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SI Digital, Innovations in Learning, a new interactive medical digital education system, an association with UCLA neurosurgery, Linda Liao is the chairwoman and with its faculty are pleased to
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present to you another in the series of programs on neurosurgery the UCLA Department of Neurosurgery 101 lecture series on neurosurgery
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and clinical and basic neuroscience now in continuum for four years. This
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series of lectures are provided free to bring the advances in clinical and basic neuroscience to physicians and patients everywhere
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This lecture will be in the subject of neural radiology and the title will be neuroimaging falls and the lectures be given by Noriko Solomon, who is a professor of radiology, neuro-radiology at the
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David Gifford School of Medicine at UCLA in Los Angeles, California.
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Good morning everybody, my name is Noriko Solomon, I'm the neuro-adiologist and so I'm going to talk about today then you know imaging pitfalls and we don't have any disclosures and so I prepared
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this talk based on all the phone calls I got from the university resident and so they randomly text me at the middle of the night about questions and then so this is the most frequently asked
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questions many of those are sometimes tall-based regions from the outside study they got and then is this actually mass or is something in the skull-based mass? What is it, you know, differential
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diagnosis? Or post-surgical imaging. This is very frequently happens. Is this hemorrhage or abscess? Or is this any recurrent tumor? What we are looking at this post-surgical imaging? Well, you
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did a surgery. And so that's
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very frequently asked questions and then it's important to know and then it is completely all in the same page. And also, rectum in individual disease. Sometimes in the course of cancer treatment,
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the patient on the sudden of retinal disease, it may change the treatment. And
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some enhancement can be pregnant with the major disease. And so those are the things. And then many retinal disease have a variety of course, and you can enjoy that in your system.
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Those are based on the,
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you know, they're very resonant questions. So that's what falls out of, right? So here's the first question. You guys, if you want to guess. So this is the student force of mass and then, you
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know, looks like to be a student at the normal of a big net And then usually the computer is normal in T2, where you can imagine, you will all have a computer sequence and you can expect
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hyper-intense in T2, okay? And then this one is everything is high core intense, right? So
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if you have high core intense T2, you have to think about something that
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would be something else, right? So which one is the, look at this A or B or C, all of them for a ton of the above.
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I don't think so, but I don't think none of the above
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So,
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you know, it looks like you have like a cross line and then you see a looks like arising from the lateral aspect of the pituitary force and then, yeah, if this is hyper-intense or hyper-enhancing
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mass, then, well, nobody questioned like this is a pituitary at the normal, but this is very dark homogeneous, so that's very strange looking, and how often you see this kind of
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T2A imaging, not really, not often, right, so here is the thing, when you see the pituitary at the normal, you see usually the practice, right, hi, bye, thanks. And then if you see hyper
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intensity like this, it's more of a sort, it's more kind of fibrous tissue. And so that can give you a high point density to signal. So it's not a common thing, but eventually that's one of the
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things that you know cannot be excluded when you see homogeneous hyper intensity. So you have to look at where it is located and the shape of the process. And then you have to know what is the
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differential diagnosis for you see this hypotenuse thing. So this A is sitting on the top of the pituitary, right? Not the inside. So it's already have something like us coming from the outside.
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And then when you see this, of course, what's in there in the neighborhood is you have a nerve and you have a vessel. So of course you have to do a vascular imaging, right? So then here we go you
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have a big aneurysm. go through them into the pituitary forces. So that's gonna be very dangerous to approach, right? So this is one of the neurosurgery 101 that when you see anything
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hyper-intense, then you have to think of that as all vascular disease. But this is another reason. This one, the
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B is also sitting on the top of the pituitary blood, right? And then this is, if you look at the course contrast, here is a high-boy enhancing. It's very well circumscribed. And then, in such a
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low view, here is a pituitary stock, which is a posterior pituitary. And then, I'll tell
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you, to the pituitary stock, that's where the city on the top of the anterior pituitary blood. So this is a typical right key, it's clear of cyst, right? So right key, it's clear of cyst
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happens between anterior and posterior pituitary because of the right key, how it is between anterior and posterior pituitary And then so either you can see a. He said that you run it all on the top
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of the
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TV. Yes. Because so, on that other image, so
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ignoring the T2-IPO intense, the fact that the card is not homogeneous, when he said which card, I was thinking that that other leisure was made in the pituitary. Oh, this one, yeah. No, no,
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well, one of the two. I mean, it's usually T2 is very homogeneous. I was actually suspicious that there was a tumor in the gland and ignoring that art spot 'Cause you can have collision lesions.
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Of course, of course. Yeah, so, you know, when you see, every time you see the
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surgery vision and then rapid persistence there, don't be satisfied on the search. So, you know, you have to kind of keep looking and then, as Dr. works night has said, you know, keep looking
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at those areas are very important. And then, when you see the similar intensities different in right and left, then you have to check where the location of the post-doc GVAAs. Post-serptutor may
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not be in the central portion of the post-serptutor also. If it is a little deviated, then you have a volume averaging of the post-serptutor land itself. So half of them is captured in some of the
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post-serptutor high intensity, then the signal intensity can be different. That's a very common fake images in the post-serptutor land
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So here's the next case. This is a young woman with signal policy, and then every time you see the signal policy, you think something in a skull-based tumor, especially for the kodoma from the
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cribus. And then the kodoma is usually is a very T2-brite and then variety of degree of enhancement. And so this one looks like, Here it's the Coondyle and then the Co.
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cribus region here and then mass is occupying the entire bone and then extending into the posterior nasal cavity Well, that's totally typical location for coredomum
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Except it's not Enough to
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call it T2 hyperintense. It's mostly isolate dancing T2 And then Sajiro is always most informative to look at the relationship to the cribus So that you see that cribus is completely Obrelated by the
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mass this opposed to a pretty bright spot and then you have a cheetah Forza absolutely grand is going to disgrace and then deformed and then you see the very exponential mass region of buying the
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Cribus and then until you are extending to expansion pattern of the cribus if you go either until you are posteriorly You can kind of see the thumb printing type of round expansion. So you can see
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it's got a round. round expansion into the anterior or posterior portion of the lesion. So that appearance itself can be compatible with cardoma and then yes this is indeed is a cardoma. And then
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so the location of the cardoma is a cardoma is not a cardoma, so it's central portion of the either privus or sacrum that's the common location to have a cardoma. And then this is a typical cardoma.
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This is a 50 year old man with hemianopsia and then yeah that's like a sera mass, big sera mass pushing the optic chiasm. So this is where the optic chiasmese, optic chiasmese is clearly displaced
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and pushed, so causing hemianopsia. But if you look at this pre-contrast in post-contrast, and this is pre-contrast in post-contrast, looks a bit of the loginias inside than typical. tutor at the
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normal. So then it's a question of this really, the tutor at the normal or something else. Maybe there's something else what this could be, right? So what this could be, the tutor officer can
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have many things can happen, but first you have to look for where it's going to be the normal tutor at the ground is. If you have a meningioma, for example, pituitary ground exists in the cellar
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and then meningioma is going to push them downwards. So that's how you know. And then this one is generally make up where the pituitary ground is. It's kind of too much extensive, too large, so
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you don't, you can tell, right? You know, one of the hinges, so we don't really do the ZRE sequence, so this is outside study, so you have ZRE sequence, and then you have a lots of dark spots
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inside and then superficial portion of the region. When you have a GRE, it's a high-boy index, you have to think of costification, or a bit of understanding, meaning, like a hammer.
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pretty much hemorrhage, right? So
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the T2 weighted imaging is a little bit brighter. And then so internal content is some kind of multilobulated and septic. So, and then you have to look at the location where exactly which structure
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is related to. So of course, this portion have Cordoma, it's again a B and then it's T2, right? So it's in an identical match. If it is a bone tumor, have lots of constifications, you can
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kinda see these GRE changes. So I look at the cribus, the cribus body of the cribus itself looks fine. And then you, I noticed you can see a little stuff here in protruding into the nasal hurings.
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This is pre-contrast, that looks like a remote cosa, but eventually the pattern of enhancement in this adhesion is very similar to
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this therapy, right? So, that's the looks. And then if you look at the margin of this vision, this ventral portion of
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cribus is a little bit eroded. You see that cribus ventral margin is not really quite right, right? So this was a cardoma, right? So I want just
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sort of T2 is much more high-brain dense and then much more cardoma, right? And then the location here is important And the cardoma of the
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nautocodalromin dominant region and the tumor of the cribus happens in the body of the cribus. Like this case, and in that case, it's before I showed you, or you can see oftentimes arising from
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docemsera. So I'll show you a posterior portion of the seratosis condosome sera.
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And then that this mass is arising from the docembrane and grew into this pituitary false-celled system So
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that's also the important point to remember that cardoma can grow into the sera. arising from the dorsum sera. And also, Cordoma can be arising from the tip of the cribus and then grew into the
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nasopharynx oropharynx and then manifest as a nasopharynx oropharynx oropharynx otumuline, go to the
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ENT, right? So that's one of the location-based imaging features that an overall appearance of the pewteri for some mass can be called O. That's a GRE signal that's from
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O, thank you. Probably 50 feet. No simplification. No, this is something. Yes. Okay, so next one, this is what we'll see this often, that the patient has a headache and get the CT scan and
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have an incidental, little expanded sera vision. So that could be, a bit more could be any type of the mass vision, which is very
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difficult assess just based on the non-contrastities, cancel and do a MRI, of course. So we're going to MRI. So now you see the T2 hypoietense things, which is sorry, as far as three is all
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hypoietense in T2. And then T1, we're limiting also hypoietense, right? So that's, if this is a, a big giant rocket craft system, or you should see at some similar, they see a little bit
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different. And then,
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you know, it could be just a fibrous de norma. Well, and then before going to the discovery surgery to be recommended, what do you have to do next?
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If you want to go to the surgery, and this is the case, CT-A, yeah, so you just make sure that, you know, that's always okay, and then one of the CT-A shows that homogeneously enhanced, and
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then this is communicated with the internal quadratic. So this is again the gigantic organism protruding into it, and this is incidentally found because
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it's not raptured, but that's the care with us that went underism, okay. Just for the residents, you know, we ultrasound every time we, you should ultrasound anything that looks atypical,
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because one of my colleagues basically thought it was a pituitary tumor, Dr. Shana said, Whoa, this, this, this, this, why is this going?
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and stopped, and it was a huge aneurysm of self-esteem.
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This is gigantic aneurysm but, you know, we are situated on associative aneurysm in the cavernous segmentals, but the cement is very common. I mean, so I think we always pay attention to others
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and future you are the normal, but we have a follow-up scan, but oftentimes during the course of follow-up, the aneurysm is slowly growing at those six cameras. Okay, so next case, having all
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these
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kind of differential diagnosis in mind, this patient has a headache and sinus pain 32 years ago and then a sinus CT was obtained and you can kind of see the good retention system, the max rate sinus,
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and then how little needs of range of protruding stuff, right? So, okay, well, this one is a little bit obliterating, so maybe kind of scope it or something is planned and then they just ordered
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MRI.
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MRI was ordered and T2 was kind of bright. And then, so this is the pre-contrast and post-contrast, yes, enhances. And then, this is in the surface of the clay bus in the surface of the sky.
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And then, usually, ground is fine. The clay bus margin looks fine. And then, you see a mass in the sort of nasal pharyngeal tissue posteriorly, and here, right? And then, you can see the
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little restricted diffusion and diffusion, where you can imagine So, well, this is outside of usually for some mass. So, you know, and then, it's kind of ENT territory. So, well, what kind
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of things can be seen around the sphenoid sinus and nasal pharyngeal region. And then, you may not be so much familiar with the differential diagnosis, but primarily tumor sphenoid sinus mass.
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It's, well, scroma silica is normal, it's most common. And then, condrosalcoma, prodoma, because those are the neighborhood of the things. And then, you know, endocrine tumor,
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You saw the restricted diffusion, so you may think this could be informal, but can't be informal. Can happen in the nasopharynx, yes, it can. And then all these eccentric tumors can be happened.
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So, well, this is one of those. And then what neurologist, when you see this, we think always something else. And then I'll show
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you the example of the spinal is sinus, may as well as squamous cell carcinoma. Look like this, it's like a very gigantic, and then looks very necrotic, malignant look. And then, so this is a
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case of
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recurrent nasopharyngeal preamorphic cataloma, and then in your aspirate. So anything happens in those areas of abitrine enhances, and then clearly, relatively well circumscribed, but looks have
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a different look. And then easily invade into the neighborhood structures So, this one is ended up. to be a ectopic spenoid sinus pituitary, the normal. So apparently if you heard of this, and
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in the neuroradiology community, this is one of the common questions. And then in the
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key is location, okay? So the location of this inferior margin of spenoid sinus, and then posterior portion data, right? This is always a location that this
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ectopic pituitary is not. Why? And the, you know, there's many cases being presented. And the description says that the location is a key features. And then T1, T2, this is the diffusion, not
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this very variable. But why this happens is, you know, you think about anti-embostoptery and pituitary force of
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the, or how this is originated So you have this. the neural hypothesis and neural hypothesis have a different origin. So neural hypothesis arising from this diacyphiral tissue component and then to
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come merges with this
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moiety arising from this because of surface connected to the nasal pharynx. So these are pharynx tissue and then that's lined up and then this portion is kind of protruding into and then the merges
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with this enseventant tissue become anterial pitillary ground. So if you look, this portion has a some pitillary anterial pitillary ground supposed to be cell can be stayed into this canal.
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So this canal called cranial pharyngeal canal because it's a cranial part in the pharyngeal part in communicating that canal and this canal closes and then kind of stays in the sort of spending with
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Bono Prabas, part of the Prabas, areas.
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And so if you look at the
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CT scan in this side worldview, so here is a serwriter's condition, he is a Frank's and he is a nose and stuff. So this is Clive's here. And then you have a sphenox spelosine condrosis. In the
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young person, this is not fused yet. So you can see that it all does cleft here. And then also from the serwriter to the nasopharynx, you have a disc and a little canal, which actually you can
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see very tiny now. So this is called cranial range open now You can have a lumenal tissue along this canal. So this end of this canal is here the nasopharynx. So that's what the location along the
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nasopharyngeal canal. If you see the mass here, potentially this could be a ectopic pituitar as normal. And then the tricky part is, so
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this is the cribus and then sinus analysis, sinus analysis of us to aerate So, yeah, the person. If you look at the 3 or the k that you can see the completely bony around the cell is going to vary
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bony. And then eventually this becomes air rates. So the aeration happens and the cribus become much more smaller. And then it depending on how much the aeration happens and the cribus shape can be
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variable. But this is from the cell, if you're a portion too, that's where the cranial for angel canal is. And then end of the canal or along the canal, that's where the tissue is treated and the
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top of it can happen. So when you have an aeration, it's kind of hard to imagine like where you beat, but eventually this is where the proximate location of the mask could happen as a pediatric
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normal. So when you see in that location mass, we'll check the product for hormone testing. So these are the examples of, you see often times you see along the canal, So then you can have a
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poster of your straightener designer's mask. or this is like a similar to our case or very expanded and occupied the entire spanish sense, right? So in this case is when we see this and then check
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the whole, we commanded to check the hormone patientless period, asymptomatic, but it was over 500. And then so did the, the therapy. And then after the treatment and the mask gets smaller in
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the peroxide. Yep, no one So I think that's, well, you know, if you do assign a surgery and remove it, what does make, you know, there'll be a big surprise for the pathology, but eventually
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you can make a diagnosis based on this application.
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Right.
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Another thing, this one happened in at UCLA as well, but this is the patient who, other clinical symptoms did them all right, and incidental findings and then you can see a little. within the
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posterior pituitary have some hypo-enhancing focus, right? So, you know, you can see the posterior pituitary, but that looks strange. And then, if you look, there is a little contiguous to the
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bone region is protruding into the pituitary gland, right? And then, so, this is called cellar spine. So, you can kind of see the bone is, bone spine is protruding into the pituitary gland.
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And then, it's kind of forcing it. But eventually, this is grew, pituitary gland is going to grow around this spot. So, when this spot is completely midline and
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sort of smaller in caliber, then it looks like a bone. So, you don't nobody even know this or won't know why about it. But oftentimes, it's located in off center and off center and bulky and
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looks like hypo enhancing mass.
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And I think you've operated one, right? So I think this is one of the very problems of mimics. And then CT can help to identify this point is part of the thing. It's because there are spines, and
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this is one of the sort of remnant tissue And then it can happen as a state of findings,
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right? Anyway, so here is a patient who have
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an incident of pituitary mass. And then he has, obviously, this person is like over 60. And so you just shouldn't have this big pituitary ground itself. And then find the previous MRI scan, and
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then it looks very normal So it's July and December and then all of a sudden have a big. as it's like a very strange, right? So, and then the post-conjure study shows kind of also very strange
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enhancements. So it's like a post-reportional enhanced and teleportional enhanced and heterogeneous areas. If you have a simple, which is a hypertrophy or hyperficitis, you often have to, you get
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this kind of heterogeneous enhancement. And the
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patient does not have a typical hyperficitis clinic or symptom, but this pituitary ground shows this abrupt changes, right? So then, when you look at this, one of the things which is commonly
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seen in these days is a, so this is very heterogeneous. And then you have posterior, anterior to posterior disc, kind of little lumen here on this one. This may be the right case crevices, but
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anterior portion of the hyper enhancement is a something strange, right? This is a drug-induced hypothesis, and then symptom is very variable. And that's an immune check on the inhibitor-induced
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hypothesis. So those are patient days under all these
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immune therapy. This is one thing you have to be watched. And then many times imaging is the first manifestation. And then you check the hormones and then symptoms And then eventually patients have
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some pretty awesome symptoms, but it's very hidden. So that is also a, we do a lot of immune therapy. And then those immune therapy can create a sort of unexpected imaging findings. So those are
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interesting incidental findings.
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So those are the kind of scow basically frequently asked questions. You're now going to do the post-surgical imaging. So those are pretty straightforward questions, and then you have
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post-surgical change, and then this cavity do correct something, and then you just really know, is this hemorrhage or abscess or something else, right? This is the in meningoma left-tentorial
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with patient a
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past CP angle. She thought it's kind of straightforward tumor to begin with And then did a surgery. And then so this is a post-surgical imaging. So this is where the mass was. So you see the air
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of redo levels. So this is the air and then the fluid in there. There is some air which expected in post-surgical. And then you have a big defect and you have a high brain density to see the
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nostril. And then to try the GRE, and then - dark and GLE is AI is black and blood is black, and then post-op they are always looking for the hemorrhage, right? And then so is T1 is bright and T3
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is also bright and then that's kind of the GLE is dark. So what do you think this is? So they are looking for the hemorrhage.
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So when you see GLE is dark and then, well, you know, T1 is dark, T2 is dark water, so the hemorrhage can look like this.
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No,
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I would never call this hemorrhage.
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I wasn't in the surgery, but I just, I know this is not the hemorrhage, based on the sigma intestine, right? So, here's a couple of things you have to think. If it is acute hemorrhage, T1
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weighted imaging doesn't show up to the hemorrhage right enough So, that's one thing. The other thing is, what is the tipo's T1, T2, bright and G early stock?
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G early can be dark in the air, blood,
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and fat, right? So, it could be a fat, T1, T2, bright, and why you have a fat in there. Well, because you did the surgery, you have a fat packing So. So, in the red, I don't really show
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much, but eventually this is a flare imagine with fat suppression. So, T2 was very bright, and then if this is a non-fat grid or something, then it should stay in bright, but this is completely
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suppressed because the fat is suppressed, right? So, that's the fat packing material, and you don't have to worry about, but you can see the fat material placed in somewhere, and then there is
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very black, and then, you know, if you don't know
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the information, then people may easily call that delta hemorrhage, right? So, it's important, that's why you do a CT scan, but I mean, you know, CT is way more sensitive and specific for
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hemorrhage than tomorrow, right? So, and then, some of the inpatient scanners sprayer is automatically fast suppressed, so that's gives you a bit more. sort of security of T2 and brain-dancing,
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is if it
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is a bad, it completely suppressed, right? This is another thing, and the patient had a surgery and both surgery somewhere else, and then having acute headache and
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then pain, and then so this is the data stroke protocol, so you don't have much of the sequences, and then so the GRE, and then people filled out with like a massive effect and then it can be
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fixed GRE, but stuff, and then so this is really obviously the clinical site, so near the surgical site has a big hematoma pushing, causing some tonsillination, while
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you look at only GRE, and again, GRE can be, you know, blood, but in the air, right? So, and then
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look at the T2 imaging, Well, that's still, well, you know, so bad kids' blood can be. dark, so while still people think of this is having a massive effect.
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So causing massive effect is something like hematoma, right? That's what people may think. If it is, if it is, well, you can't really place the
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fat in those areas, but there's no reason, right? It is could be an air,
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right? So here is the CT can help, of course, and then CT shows this
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is a fat density and so that's definitely the air and then just air bubbles coming from the post-surgical site and then so this is the tension numerals and then so if it's a tension numerals can air
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comes in but it doesn't come out so it's a key for accumulating and then so it's gonna cause a big mass effect so that's a little bit kind of scary when you see this but That's it's too homogeneous
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for the hemorrhage as well in the cavity.
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That's what's the air. And then this is the patient with the brain with diastasis resection. So here is a
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resection cavity and then you know there's nothing going on and then just you know patient went home. And then came back with a seizure and then so ED ordered the MRI of the brain and then so here is
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a creo shows big DMA and then so here's a diffusion of the imaging showing like a paper or a crystal diffusion and then but inside is not restrictive. So if inside is restricted that's going to be a
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person and abscessed but it's a playful organ capsourcing restricted so that's doesn't really look like a abscess cavity causing a DMA.
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And this is a pre-contrast and post-contrast imaging right they'll have a surrounding DMA. And then you have this enhancement going towards the ventricle and this is kind of infectious process and do
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it. So some, and then plus this capsule is an enhanced so there are some inflammatory process going on because of the edema as well. The strange thing is like an insect, there are some spontaneous
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hyperintense material
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and then it's kind of sit a little plate like material
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Right, so the immediate post-op didn't really show much because traditionally it's been collapsed in small but eventually you can kind of see the little plate like material in it. So this is a
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gliadial weight loss reaction so if you place it in the cavity and then those things can have a reaction after And then that's can do it, yes Thank you.
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I don't know in this institution how often you use this. I don't really see that often, but sometimes those people may come from outside, right? So you have to take attention to internally you see
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that it plays like linear enhancement then that's what you're doing and that's very common And then you don't scan them, you can treat critically if you scan them, that's become a very scary issue.
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All right, this one is a, so the
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patient has a tumor, so T1, T1, T1 doesn't have enhancement and kind of heterogeneous risk, you know, the big mass, no edema, nothing restricted So this is the image of a 2 of the R13 to H
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mutant, and then so that's it, you know. and then did a surgery. This is right from hemisphere and then dominoed and then did a surgery. So you see
37:02
the
37:04
reception cavity is usually a kind of fluid build and then so this P1, P1, P1, P1 doesn't enhance. And then there's two months later, every month you do the follow-up scan and then you can see
37:18
the little enhancement And then those enhancement happens, you have to compare to the perfusion imaging and then you see it could be current tumor if you have a perfusion is increased. But it could
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be a post-treatment change if you have a radiation, et cetera. Then those can be some reactive enhancement and they can disappear, which was the case on this one. And then you can kind of see that
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the enhancing tissue was kind of shrunken, no longer enhancing And then the session heavily is kind of subsided that they're all a small compartment, right? But if this is small compartment, have
37:54
a restricted diffusion. So this withdrawal rate collection is restricted. So is this could be an absence or enhancement? It's kind of considered like something like abnormal. And then just keep
38:11
pulling up. And so you have this rate collection is getting smaller and then kind of stable and it doesn't really going anywhere. But this rate itself can have a restricted diffusion for about five
38:24
to six years. And then then finally it gets no longer restricted diffusion. So this phenomenon happens. All the fluid related restricted diffusion, not all of them are the abscess. The restricted
38:37
diffusion is just looking at the water restrictions. So you have a little quick secret than you
38:45
may have a restricted diffusion. If you have a, you know, or a two-dimensional tissue inside or. some protonaceous content is so thick, then you can have a specific diffusion. So, of course,
39:00
clinically correlated is important, but often, this patient have some people's and mild infectious disease signs, and then you have a specific diffusion of people's say, Oh, this is an opposite.
39:12
But, you know, in post-op, we often see this a distinctive diffusion,
39:20
and then such a data, you know,
39:24
helped us to put this together. But eventually, this is a, most of the such cells can induce granular metastas issues, and then, such is known to be a post-surgical site, have a kind of bizarre,
39:38
restricted diffusion, free and hyperindense content states. And then those,
39:45
the section of happily itself, or the resection site tissue change is, can disappear, But. can create a food collection, if you have a study cell being induced granulation, this you can sort of
39:57
continue to be restricted to diffusion. And how long that's going to be restricted? And then how much you have to worry about is like a case by case. But eventually, many people don't know how
40:11
long it's going to be saved. And then we have a proof of this one is to quite years and a half to restrict diffusion to be resolved. If it is stable, don't worry about. But eventually,
40:25
if you see a patient coming from the outside and then three years out from the surgery, and then you have a research of cavity-restricted fusion, and the patient is seizing, then you worry about.
40:37
So but that's the thing. One of the things we say all these restricted diffusion is not always access So you didn't have to think of A as a. normal post-surgical change as a differential diagnosis
40:56
and then we are educating the neurologist to don't call everything in the abscess which tend to be the case but that's the you know neurosurgery part is also you know if you have a post-surgical
41:10
experience a bit homogeneously restricted and then patient is doing okay and then that could be just a post-surgical change from the brand-new it was tissue eat the surgical we
41:24
throw so much so many different things that he spaces now we there's fribble our searches out caca seal he looks that dirty I mean
41:39
you're just showing one search a cell like a you familiar with caca seal and what changes that kind of I mean how is Does anyone know what you expected to be?
41:50
You know, we don't exactly know what is put in exactly where and then how much and then so we just really have to investigate so what is in there and then what is exactly causing. In general,
42:05
everything you put in can have
42:09
some chemical changes and then you can have a you know tissue become free to become a some changes and then that's free changes doesn't really show much and then can resolve mostly but eventually it
42:23
can create some you know graduation tissue and then
42:30
well my answer is I don't know
42:34
right so I don't even know how much you know how a variety of things you put into one you know surgery so we read that note when we have a note and we have a note.
42:50
And then, so we just think, wow, that's just put lots of stuff, so probably this is it, right? So the more stuff I put in the less likely you'll call it an abscess?
43:03
Again. And then the,
43:08
you know, the difference from, and then oftentimes those can be just a hemorrhaging in some early stages. And then the, you know, the hemorrhaging, you know, the OPC, the OPC, methanomyolinin,
43:19
intracellular and hemorrhaging.
43:21
So this is like a, you know, this different signal. Intensive change happens in T1 organism. Be careful that this T1 change, T1 T2 changes are only the
43:34
intraprenechimal environment. So if you are assessing the subdural fluid, or surprisingly fluid, that's the stage is different Okay, so it can happen a much. data ops generation. So the signal
43:53
changes, it's very, very, you know, you can't really count on, you know, all this is the optimal growing too, because this is, you know, when you have like an inventory based on the signal
44:07
intensity, so we're just going to judge for the hypercomputer, the artist based on the good. That's only the intro-prongable environment of the image, right?
44:18
So if you have a philosophical section of gravity throughout content, you know, that's not really interesting, right? And then oftentimes diffusion is the one who kind of troubles, you know, so
44:30
that the diffusion with the imaging usually a susceptibility imaging on the overcomes to the any signal intensity, so it's hemorrhaging diffusion is always dark, right, except if you have
44:43
hyperachute stages, if you imagine to restrict it. So if it is, so you but you have to see this is also interpretable environment. So if you have an interpretable hemorrhage,
44:54
one is ISO index and it is hyper-indense. So that's what the acute hemorrhage typically look like. And if you look at the fusion, when you're imaging in this hyper-grid status, then you see that
45:07
this hemorrhage content is heavily restricted, right? So that's what the acute hyper-grid hemorrhage
45:15
in the interpretable hemorrhage image in findings And then, so GRE follows the T2. So if the T2 is bright, GRE is also bright, right? And then from the surrounding component, there's much more
45:29
hyper-grid index. And then become obvious about acute hemorrhages. So now the T1 becomes hyper-indense, and T2 is still hyper-indense, right? And then still you can see the high density here.
45:41
And then in this stage, now the T2 is dark, so that you are in very dark. and then the fusion become a completely dark through and then hypotenuse. So that when you have this big hematoma changes
45:57
and these are very dozen, you don't even look at the DWR because you just can't see it. But in the very hyper-accured stages, you can have this phenomenon, right? But this is different when you
46:08
have a subdural cohort of the changes, right? So those are the post-surgical one And then, finally, you're just gonna go through the
46:21
leptominee of disease. So here's the question. Well, so here's a T1 shorting, maybe seen here, right? And the miniature place in this August. So what can be resulting? What material can cause
46:38
T1 shorting? It's, you know, melanin fat, extra serium, etymium, and protonaceous material And then with the way you ask, and the answer is, you know.
46:49
All of them can cause spontaneous hyper-indensity one signal. So when you see a meningial process, it's usually you're looking for a
47:00
cancer or you're looking for meningitis, but pay attention to a
47:10
pre-contrast imaging. If the pre-contrast imaging already hyper-indense, you have to think those stuff could be bright, could be a fact, could be some protein or melanin, right? So this is a
47:22
patient who has spontaneously hyper-indense and you
47:27
can't appreciate the contrast imaging in these hyper-indense areas, probably hyper-indense, but this present or soccer portion is not enhancing now, it's enhancing in a much more different way than
47:40
other south side, so we need your process and this is a primary of the melanomyelisidosis So the mananine. content is specifically hyperintense and chemo. So how do you know this is not the
47:53
hemorrhage? Well, I don't. But eventually, you know, you have to look at the CT scan to see if they're doing your clinical history can help you. And then this meninger, my domain of mitosis,
48:06
if you look at the surgery, it's very, very, very, very normal in there. So see that CT doesn't really show identity But eventually, freer is kind of very obscure, but that's a pretty
48:21
interesting one. It's very helpful, right? And this person
48:26
is coming from the East Asia, for the visiting East Asia. And then you have this south side face in this area. It's very similar to this melanosis patient. But if you have a freer, again, this
48:39
portion is a little bit face and a hyper-intense We are sitting at the same distance outside. And then you have a record. subtle enhancement. So meningial enhancement, meningial enhancement, you
48:50
have to look at the enhancement in the salsa, right? So, again, this is focal. So, well, because of the trouble history, well, this could be like infection, it could be a cochcy, either NBC,
49:02
other, so you have to do LP, right? LP was negative. So, and then if you follow it, like a more thick enhancement, if you treat it, that's gonna be gone So, this was a, eventually, elevated
49:16
protein, et cetera, but, you know, doesn't really show anything. And then, the rheumatoid factor is positive. And then did a brain biopsy, showed a kind of reactive inflammatory process. So,
49:30
in those many of your processes, if you do a biopsy, there's a broad
49:38
pictures of inflammatory changes And then still, if you see the cancer cell, that's fine. But if not, pretty much kind of vague pathology report you can get. And then this was a rheumatoid
49:52
meningitis. So rheumatoid meningitis is kind of rare disease, but usually aseptic meningitis, and then treat it with steroids or chemo belt.
50:03
Eventually, the
50:05
tumor necrosis factor, inhibitor treatment may induce the meningoprosis. So this is another disease process can be treatment can induce those disease So when we never run as a remuner to the
50:17
arthritis, meningitis
50:21
can cause meningitis, but after this treatment happened, and then it's increased the rate of this focal meningitis for the remuner to the arthritis patients. So that definitely has to be in your
50:36
differential diagnosis when you have a patient is treated with arthritis, right? So, differential diagnosis, very broad, could be.
50:46
When you judge this fungal TB. of the LEO, and then calcium adrosis, that's, you know, all the tumor board is going to worry about, and then some of the informal, some study where a plexi
50:58
patient, and melanocytosis, and mening or angiomatosis, those are the people who can present with seizures or epilepsy, and then come up with a mening job process. So the pattern is, what do I
51:11
look at? Is there any nodularity? If your nodularity does more likely to be cancer or sarcoidosis or lymphoma, if it is smooth, those may be a, most likely, an infection throughout this more
51:22
common, and then distribution based on systems can be
51:30
seen more commonly in coxin and TB, and then you have like a spinal cord dissemination. Those and things can be dropped with us as it has to be in your differential, and then of course, history
51:43
returns or history of infection can be helped.
51:47
And then some of the complications can induce the meningial process, and then that can be a key feature to make a diagnosis, because TB epoxy can cause hydrocephalus because of the
52:01
hybrid dissemination, who is obliterating all these resorption side of the CSF.
52:07
And then also, basal system involvement can occlude the alpha-ray rubber source from the severe pressure in CA, et cetera, so it can cause stroke, right? So the basal ganglia stroke and the
52:16
somamics stroke can be
52:23
the first manifestation of the repertory major process in the TB or coxi patients, right? The coxi can have a, this is not the T2, this is a post-conscious T1 radiative agent, it looks like a T2
52:36
radiative agent have a massive enhancement within the repertory major space, so see the post-venture does not enhance all the rest is going to enhance. and then cause hydrocephalus, that's the
52:46
common manifestation of copsie. And then this patient has a seizure. And then oftentimes those people have these meningial calcifications. And then so one of these things you see is a focal
52:59
calcification with some enhancement. And then often have a
53:06
pregnant with the seizures. And then this is a meningial
53:10
angiomedosis And then those are related to often them to NF2. And then it was very difficult to treat, but to be enjoyed that's manifest. And the posterior quadrant is very common manifestation.
53:26
And then
53:31
imaging findings are variable, but this journey from meningial, you have a meningial angiomedosis, and meningial angiomedis, can't happen
53:42
the myromatosis and myroma patient can go to a enhancement within the spinal cord and then called the surface then you can see that lots of people even and then it looks like a lymphocybosis pictures
53:55
as well. And then this is a patient who has a radio system and then also has spinal canal enhancement. So when you look at this and it could be TB proxy, it's different with that differential
54:10
diagnosis, but this person has a GBM. So the meningial GBM is very up, but eventually without performing the mass itself and then only the meningial component of GBM can exist. So as the this is
54:26
the meningial only involvement of the major breastoma and then didn't have a mass vision within the cerebrum, but this is entirely meningial component of some and the video of our store, for example.
54:41
And then, this is a multiple cranial nerve enhancement and then the resistance and then nodular pial enhancement is a very big, looks very very progressive enhancement and this is a disseminated
54:55
depending more on. So, you know, mass barrier is in the spinal canal in the normal sacral region. So that's probably initiated and then just then flooring up to the entire, your system And then
55:10
this is a patient who has a, again, the seizures and they have multiple cystic regions in the surface of the brainstem and surface of temporal lobe and have a very low enhancement. Looks really
55:24
kind of malignant and disseminated and then also going into the spinal canal. And then this is a diffusory of the mening to gliognon. Gliognonoma is a very low grade this acting leg up by Bernard.
55:40
So, these are the entity of disease which has been sort of new classification on it. And then, Guillermo Chima is kind of a term in this case, but the bacteria have a very benign type of, you
55:56
know, DNA at the Guillermo type of thing to
56:02
this diploma in Guillermo Chima is very, very troublesome
56:06
So that's the other case in the paper showing a very similar appearance, so it's very disseminated. But the features of interest is like a
56:19
very cystic appearance in the superficial surface of the brain. So when you see this, that's the most likely Guillermo, Guillermo Chima, for example. And then this is a patient who has a lung
56:31
cancer, and then have a metastasis treated, and then, again, drink it, and then just going forward. doesn't have any abnormal meningial enhancement to speak of. But you have this bizarre
56:48
playful brainstem sign, and then have some cerebellar surface. And so it doesn't have enhancement, but probably it has a meningial process. And a very strange look, superpilonco in the surface of
57:01
brainstem.
57:03
And then this is a new sign, or it will be in sign And you know, among their teeth, you have a little mold area, have a little thick margin. And that's a good practice.
57:19
So make it. But eventually, so that's a meningial - left meningial process, but no enhancing. So you have like a - so this mostly is a positive patient. And it happens, this type of features.
57:37
When you see this, you have to consider this person to have a major process, even you don't have an asthma, right? And then so somehow this superficial surface brain stem is one to be more
57:49
commonly affected. And then if you treat it, it's going to change it. But if you don't have an asthma in the first stage and then in a long time, so it's just like a demon is so thick that the
58:02
gathering doesn't go into those areas So that's for today's pitfall talk. So I review the Scovese regions and then, you know, the right-hit quest is
58:18
calledDormine. And if global explainer is not in this picture, the Dormine is a very good one to know. And then if
58:24
you know this, it will just impress people that, you know, how do you know? And then so you can just ensure that how the, you
58:34
know, right-hit spout is formed. The cello spine is also, it's rarely seen, but you shouldn't be fooled by that to do a necessary surgery. And then many drug-induced disease processes, like a
58:48
blooming rain sign and drug-induced high-purpose eye disease, commonly happening in the older immune cell application, and then everybody can be seen. And you may probably sometimes overlook
59:01
post-surgical imaging, anything like you are the older cell and packing material, those are important. And then I think it's good to communicate
59:16
with a radiologist. So let me know what you're putting in. So
59:23
I can help better ideas. And then, you know, recommend your process is a variety of disease but eventually you have to have like a sum. looking for notoriety, looking for the location, and then
59:37
in Puerto Rico's critical syndrome. And also something like if the major granular tumor is a new thing and very odd, but eventually very typical in imaging findings. So I always have to help you to
59:52
resolve some of the your questions and then I can get the list from going in the middle. Thank you. I always just thank you. You always love being here too. Yeah. I'm close. I don't know if your
1:00:07
lecture succeeded because my comment was going to be that every school based lesson that you show,
1:00:15
I think there are surgeries you call a preliminary radiologist and have this discussion. Although I said, I'm the middle of the night. So let the doctor's all in sleep. But there's, I think one
1:00:29
of the biggest risks of surgeons and all that is confirmation bias. all of the patients referred to you at the Tuertiary Anoma, and you look at it, and it doesn't quite look right, you should call,
1:00:40
and you'll be amazed on what you'll learn, but it is vice versa. I think the fellows and all that appreciate, I hope, being called, and because them being stumped is how they become perked,
1:00:57
because you are a blessing here, and I want to thank you, not all the faculty know as much as you do, particularly the fellows and all that, so thanks for everything that you do, because
1:01:13
these are all cases that I could tell you. Every single one that you showed, I would have called,
1:01:19
the number to be. What is this really interesting, Rob? I'm not sure what this is. I don't mind people calling or texting, and those are usually the more interesting cases when I evaluate it.
1:01:33
So I think it's good to communicate. And then, so give me a
1:01:42
good sufficient information, like, just like, I want to look at this. Not that, but what is your question, and then how they being presented, and then so that can be very helpful. And then,
1:01:54
but I think you should call your radiologist more,
1:01:60
so that hope that will be helpful And then, also, that helps us to communicate more with you. So great. I would say the most common reason I think that I call is radiologists who read a pituitary
1:02:16
lesion on a normal MRI scan. That's the heart of - you see a patient, and you're trying to convince them, no, you actually don't have anything wrong with you. You just have 18 years old, and you
1:02:26
have a -
1:02:30
people too much, I think. Yeah, and then patient come with a complete diagnosis in many times, or this is a follow-up of your clinical history tells you like a follow-up procedure at the normal.
1:02:42
So then our mind is like going to and then hold by and then have a satisfaction of surgery, right? So I think it's in both ways and helping to commit it.
1:02:59
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