, and Hydros is on so That's right, as it's considered as know and hydros. It's and based on these sort of symptoms, differentially differentiating symptoms you'd be able to narrow down where exactly this has happened. Now these are all the different kind of causes that could cost the first of the neuron. As we talked about Central, first of the neurons stroke and all this stuff preganglionic, which is the second order neuron you get in a thyroidectomy trauma or a pancoast humor, which is a long to my the Apical border. And finally, a post ganglionic region, which is a third of the neuron where we got a carotid dissection, cavernous Sinus thromboses estrellas cluster heading where there is no and higher doses. In the first question, we notice only ptosis there now facial nerve palsy. And if you notice I call it patient policy because it it's not called Bell's palsy. Bell's palsy is basically the idiopathic nation nature facial, nerve palsy, idiopathic, meaning that there's no known cause for it. Now, looking at this wonderful diagram that I've drawn, I hope you're able to understand it. It's basically the connection between the brain stem, brain stem cortex as well as the face. So as you can see if there's an upper motor neuron vision, uh, the upper upper part of the face has supply from the other side as well. So as long as this, if one side of the so called brain is affected, it still has this dual supply off nerve fibers here. So the forehead will be spared on an upper motor neuron vision. However, in a lower motor neurons lesion when this whole, both the the's fibers are affected, both the forehead as well as the face will be affected today. No forehead sparing. And that's how you difference yet Upper motor neuron and lower motor neuron in official now and just to read, read again. Bell's palsy is an idiopathic cost of this, so it's not. It's not a stroke that's causing this. We cannot find out the reason, what's causing this policy here, right? So let's just have a quick weight off brain tumors. They're different types of brain tumors, the first the meningiomas, which are benign, and it's generally left benign for a long period unless it grows really big and it's causing on a mass effect on. So that's when you surgically resected global blasphemous are very aggressive types of tumors. The prognosis is about 15 to 18 months. Want to get diagnosed with it even after the removal of it? Because it can grow back now. Acoustic neuroma or vestibular? Shandra noma is a tumor in the cerebellopontine angle. It presented what ago? Hearing loss, tinnitus and absent corneal reflexes. Because prednisone seven supplies the chromium corneal reflex and cranial seven and eight Take that huge ton at the cerebellopontine angle. And so that's why the compression causes this loss of loss of corneal reflex. You do an MRI of the cerebral, cerebral oh cerebellopontine angle and a bilateral diagnosis of accosting You're on my seen in men do covered in our endocrine session last week. And you need to surgically resected depending on core morbidities and stuff like that, right? But your pituitary tumors can be divided into adenomas and craniopharyngioma as, and that's still going to the differences between I don't know my craniopharyngioma, and that will be a last topic for today. Um, so the difference we didn't adenomas and create a friend dramas is that, uh, pituitary adenoma, as we talked about earlier, sits in the Sella turcica so that this the Sella turcica is kind of a sack that holds the preacher pituitary gland. This is the projection, and then this is the off the optic chiasm now. So now the predict pituitary pituitary gland is basically meant to be contained within within this Sella turcica. So when there's a two minute pituitary gland, there is a in for a checkup mass. That's priest. That's kind of extending super super just above the pituitary gland. And so when this is extending just above the pituitary gland, it is converting, and it's compressing the top bit of the optic cars. And so now, if does it, if there's a compression top bit of the optic chiasm right, the bottom fibers would be affected. And so there is a lower density in the bottom five of fibers and a higher density in the top fibers off a pituitary adenoma. That being said, the opposite happened for craniopharyngioma. Craniopharyngioma is a it's The cause is not really known, but it says that it said that it's because off MBA it's off embryologically origin that could have a cystic component in it, or a calcified component in it that's slowly growing in older people, it's no. It said that it's because of a metaplasia in the cells there. Now, since this craniopharyngioma is compressing from the top the optic chiasm, it would have the higher density in the bottom and the low density in the top, if that makes sense. Um, and if anyone has any questions, do, uh, put postings. So that's that's that's a different setting up pituitary adenoma craniopharyngioma compressing on this region here, optic eyes. And I think with that, we finished today stuff. Thank you so much for listening. So, density, what I mean by this is so this