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I'm a replacement. I'm a replacement for Dr Fiona Sim this morning and I'm just going to show you some X rays, CTS, MRI scans. Um If anyone has seen any of these before, just let me know and we'll skip over them. Um But I presume that a lot of people won't have seen, seen these. So I'm going to share my screen with you and hopefully you can see uh this Ukraine medical students. Uh December 22. I think I may have shown you some of the cases here, but if not, um I'll show you them again. The other thing I want to do is I want to just post this link if you want to find out about chest X rays uh in short videos. Um I and a colleague, Doctor Rodica Prasad had produced these videos online for the BMJ and I believe that Ukrainian medical students can access this free of charge. Um There's a link also below uh showing you how to, how to access these resources. And the final thing I'm going to do is I'm going to give you a link to the cases. I'm just about to show there you go. So if you can all on your computers open that packs been link W W W dot peck spin dot com dot collection dot uh sorry slash blah, blah, blah. Uh If you can open that and let's go to case number one and I want people to uh either we haven't got a big audience, so I'm very happy for people to talk about the diagnosis or if you want to put it in the chat. Um So let's scroll through this case here and you can all scroll through that case at home. So it's case number 001. Can anyone tell me what's going on here? This is a patient who experienced a severe thunderclap headache. Any thoughts? Yeah, subarachnoid hemorrhage. So the characteristics of a subarachnoid hemorrhage are that the blood goes under the arachnoid layer on the surface of the brain. And therefore the blood, which is high attenuation mirrors the source i of the brain. It also goes into the surface of the brain adjacent to the folks. And you get an intraventricular extension which you can see here the in the fourth ventricle, you can also see that you've got blood around the basil systems around here. And uh blood in the Sylvian fissure is which is here and the most likely cause for spontaneous subarachnoid hemorrhage is a ruptured aneurysm. Now, aneurysms tend to occur around the circle of Willis where you get a bifurcation. Okay. So a rupture of an aneurysm near the circle of Willis will tend to cause this very dense hemorrhage in the basal systems. And you can imagine when this heals up. So you get organization of the clot, you get adhesions and adhesions around the basal systems, uh forces the ventricles to dilate. And so, one of the big complications of the subarachnoid hemorrhage is hydrocephalus. And you can see here that there's early hydrocephalus. So I know as a radiologist that one of the earliest signs of hydrocephalus is temporal horn dilatations. Okay. So this is a patient with and I uh there's the third ventricle. So it's just a bit sensitive, this trackpad, it keeps on jumping, they go, there's, there's blood in the interpret uncle er system, there's the top of the quadra general system, there's the silver and fissures and uh this patient is likely to have an aneurysm. Uh And so the patient would then go on to have a CT angiogram which will confirm the site of the aneurysm and then in the UK and I expect everywhere else in the world, these patient's are then referred to an interventional neuroradiologist for coiling of the aneurysm. And this prevents um rebleed and improves survival in the old days before coiling of an aneurysm via the interventional radiology route. Neurosurgeon would have to do a craniotomy, go into the brain and clip the aneurysm and that of course, resulted in quite a large amount of morbidity. So, uh nowadays, this is, uh this is much better. Let's go and have a look at number two. So this is a patient who's got abdominal pain and you can see that if we change the windows to lung windows, they've got a little bit of eight electricity cysts in the right lung base. And that just means that the right lung isn't ventilating quite as well as it should be okay. And because of that, um you get atelectasis, okay. So it's not infection, but it's just under ventilated lung and you get it quite often in patient's who've got abdominal pathology. Presumably there's something in the diaphragm that prevents it from moving satisfactorily. Okay. So let's have a, let's have a look. Um uh if you want to change the windows, you can click on the, the sun icon and just go down here or you can do uh click on here and then just hit 12345 and six. So we're now on soft tissue windows and I want you to work out what's going on. This patient is a female, young female with write a lack faucet pain and anorexia. And what I mean by anorexia is just an acute lack of hunger. So the patient no longer wants to eat a meal and they've got right iliac fossa pain. So bit of anatomy for you, there's the left liver lobe, there's the spleen, there's the aorta, there's the inferior vena cava, this y shaped structure is the adrenal gland. This is the right kidney and of course, the right kidney, the adrenal gland, the IVC and the AORTA lie in the retroperitoneum. There's the left adrenal gland which you can see here and there's the left kidney, there's the aorta, there's the left renal artery, there's the left renal vein which is joining the IVC over onto the right hand side. Let's have another look at the liver. There's the gallbladder, there's the left liver lobe, there's the cord eight lobe and this is the right liver lobe. There's the right ventricle, there's the left ventricle, there's the inferior vena cava, which is seen to enter the right atrium. There's the coronary sinus which drains venous blood from the coronary circulation into the right atrium. Okay. This is the latissimus dorsi muscle and it comes from the Latin for the most lateral of the back muscles. Latissimus is the most lateral and Dorsey means of the back. So easy way to remember is the most lateral of the back muscles. There's trapezius, the serratus anterior. And so as we go further down, we can see the descending colon, the ascending colon and there's the transverse colon. All of this bowel here is small bowel. And as we go a bit further down, we can see that there's an abscess collection in the vicinity of the cecum. And within the abscess collection, there's a high dense um opacity, there's no fluid level and there's some increased attenuation of the peri sequel fat. Can anyone tell me what the diagnosis is here? Is that the appendix? It is. Yeah. And so the patient has gotten appendicitis caused by an appendicolith and what's happened instead of just presenting as an appendicitis and then going for surgery, the appendix has burst and the patient has now got an appendix abscess. Okay. And sometimes appendix abscesses are treated conservatively and sometimes the surgeon just go straight in and removes the entire uh inflammatory mass lesion. Okay. But this is an appendicitis which has led to an appendix abscess. Now, what I'm gonna do is I'm going to put the two scans side by side. And so at the same corona level, you can see this abscess is clearly separate from the large bowel because it's arising from a ruptured appendix and it's in a typical position. Now, it comes as no surprise then that the patient because they're in so much pain, they under ventilate their lungs and they get eight electricity's and in this case, uh small bilateral pleural effusions is everyone, everyone clear about the CT scan and what it's showing. Do you, do you like this type of teaching where you can scroll through the images yourself? Is that helpful? Yes, sir. Yes, great. OK. Super. Okay. Let's go to number three and number three is a patient who has chest pain. So you can see here they've got a nice white line and a white line here and the lucency, these are streaky and they are going from the mediastinum up into the neck. Okay. And if we explore this a bit further with the CT, we can see that there's lots and lots of gas in the mediastinum. And this is a pneumomediastinum. Can you also see a bit of surgical emphysema here? And if we look a bit further down, it shows the anatomy beautifully. There's the esophagus, there's the ascus vein, there's the descending thoracic aorta, there's the left pulmonary artery, there's the pulmonary trunk, there's the right pulmonary artery, there's the left ventricle, there's the right ventricle and all of this low attenuation is gas in the mediastinum. Now, if you look a bit further down below the abdomen, below the diaphragm in the abdomen, you can see that the patient's got portal venous gas and they've got intramural gas and that's gas in the wall of the stomach and gas in the retroperitoneum. So, here is the pancreas and we've got gas in the retroperitoneum. We've got gas around the intra uh inferior vena cava and gas around the kidney. So, we've got a lot going on here. We've got gas in the mediastinum. We've got gas in the retroperitoneum. We've got gas in the wall of the stomach and you can see it very nicely here, gas in the wall of the stomach and we've just got a small amount of gas in the paris nasal cavity. So what's happened here is that this is a young guy who's had a gastroscopy and the gastroscopy has uh induced um a into a ter to the mucosa. And the insufflation of gas uh during the gastroscopy has caused pneumatosis iss, it's also resulted in pneumomediastinum. So there's a small tear in the esophagus and the gas is escaped into the mediastinal cavity and then it's tracked into the retroperitoneum, which you can see here And when you get gas in the wall of the bowel or the stomach, in this case, the only way the gas can escape is via the mesenteric veins and the mesenteric veins all lead to the portal vein. And that's why the patient's got portal venous gas. So it's a well recognized but rather unusual complication of a gastroscopy. But I've shown it to you just to illustrate what a pneumomediastinum looks like. And when we see this as a radiologist, we are always thinking, could this be due to a soft deal rupture? And does anyone know what the radiologist can do to confirm Asafa Jill rupture? Would that be the contrast or? Yeah. So we can actually, we can actually give the patient very dilute contrast uh on CT and we asked them to swallow the contrast and it might show the leak okay. Or alternatively, we can stand the patient up and do fluoroscopic examination where we give them um contrast and that contrast is then um seen to leak out of the um out of the esophagus directly know some, somebody asked me, could I show them the portal vein? So I'm going to show you on these windows where we've got contrast. So there's the gas in the portal veins, the small portal veins. Um Now the portal vein is going to be um I can't see it. The reason I can't see it is it's an arterial phase and we really need to um leave the contrast in for at least a minute in order to see the portal venous phase. Um but the portal vein is going to be on the right hand side of the uh superior muse enteric artery heading up towards the liver. And I'll show you on another scan where the portal vein is. It's just that we haven't been able to pacify it properly on this particular examination because it's in an arterial phase. The chances of rupture for this patient would be extremely high, right? Uh Well, um So what's happened is the gastroscopy has um caused a tour in the esophagus. So the mucosa has torn and as you um as you uh put gas into the stomach, because you've got a tear in the mucosa, the gas tracks down into the wall of the esophagus and then the stomach, which you can see here. Uh But it's also gone into the mediastinum. So it must be that there's a rupture which is full thickness, but also partial thickness as well, the partial thickness means that gas tracks into the wall of the esophagus and the stomach. But also it tracks outside the esophagus in the mediastinum. Say so in effect, it's already ruptured because the history tells me that this patient had a recent gastroscopy and that was the cause. But if the patient doesn't have a gastroscopy and it's been vomiting. Um, the radiologist and the clinician are probably, uh, kind of think the number one diagnosis here is a ruptured esophagus. Okay. So bore half syndrome is where you get a rupture of the esophagus after a prolonged vomiting. Um Now, there are other causes of pneumomediastinum, notably ventilation in intensive care because that produces barrow trauma to the small airways. Uh asthma can cause it and diabetes when you've got diabetic keto acidosis, that can also cause a rupture of the esophagus. Okay. And um sorry, uh well, it can cause rupture of the esophagus if you, if you vomit with DKA, but it can also cause um barrow trauma to the bronchus because of course, in DKA, you get a metabolic acidosis and a metabolic acidosis is corrected by the human body by hyperventilation to give you a respiratory alkalosis iss and the very uh rapid breathing is traumatic to the bronch. I so the various causes of pneumomediastinum. But the one that we fear the most is a ruptured esophagus because all the other causes just get better without doing anything. Okay. Clearly, you need to treat the diabetic keto acidosis. But actually all the other causes of, uh, uh, pneumomediastinum, they tend to get better of their own accord, but a softer gel rupture, you need to obviously do something about it pretty quickly. Okay. Number four, this patient has presented with chest pain. Any, any thoughts have a good look at the chest X ray at home, zoom it up. Any thoughts they've got left sided chest pain? I'm going to guess this. But is it a form of pneumonia? Uh, pneumonia were about, I'm going to move the arrow. Tell me where to stop. I don't know because I mean, where the heart is, there's like it's building like the heart looks more covered than it should if that makes any sense. Okay. So, so the heart, there's the right heart border, it's nice and sharp. There's the left heart border, nice and sharp. There's the right hilum, there's the left hilum, there's the aortic arch and all of these structures are very crisp and clear and in fact, the lungs are free of any consolidation. Okay. But I'm just going to invite you to zoom up. Um, can you see a difference between that apex and this apex here? And can you see talker a lung edge? Can you see that lung edge? Yes, sir. Yeah, so fine. Yes, we can see it. Can you sit there? Yeah. And one of the other things you can do is you can adjust the window and sometimes that can enable you to see the lung edge a bit better. Yeah, by doing, doing this. Um this patient has a left sided pneumothorax and the left sided pneumothorax is visible because I can see a lung edge. But sometimes when you can't see the lung edge and you may not be able to, if it's superimposed over the rib, you will be able to see that there's a pneumothorax because there's an absence of vascular markings. Okay. Now, this is quite a subtle pneumothorax. But when you are qualified doctors, you'll be on the ward and you will come across patient to have spontaneous uh chest pain and breathing difficulties. The one of the big diagnoses, I always try and think about when I see that situation is to make sure that the patient does not have a pneumothorax. Okay. And this patient clearly does have a pneumothorax. Now, whether or not they need that draining um is another matter and that's a matter for the clinician who assesses the patient's clinical state with respect to the pneumothorax. They may not need anything doing if they are not compromised. Okay. Number five, what do you think is going on in this elderly male? Just by looking at the abdominal film? Any thoughts, what type of bow is dilated? It's morning this time it's a small bowel, isn't it? Why is it the small bowel? Because I can't see the large bowel and all the, uh, that's good to know about. So, you're absolutely right. You can't see any large bowel and this is centrally placed as you might expect small bowel to be. And you know, it's small bowel because the valve in the convent is go right the way across without interruption. Okay. Now, if it was large bowel, it would be more peripherally placed. The delectation would be bigger because large bowel is bigger by definition And you tend not to see the valve Elocon event. He's going right the way across. They get interrupted by what's called the Taenia Coli. So this is small bowel delectation. Now, here's an important thing in medicine and in radiology. When you see somebody with small bowel debilitation, uh everyone automatically assumes it's due to obstruction. Okay. Now, quite often it is due to obstruction, but it can also be due to paralytic. I'll ius and the difference between paralytic ileus and obstruction from an examination point of view is that you'll get tinkly bowel sounds with obstruction and you get silent bowel sounds with paralytic ileus. Okay. Now, in this particular patient, uh, the clinician thought that the patient was obstructed because they had tinkly bowel sounds. Now, the whole purpose of doing a CT is to work out whether it's mechanical obstruction or not. Okay. But one of the other causes of small bowel dilatation that everyone forgets is small bowel ischemia. Okay. If you've got an ischemic gut, it tends to switch off. And so it is one of the causes of debilitation of small Bell. So, with that in mind, when I'm looking through the CT, I'm looking for evidence of mechanical obstruction. But also I'm looking for evidence of small bowel ischemia and small bowel ischemia might produce gas in the wall of the small bowel. It may produce portal venous gas as you saw earlier. Although that wasn't due to a ski mia, Uh, in fact, this is uh, biliary tract gas and they can often be very difficult to, to work out. But biliary tract gas tends to be more central, peripheral branching opacities tend to be due to portal venous gas. So it's just unfortunate that this patient just happens, uh, portal, um, sorry, uh biliary tract gas. And that's not because they've got a gallstone. I'll ius although that would be the number one thing I would think about. Okay, gas in the biliary tree. Small Bell delectation. Let's look for a gallstone. But actually, I can't see a gallstone. What I can see is collapse of the descending colon, which is here and all of this bow is dilated small bowel. We've got collapse of the cecum on the right hand side here. And as we go further down, I can see that there is normal caliber small bell. And that tells me that because I've got dilated small bell and normal caliber small bowel that there must be a mechanical obstruction. Okay there must be a mechanical obstruction. And so the next thing for me to do is to work out where that obstruction is. No. What does this show here started? Bloodless. Uh, sorry, say that again. I missed that. Uh, this is a bit of small bowel which is in the groin. So, if we follow it back, so it's herniation. Yeah, it's a herniation. Yeah. Can you see it there? So, we've got two loops of bowel. There's the dilation of the small bowel, it goes into the hernia and then the bit of bowel that comes out, um, is not quite as dilated. Okay. Now, what I want you to tell me is, is this an inguinal or femoral hernia? I think it's a female. Why is it a femoral hernia? Because it's not going more central to the pubic surprises. It's, that's the, the actual side. Yeah, that's one reason. So inguinal hernias tend to be more medial. Okay. And inguinal hernias tend to over lie the pubic tubercle, which is here was femoral hernias tend to be more lateral. Now, here's another interesting thing. Do you remember from your anatomy? The contents of the femoral canal? What's in the femoral canal? People are tree vein and, uh, yeah, a non artery and nerve and the femoral canal is very, very narrow. Okay. So, if you've got bowel that's going through a narrow canal that already contains three structures, what do you think is going to happen to the femoral vein compress, it's going to get squashed, isn't it? So, look at the femoral bein on the left side, it looks normal as the femoral artery is the femoral vein. There's the femoral artery, there's the femoral vein. Now, look at this, what's happened to thermal vein? They're squished, squashed and it's squashed because we've got small bow in ephemeral hernia through the femoral canal and it's squashing that vein. Therefore, this is a femoral hernia. And what's the importance of the femoral hernia as opposed to an inguinal hernia, anyone know, support rigidly entire blood flow for the black. Well, it doesn't actually compromise the artery friendly enough, but because the canal is so narrow, you've got a greater chance that this is going to cause strangulation. Okay. And so it's much more important to uh decompress and fix a femoral hernia than it is an inguinal hernia because in the inguinal canal, the aperture is so much wider for the bowel to go in, it's less likely to strangulate. So femoral hernias tend to strangulate and this is an example of a femoral hernia uh in a male patient, um, which is slightly unusual because they're much more common in females. Um I don't know the reason why, but the female to male ratio for femoral hernias, I think is about six or 7 to 1, which is interesting. It must, it must be due to some anatomical uh quirk. But anyway, there's a femoral hernia with small bowel obstruction and it's nicely shown here with squashing of the thermal vein. Yeah. So if anyone ever asks you, uh, to look at a CT scan and you see a femoral hernia and they ask why you so certain this is a femoral hernia. What are you going to tell them? Two things? One, it's lateral to the pubic cubicle and two, it causes compression with femoral vein. If you have an inguinal hernia, it doesn't compress the frontal vein and it drapes over the pubic cubicle. Okay. Number six, have a look at this one. What is going on here? Just have a little scroll through that and tell me what you think is going on. Any thoughts this patient has been hit on the head. It's a head trauma. Yeah. So there's the scalp hematoma and what is going on on the left hand side of the patient? Oh, and that's the banana. So that's a subdural hematoma. Yeah. Yeah, that's right. It's, it's an acute subdural hematoma. Have you ever heard of the expression contract? You? No. So contract. Who is a French word? And it means the other cut. Okay. So if you get trauma to this part of the head, you need to look opposite to see if there's any other trauma. And in fact, there is a scalp hematoma here and there is a subdural hematoma here. And can you also see that there is midline shift? Yes, sir. Tell me that, that subdural hematoma is under pressure. Okay. And unless this is evacuated pretty quickly, the patient is going to die because the brain herniates across to the other side. But it also forces the brain stem down into the frame and magnum. And that's what we call Koning. You heard that expression when the intracranial pressure becomes so high, it forces the medulla oblongata and the brain stem into the frame of magnum. And that's called koning. And what we've got here is we've got severe midline shift and we've got effacement or squashing of that left lateral ventricle. And you can also see that the sauce i on the right hand side look recently, okay, but there are no sores on the left side because of the raised intracranial pressure. Uh Now you also notice if we go on to bone windows that the patient has got a defect in the right temporal parietal bone and that, that's from a previous craniotomy. Okay. So the patient just happens to have had a previous craniotomy and this has caused um a little bit of what we call uh careful O Malaysia. So they've obviously had a previous craniotomy for some problem. Maybe it was to evacuate a tumor or a hemorrhage. I don't know. Uh But uh the new presentation is that this patient has had trauma to the head and trauma to the head has resulted in a scalp hematoma, an acute subdural hematoma. I'm so sorry. That's my dog who wants to go out for a walk. There you go. He's gone into a different room now. Sorry about that. It's the spleen that, right. Okay. Sorry about that. I'm just, just muted it while the dog was barking. Um, okay. So the next, the next one is a patient who has got abdominal pain. So if we look at the abdominal film, we can see that there is a little branching of lucency and there is small bowel debilitation. Now, this is not as uh marked as a small bowel dilatation that you saw previously, but there is small bowel dilatation. I know it's small bowel because it's central, it's about 3.5 centimeters, it's not too big. And you can see the valve Elocon event is. And so again, when you see gas in the liver branching, you must always think of either a ski mia in the case of portal venous gas or in the case of Gallstone, alias, this could be biliary tract gas. So if I look at the the other view and again, I'll just alter the windows, I can see some very faint branching. So let's go straight for the CT. And again, I can see biliary tract gas, I can see the pancreas, I can see the right liver lobe. I can see small bowel debilitation note, the large bowel has collapsed. So in, in true mechanical obstruction, you do get collapse of the large Bell, but all of this is small bowel delectation. And I've got something in the, in the bell just there and I'm going to show you what that looks like on the Corona all and on the Sagittal. So anyone know what the diagnosis is? So, we've got gas in the biliary tree. We've got dilatation of small bowel and we've got uh, an ovoid opacity which looks calcified in the distal small bell substructure. I've, yeah. So there's a mechanical obstruction, I can see normal caliber small bell. So there must be a mechanical obstruction. And so what is this? That's cool, causing the obstruction. We can call it a foreign body, but, well, it could be a foreign body, although not in this case. Uh, let's go back to the liver. Now, it's very difficult to see, but I can't see the gall bladder. Okay. The gallbladder is shrunken and there's a little bit of gas, which is probably in the common bile duct just there. And the gallbladder, which is normally seen is just shrunken. And this is a case of gallstone, I'll ius. So what happens is the gallstone produces a thickening of the gallbladder wall. So you get a chronic colecystitis and eventually that gallbladder wall becomes very thick and friable and you then get a fistula developing between the gallbladder and the duodenum. And when the gallbladder goes into the duodenum, it goes right around the small bowel and ends up in the distal part of the eye liam and this is a gallstone, a lius and it's known as Reglas Triad. I'll just put that in the chat for you regardless triad. And it consists of one uh new mobile eah, two ectopic gallstone and three small well obstruction. Okay. So that's Reglas Triad. And this is a really, really nice case of gallstone Eilis. Uh Now, this can be quite difficult sometimes to differentiate between portal venous gas and gas in the biliary tree. But in portal venous gas, which was I think uh number three, the the gas goes right out to the periphery. Can you see that right out to the periphery, see there? Whereas in this case, it doesn't go right out to the periphery and, and that's the difference between the two from a radiology point of view. Now, uh an earlier comment on the chat was, could you show me where the portal vein is and I'll try and show you on this examination. So, in this patient with the family hernia. So it's number five, there's the splenic vein which is behind the pancreas and the splenic vein joins with the superior mesenteric vein to form the portal vein which is here and the portal vein goes into the liver like that. Okay. Now, the portal vein is very difficult to see in a thin patient during an arterial phase. You really need a portal venous phase. And that's why we call it the portal venous phase because you can see the portal vein very well, but if it's arterial that you don't see it particularly well, but there's the portal vein, I am going to finish their. Does anyone have any questions? Um I have a question for you guys. Is this the kind of radiology that you like or would you prefer a formal Power Point lecture or do you like scrolling through the cases yourself? Both are better in their own ways and this is better? Okay. Yeah. So is it uh is it useful to scroll through the images yourself? Yeah. Yeah, it's good. Thank you. Okay. That's great. Any questions on anything I've discussed this morning? No. All happy. Well, look, I have a, have a great rest of the day and if anyone has any questions, you can always contact me on my email address. I'd be very happy to answer anything. Um I'll just put it into the chat. Okay. And thanks for your attention. So enjoy the rest of the day and thank you. Thank you.