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Good morning, everyone. We like to welcome Doctor John Curtis. Who's a consultant? Radiologist on D. I believe you're doing CT of the brain this morning. Is that correct, Doctor Curtis? So absolutely right. Brilliant. Say, I'm over to you, then. Okay, good. Good morning, everyone. My name's surgeon Curtis. I'm a consultant radiologist in Liverpool Onda. I work on the entry site and we are a big trust comprising Aintree on the royal of a pool University Hospital. So I've been a consultant radiologist for 26 years and I've seen quite a lot off with ology. Uh, what I'm going to do is I'm gonna try and pick. It's this eso that it is suitable for medical students. So what I'm what I'm gonna do is I'm not going to show you anything too difficult, but I'm going to show you some radiology off the brain which is relevant to your future careers. Whatever career you go into, the first thing I'm going to do is I'm going to give you a link on. It's this link here. I think Dan is very currently posted it back onto the chat. And if you open this link, this will allow you to see some of the cases on going to go through the slide presentation first. Then I'm going to invite everyone on their own computers to have look at these cases and I'll go through them with you. Does everyone understand that just pretty? Yes, in the past. If you do, this is going to be the most interactive online teaching you've ever had. Okay, right, let's start. So here's the brain. On the most important part of the brain, as far as you're concerned, is the internal capsule. There's the anterior lane. There's the posterior limb, the follow ms the Kordech nucleus, the external capture on, then the occipital cortex, the frontal cortex onda. As we go further down, I'll show you the brain stem. So the reason why this area is very important is there's a dense network off neural networks, which go into the internal capsule and then the posterior limb on. These are really like the main motorways off the central nervous system. So here's a CT breaking. We know to see TI because the brain settings reveal the bone is white. Here is Theo anterior horn of electoral ventricle, anterior horn off the right lateral ventricle. Posterior horn. This bit of calcification. Here is the corroded plexus on you can see in a normal brain. We've got source. I like the valleys. July, right? Like the mountain tops. Okay, so I've tried to reproduce this in this diagram, which I've drawn myself. So we've got the cortex, which is gray. The black is the white matter. Okay, Onda, we've got the gyre I which mountain tops? And then we've got the source tie. Which in the valleys there's the internal capsule on. You can see that you don't see it very well on a CT scan. You can see it much better on an MRI scan on. I will. Trying to illustrate that a little later, there's the cord at nucleus, which is great matter just in front of the internal capsule on behind the lateral ventricle. Then we've got the thalamus, which is great matter on it's posterior to the internal capsule. And there's one on each side. So these of calamari, This is the so called external capsule again. You don't see it particularly well on CT. You see these structures much better on MRI. So the MRI illustrates that these structures are better seen. So there's the internal capsule. There's the court date nucleus. There's the external capsule. Okay, there's the thalamus. Come on. This T two weighted image, you can see that there is high signal which represents CSF. The CSF was also seen in the So sorry. And you can also see blood vessels in those still site. Now, the vascular anatomy off the brain is very complicated on this. Is that a beautiful illustration by Frank Netter, that famous doctor who was also a pill. A straighter aunt, he shows the first block trees, the buster artery, the pontine arteries. And then the so called circle of Willis on the circle of Willis is in fact, around about made up off off trees which linked to one another. So we got the anterior cerebral artery here. We've got the middle cerebral artery, which is a big artery. We got the internal carotid artery, and then we've got the posterior communicating artery on the posterior cerebral artery. Now it's it's quite complex on. You don't need to know all the branches to understand the pathophysiology off vascular stroke. Vascular problems in the brain so often this diagram and I'm very happy at the end of this. Talk to all of you. A pdf copy of all my slides. So here's the anterior communicating artery here. The anterior cerebral arteries one on either side until the cerebral artery. There's the middle cerebral artery. Posterior communicating artery, cerebral artery posterior. Uh, this is the bustle artery on the foreseeable arteries lead into the back surgery. So this is a normal brain now. A normal brain. What does that look like? Well, I'm going to show a very short video on this. Should there's the frame and Magnum. There's the medulla or born Got the Is cerebellum cerebellum. Here's the brain stem. Who's the cerebellum? Cerebellum. There's the brain stem. This is the fourth ventricle. Four fat trickle here does the pre pontine system. This is the ponds. This is the ambient system. This is the quarter general system. There's the temporal lobe. We're now getting into the cerebral hemispheres above the tentorium cerebella. Here's the quarter general system shaped like a W. There's the Sylvian Fissure, in, which runs the middle cerebral arteries. So here's the court date nucleus, the internal capsule not very well seen compared with memory, skin But this is really important part of the brain, which, if insulted by a Ninfa, it can lead to devastating problems. Now you can see that there are still see on these cells I representative valleys between the mountaintops, which are the gyre I on. These should be symmetrical on present in a lot of patients, although in younger patients they can be a little bit tight. Actually, get older, you get more brain lost. So the valleys, all the salts I'd become more generous with CSF. So here the lateral ventricles and then this is called a central, um semi of all eight, which is a for a large area off white matter. And then here's the Vertex when we got the front law on the parietal lobes. Okay, Andre just Teo illustrate the difference between Steet E and MRI. CT uses ionizing radiation on brain windows. The bone looks white. This is a powerful Simon in June. It's powerful, son, because here's the folks on it's adjacent to the folks. We've also got him in in gym here on t one way to the MRI. And this is an olfactory groove. Meningioma, cause this is just above the crew perform plate No, be anatomy is really quite nicely demonstrated on t two weighted imaging because you can now see very exquisitely the gray matter which is gray on the white matter, which is rather block so low. It's called White Matter, you know? And I know, uh, that on MRI, it's the opposite on So this is black on MRI here, the lateral ventricles with CSF Say I'm gonna show you something that's really, really important. This is the anatomy of the jewelry. So the jurors lines the brain and we've got one out a layer which is right up against the scope on the important thing about the outer Joram a lotta is this. It's stuck to the skull except at the suture is, well, it's completely glued to them. Burst the jurors. Although it's stuck to the skull, there is a potential space between the scope on the jury on this forms the basis off on extradural hematoma. Then we've got the inner layer of the jewelry which forms the fox has it condenses on the inner and outer layers of the jurors, form the boundaries off the venous Sinuses. So this is the superior sagittal Sinus underneath the dura. We've got some bridging veins on. We've got some little connected tissue connecting rods, if you like. And so when the brain becomes smaller in old age, this space becomes bigger on these veins have to stretch to go from one side off the underneath of the jurors to the to the brain surface, and they can be easily damaged during traumatic episodes on. Then we've got the subarachnoid space, which is in this particular space here. Okay, on again, we've got some bridging connective tissue, and then we've got the pier, a martyr, which is a very thin film overlying the brain. This is Ah, modern illustration. This is Grace Anatomy where we've got the cranial bone. And then we've got the jewelry Marta, which of course, splits to become the outer layer on the inner layer around the Sinus. When you get an extra dural heme tomer, what happens is the fracture. Usually a fracture through the school causes a disruption off a branch of the middle meningeal. A artery on this leads to bleeding between the skull on the jeweler. And that's what's called an extra general or the Americans call it the epidural hematoma. Now I mentioned that the jurors is bound to the skull, but it easily gets peeled off during an extra dural hematoma. But where it's glued to the suture, it never crosses the suture, and I'll show you some examples of that when you get a symptom relief. Um, a tumor. The bleeding occurs to to Venus bleeding, and that's what colored blue here on D. You get blood underneath the jurors because the jury is still attached to the school and it's usually due to rupture off a bridge in vain. Okay, now it's possible for an accident or a hematoma to peel this juror off the skull across the midline. But it is not possible for a subdural to cross the midline because the folks is stopping it. And that's a really important anatomical consideration when you're looking at head injuries. Okay, so what does this translate to in real life? Well, here's the folks. Here's the folks it's made by the jurors on the jury is surrounding the superstar little Sinus, which you can see here on at the Lambdoid and Carina LSU teachers. The jury is glued to the school, So here are the adrenal suture is deaf. See them particularly well. You see the landlord suits you much better on the bone settings of CT. There's the landlord suture, and there's the Corona suture and said the jewelry is absolutely stuck fast at that level. So when you get an extra dural hemorrhage, this is because you get bleeding from a branch off the middleman Angeleri. And it's almost always associated with school fracture on blood collect in this extradural space, it tells not across the suitors. Unless, of course, is a fracture through the suture On the resulting extradural hematoma is Len shaped or biconvex on. The pressure that builds up is very rapid on could kill the patient very quickly. So it's typical that these patients have a Lupus it phase, and that may have a phase where they have a complete cerebral breakdown on the GCS falls very rapidly save his next door. Hemotomas Um, you get this leading shape. It's an acute onset your polluted interval and goes off on. You got damage to the middleman In July, artery blood accumulates in the by combat space and strips the jurors off the skill leading to very increased pressures on here is such an exam. Pulse say we've got a suit here on you can see that the jurors is bound to the suture on the hemorrhage in the extradural space. This is associated with a fracture. It can cross the midline, but it can't cross the suture here. And we've got an actual human tomer here. Now this is called a swirl Stein, because it has different attenuation on the darker blood is actually the acute bleed. And the brighter blood is the bleed that's been there for about five minutes or so on. Did you concede that the extradural hematoma does not cross these suits use? There's also been a confusion in the price low just behind the extra or hemotomas. On. This is the CT video off this particular study. It's on. Repeat. So I hope you can. We'll see that. And here's another example where we've got on extradural hemotomas between the Caribbean or on the lamp cord. Suture on again. This is the anatomical reason why the extradural hemotomas looks that way. It does now. I did mention that extradural hemotomas tend not to cross the suit use, but they can do if you have a fracture through the suture. So this is depressed. Skull fracture. Now, what I'm going to do now, I'm going to invite you wall to open that link, and it's a pack spit link on. It's a link to some cases, right? Say, can you'll see that screen? Yes. Become excellent. Okay, great. So let's have a look at case one on. I hope you can also scroll through these yourselves. Could somebody in the chest just tell me whether or not that they're able to do that? I can scroll through it. Yes. Already says, Yeah, that's great. Okay, so this is gonna be really interactive on at the end of this talk. You guys can have a look at all of these images now. Case warm. If you press the blue like blue button here. Gives you a little history trauma lucid, then goes off. That's a clue as to what's going on here on. You can see that the patient has got a lens shaped extradural hematoma, which is going from the career ulcer to the landlord suture. Okay. But also, this particular patient has got a small subdural collection. A swell, which you can see here and you can just to see that this, um, made line shift from right to left on this patient has got a faced lateral ventricle. Say this is an extra, or hemotomas, which is building up so much pressure that the, like actual ventricle is being faced on. Unless this patient gets evacuation of the human Tomer, they will die. So this is a neurosurgeon Emergency on. We've got a subdural. Well, so looking at the bone window is you can actually see. This is associate with occipital bone fracture, which goes into the base of the skull. Okay, so most extradural hemotomas are associated with fractures off the skull on D you get a fracture or a laceration off the middle? Manager the lottery. Okay. I'm gonna go back to the presentation. I'm going to talk about subdural heat hematoma or hemorrhage. A symptom oral hemorrhage because it's been low. The Jura, you get blood, which crosses the suture on its Konchellah. Eva Convex. So it's not lens shaped. It's con cave. Oh, come backs or crescent shaped. And here's an example of an acute subdural hematoma. We've got some scalp swelling on the left hand side at the front on opposite. We've got this subdural hematoma. It's crossing. The suture is and it's come cave. Oh, comebacks. Onda. You can already see that the soul still pattern and no other words. The valleys between the mountaintops has gone because the brain has swelled up on the right hand side. We've now got midline shift, so subdural hemorrhage, although it's caused by a bleeding vein constituent, build a significant pressure, too, cause cerebral edema on midline shift. So this is a subdural hemorrhage. You can also get subdural. Hemorrhage is adjacent to the folks, so here is a powerful sign subdural hemorrhage on the right hand side on this is because the blood is free to move underneath the jurors. And don't forget, the jurors binds to the you're on the other side from the folks, so it comes as no surprise that you can get blood on the right or the left hand side of the folks on that. This is a subdural hemorrhage tends to develop over hours. Two weeks on is a little less immediate than a next door hematoma, but it's non less, Um, equally as important has another acute subdural hematoma where we've got herniation off the left brain underneath the folks, so it's called a stupid full sign herniation. Sometimes you don't see the septal very well, because after a few weeks, if the patient survives the full, the blood turns into on ice. So dense matrix, the fluid consent times look the same dentist, his brain. So here's an example at this patient has got a CT on enhanced Nothing much to see. Really, I can't really see the sole cycle meaning out to the periphery here. Giving contrast doesn't really help that much. But then one hour later, doing an MRI scan, you can see the subdural a lot better. So this is an eye so dense subdural on. These can be very difficult to stay some way down the line. So if you wait a week or two, the situation hemorrhage it will become less dense and can be confused with your brain. Somebody's asked, Why does the subdural hemorrhage have a conclave? A convex shape? So what? What it's doing is it's assuming the shape off the outer aspect of the brain. Okay, so the lateral aspect of the subdural hemorrhage, how's the same shape as the cranium on the inner aspect of subdural hemorrhage has the same shape is the brain. So that's what to conk. A very complex Onda crosses the suitors because off the anatomy, um, differences between an extra on a structural hemorrhage on this's really summed up in leads the's images. There's the extra dural, which crosses? Sorry, it does not cross this teacher as the cradle teacher here has. The Lambda was sent you here on. This is the subdural hematoma which does cross the suitors. Is everyone happy with that? Any questions on extra and subdural hemorrhage. Okay, great. So what? Half an hour into this talk? I'm probably gonna go on for about another 15 minutes and then very happy to have some questions, but I just want to go back to the Paxil. Been link on if you go to case too. It's a trauma case, open study, and you can see that this is a powerful sign. Subdural hemorrhage. Can anyone tell me which side subdurals on got 50 50 chance? I'm guessing it, right. It's the right hand side, Okay? And I'll tell you why. It's the right inside, because the blood it's wavy on the right hand side on it, straight on the left hand side. There for it must be on the patient's right. So it's a sexual hemorrhage following minor trauma. And he could actually see the subdural hemorrhage, which goes around the superior. Such little Sinus. Because, of course, the superior such little Sinus is bounded by Jura. So this is below the door of subdural hemorrhage. Show you another case case to a And if we have a look, at case to A I'm hoping that you can see what I mean. This is a symptom collection that is about 3 to 4 weeks old. Okay, might even build might even be six weeks. And this is a right sided, chronic subdural collection. But it's still causing midline shift, and you can see that the lateral ventricle has been squashed on. But we've got midline shift. So this needs consideration for evacuation by a neurosurgeon Case three will discuss in a second. So the rule of two weeks blood on CT for the first two weeks looks dance for the second two weeks. Looked I so dense on the third two weeks is hypodense. Now that's a rough rule of thumb. Okay, so Here's an example off hypodense bilateral subdural collections and you can see that these collections are con cave oh, convex or crescent shaped. And they cross the suitors on. They are off load in cities. They are chronic bilateral subdural collections. I'm now getting Teo talk about subarachnoid hemorrhage on the subarachnoid hemorrhage. The bleeding is below the Jorah, but it's also below the arachnoid layer between the rack note on the pier. Marta, I'm so it's free then to drop into the valleys between the mountain tops, which are the giant right skin. So because they go into the salts, I okay, the blood spreads like branches of a tree and this is typical subarachnoid hemorrhage. So I'm going to show you subretinal hemorrhage, so you'll notice that the patient has got on endotracheal tube. Got blood around the basal systems. Sorry. Blood in the basal citizens. I beg your pardon on, but here's the brain stem. More blood. This is in the CSF space. So the CSF here has been replaced by blood on. You can see lots of not to blow it. Now on this blood is going into the Sylvian fissure is on the circled interpret ankle assistant, and this is a typical sibling subarachnoid hemorrhage. And so patients who have a subarachnoid hemorrhage tend to complain of a sudden onset off the most severe headache. Now, you can also see a little bit of blood in the ventricle just here. And that's because the ventricles I haven't the CSF are in communication. Five. The basal systems blood in the basal systems will find its way into the ventricle. There's the third ventricle on this particular patient because everything is so tight because the blood we've got early heart careful. It's because CSF and blood can't flow readily into the fourth ventricle because of all the blood around the around the basal systems. So the commonest cause off subretinal hemorrhage is trauma a minor trauma. Okay, so you can get minor trauma. Giving yourself Bratton would bleed if you get blood above. The basal systems into this part of the brain alone are not below this level. They tend to be caused by aneurysms on aneurysms tend to occur along with the circle of Willis. Okay, so where you got bifurcate? You tend to get a on aneurysm. Okay, but trauma is a big cause of Suburban would hemorrhage. Now this is patient has Anania is, um okay, I think I I think I've confused to myself that I said the wrong thing. If you get blood of both from below the basal systems, it's much more likely to be caused by an aneurysm. And if you get blood just above the basal systems, it's probably traumatic related. Burst Elise Patients undergo a CT angiogram to see if they can find on aneurysms that cause the subarachnoid bleed. Okay, so let's look at case through a on. If you open this study, you'll see that the patients have a thunderclap headache. Let's have a bit of feedback while I'm just waiting for this to open. Um, are you enjoying the real life interactive cases here? Is it useful? Good. Okay. Excellent. So if you scroll through these Onda, look at the third thumbnail down, you can see that the patients got very large interest. Cerebral hematoma. Andre, the interest cerebral hematoma is the consequence off a blood clot in the vicinity of an aneurysm. So when you've got subarachnoid hemorrhage, what you have here in the Sylvian Fissure and around the basal systems just here the interest rebuild hematoma could be a a signature that there's an aneurysm in this vicinity on. So it's really important that these patients should go on and have a CT angiogram on then, uh, to have an interventional radiology procedure where they coil the aneurysm. Otherwise, the patient is likely to rebleed. Okay, So just look how tight be CSF it is around it. Well, in fact, the CSF is not being replaced by blood. But this is exactly why these patients get terrible headache, first of all, to get meningeal irritation. But also, the buildup of pressure in the brain causes a headache on these patients. Also, to get blood in the ventricles, there's blood in the forefront trickle onda with a lot of intracranial pressure. This conforms the brain stem down through the frame and magnet. And that's what we call koning on. You are able to see that on the brain skin. So there's a little bit of midline shift caused by this interest real human. The table. Now, another case case three A severe headache sudden onset on. If we scroll through that, I think you can guess what you're going to see. You've got lots of blood around the basal systems. Very nice. Demonstration off blood around the ponds. You can see hydrocephalus because we've now blocked the flare of CSF from the third to the full federal. So you get hard to capitalists and then you got blood in the Sylvian fissure Has blood in the lateral ventricles. Okay, Now, um, just, uh, just the time I'm probably gonna have to finish this talk again. If you want me to do another talk, I'm not going to rush it, but I think it's probably more useful if I show you some cases. Yeah, we could do. I think the cases would be good because your arms during questions as we go along as well, Doctor. Yeah, that's great. Okay, so if you guys want I'm very happy to do ct of the brain part, too, on another occasion. But let's go to cases full in case for the patient. Excuse me? It's got a cute right sided weakness. Onda. If you look at the brain, there's an area off low attenuation in the right posterior parietal lobe. Now it's important to know whether or not that's relevant. What do people think given up this patient has got right sided weakness. Yes. So you're looking for a left sided pathology. Really? So what I would do is a radiologist. I'd look at previous films on be established whether that was a no old cerebral infarct. In fact, that was an old cerebral infarct are looking through the rest of the brain. It looks relatively normal, perhaps a bit of loss of source of definition here, but it's really quite challenging to see. So if we go into this mode here, we then subjected this patient to an an MRI on the MRI shows that most of what we're seeing on the CT in this region is CSF. So this is an old infarct, and actually, what was seeing on the left hand side is high signal involving the cortex off the oxygen port on D. The poster proctal over. Okay, so we can do a clever trick with the MRI on. What we can do is we can subject this patient to do what's called diffusion waiting. And so when we put the patient on diffusion waiting Look at that. This is diffusion waiting, sharing the cortical in folks. So the whole point of case 04 is to show you that sometimes you can overlook a stroke on CT on if you suspect somebody having a stroke. By all means do. A CT on the main function of CT is to exclude hemorrhage so that you can give the patient curriculum. It's Androgel for for other analytics. Um, but if you are absolutely sure it's a stroke, the practice in the UK is to subject these patients to diffusion weighted imaging on D. We've got left poster parietal in Fort, which explains the acute right sided weakness. Andre without in mind, Let's go to case for a This is a patient who's got dizziness on double vision off. Acute onset was slurring of speech. And if you look through the state TB brain, there's very little to see. You can't get through it rather rapidly, but but actually this is not very much to see, but clinically, this patient is acutely unwell. They've become very dizzy. They've lost their speech. I could just see that simply wants some help with the orientation. This is the right side. This is the left side on, and what we do is we do a slice through the brain on. We look at the brain as it were looking from the toes towards the head, so this is always the right side. This is always the left side on. What I'm gonna do now is I'm going to put up the feet. Two weighted image on there's the puzzle or or three. That's the bus a watery. There's the internal carotid artery. There's the internal carotid artery. Temporal lobe, temporal lobe, Cerebellar Hemisphere Cerebral hemisphere. What's this? What's this structure here? Anyone yet? Brain stem. Actually, it's the ponds. On Do the ponds is the bridge between the cerebellum on the cerebrum. On it comes from the Latin for bridge, which is ponds. And you can see this this straight line on this high signal here, and this is a pontine stroke. Well, pontine infarct on D. Let's go to our diffusion weighted images. Unless if you can see this, there's this diffusion weighted images. It lights up like a beacon, so MRI is really useful, showing a stroke that you can't see on CT. So let's have a look back on the CT on however much are Look, I can't really be sure that there's an infarct Now with the retrospect escape, maybe that's a bit of low attenuation. But of course, we are always taught is ready or just not to rely too much on low attenuation when we are behind the pediatrist Temple Bay. Because these bones are very dense indeed. So it's the densest part of the, uh the scope on they calls were wonderful problems with, um, Attenuation in the posterior fossa. This is a very nice example. Off a pontine stroke on this has come from occlusion off one of the small pontine artery. It's that come off the bustle. Remember that diagram I showed you at the very beginning at the circle of Willis on the vascular, uh, territory. All right, let's have a look case five. So let's look at the history. This patient is confused. So let's go straight into the CT. As we scroll through anyone like a hazard of the gas is to what's going on. No contrast has been given. This is the left side. This to the right side. There's the brain stem. There's the temporal lobe, both cerebral hemispheres. So what? What have we got here? Anyone won't want a house of the guest posted in the chat Bleeding in the temporal lobe. Yep. I'll like that multiple in force. Not really. Because multiple infarcts would not tend to give you these rounded areas here on. In fact, these are multiple hemorrhagic metastases on this is what so called Vaseline a cardiogenic, a Dema on the face of chatting Kadeem A is caused by the metastasis. Now no contrast has been given, and yet he's a very dense I'm just going to show you the X ray off the chest and you can see that the patient has got multiple cannonball lesions. They got surgical clips here on the surgical clips up. They've had lymph node clearance on this is melanoma metastases. Okay, so melanoma metastases, which from a tester sized to the lung and to the brain on so CT can pick these up pretty quickly on quite easily on day. Of course, this is very nicely seen on MRI, too. So this patient has got these high signal metastases. They show seven enhancement. Not much, because they are already, uh, dense on ct on high signal on MRI on. This is a patient who's got multiple, uh, melanoma metastasis. Ease. Okay, I've I've kind of finished what I was going to say. I've got a bit more to talk about with this topic, but I think we'll have to do that for a difference occasion. I'm very happy to answer any questions anyone might have. Yeah, let's take a few questions. Uh, would be great. Teo. See you again to do some more cases. Like them. Obviously, you can see the Chatsworth, but more is asked. How do we know it's based? A cardiogenic Dema. Okay, face a cardiogenic. A Dema is usually caused by tumors on it goes up to, but doesn't involve the cerebral cortex. Um, so if I can get a yeah Teo way. Haven't got a t two weighted image here. Uh, okay, let's go to the CT. Say, can you see? Uh, this is royal, the sensitive This? Yeah, this metastasis here course is a demon. But you see, the demon goes as a safaris, the cortex, but doesn't involve the cortex. That's very easy, cardiogenic. A demon. If it was cytotoxic edema, which could get with a stroke, it tends to involve the cortex because, of course, the cortex is likely to suffer from the strike because that is the vascular territory that strokes occurring. Surveys a cardiogenic, a Dema. The edema surrounds the lesion, goes up to you but doesn't involved the cortex. Okay, does that have to see your question? His A question? How do I know if it's the tumor or an entrance? Cerebral hematoma. They both look white on CT. Okay, that's a very good question on if it's a solitary lesion, sometimes you don't know hemotomas very rarely are rounded. They are anything but round, really. They follow the shape of the brain, whereas tumors tend to be rounded. So that's 11 clue. The other clue is that the history that the patient gives you with a hemotomas is usually rather certain on with a tumor. It's usually over a long time on, so don't forget that radiologists, When we look at scans, we also look at the history. Yeah, so MRI of you. It's exactly the same. So imagine the patient is lying supine in the scanner on. We're looking from the feet towards the head. We've done a slice through the head. That's the patient's right side. That's the patient left side. That's the patient's right side. That's the patient's left side. Okay. Sorry. Asks what's the consequences of a infarct stroke on the ponds? All right. Okay. Well, it's quite devastating, actually, because the ponds carries Ah, lot of fibers from the cerebral hemispheres down towards the spine. And so you're gonna get parameter weakness. Onda. You're also going to get dizziness because, of course, it's in the facility off the cerebral hemisphere. So it's the It's the bridge between the cerebrum on the cerebellum. So you get swallowing difficulties. You get visual disturbance. Usually diplopia, um, you get, um, dizziness, slurred speech at the's sort of symptoms. The parameter weakness. Well, of course, be obvious by looking at the patient the patient's gait. But you need to examine the patient speech difficulties on explore the swallowing difficulties. Thank you for that really interactive lecture dots. Curtis. Thank thank you for giving up your time, really? On a Friday morning for us. Salute me. My pleasure. I'll stop sharing my screen. I can see. Consider everyone now it's fine.