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Welcome to SNI Digital Innovations in Learning in association with UCLA Neurosurgery. Linda Liao, chairwoman and its faculty are pleased to bring you the UCLA Department of Neurosurgery 101
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lecture series on neurosurgery and clinical and basic neuroscience.
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This series of lectures are provided free to bring the advances in clinical and basic neuroscience to physicians and patients everywhere. One out of every five people in the world suffer from a
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neurologically related disease. The lecture is on neuro radiology, radiology cerebral arteries.
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The lecture is given by Noriko Salomon, professor, radiology, neural radiology, the David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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So with that, we will go ahead and
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proceed. She's going to speak to us on the cerebral arteries and neurovascular
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Good morning everybody.
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Just a few words, I also worked with Bill Walsh and I, Luke and as many of the new authorities also worked with him and then as he said he's a very happy, positive person, which all we all
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remember and all my condolences from my heart.
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I'm going to talk about today a cerebral artery. So the vascular anatomy is a,
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it's not really the main focus of anatomy running in these days because the before CT scan, before MRI, the artery, the artery anatomy is the one who we can see the brain through the vessels there
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is a a decent amount of anatomical knowledge or variations people used to know, and then we just kind of jump into the MRI and the MRA, we only looking at the stenosis and occlusion. So, but there
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are more to this field. So, I'm just going to talk about something you may want to know I'm going to go, usually that if you order MRA of the brain and neck, we read about certain things like some
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vascular variations, and then those are things you may just kind of pass by, but these may have some implications and then if you do angiogram, those anatomy may be important, and then even you do
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a vascular intervention. those anatomical knowledge can be important. So I'm gonna go over the, some of the variations and then
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sort of focusing on some of the field like ophthalmic artery and then just go to the sort of coverage of variations. And then I'm not touched based on, until you're middle and posterior cerebral
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artery and some of the internal intracranial artery which relate it to the brain. So first of all, the arctic arch does well originate the cervical vessels and go to the brain. And then we
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oftentimes in our report said bovine, not me bovine arch is bovine arch is a, usually the classic arterial branching is a, there's four vessels, but three major branches, Braco Cifaric and Deft
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Como Carti Deaudin, Deft Subaric.
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crebin already one, two, three. And then bovine
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variant is all these three branches can be one origin. And then most commonly seen is the two of them are together. So like this one, common origin of the brachiocephalic artery and the left to
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common cardidality. So
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the arrow is a left to common cardidality. So left to common cardidality can be combined with brachiocephalic artery or subcribin artery. So those are the very common variations
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that people may have. And then so the, the one of the important Arctic art branching is a where the brachiocephalic artery is coming from. So the brachiocephalic artery is a major player for the
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posterior cell creations. And then there are four compartments, as we all know So, arising usually from the support. crebin artery, and so this entering into the forearm, and so the external
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segment B12, for amino segment, which is very well protected areas of B2, and then coming out to C1, and then passing the dura entering into the intracranial segment. So if you are looking for
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trauma in the dissection, the areas which not covered, which is B1 and B3 areas, those are the areas commonly seen as an injury or dissection. So anatomically, very clear, and this is a classic
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orientation. And body body is usually asymmetric, and the left side or the right side is larger. So usually the smaller portion, one is dominant, and the smaller side is oftentimes ending in pica.
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And then you may not see the distal to the pica to about your junction. Those are common -
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variations. So you don't have to mostly worry about stenosis or inclusion due to atherosclerosis sometimes those are congenital variations.
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The important other importance in this origin of the body body can be very variable in that in a sense the origin originated from the artery and then not only going to cranially
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but also originated and then going posteriorly and then go cranially or how the inferiorly oriented and then going upwards. So in this for that reason if you do
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MRA without contrast oftentimes origin of the flow can be invisible. So that you may mistakenly think origin is stenotic or origin can be problematic. So those orientation problems and create a
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false positive finding. So you really have to work on very carefully the original body body problem can be a little bit over sighted.
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And the left body body is usually arising from the subcommodality oftentimes arise from aortic arch. So that's the common variation. And then as you can see here, the oftentimes by the body origin
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have two. So one is originated from the body body body but the
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body is originated from the subcommodality. And then there are two origins. And then you can see the two origins are also creating a big finistulation. So those are relatively common strange
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variations.
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Also, when the artery arises from the Arctic arch, which can be seen often, and then that's the, if you do angiogram for the left body artery injection, you may have to look for the direct origin
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from the Arctic arch. And then originated from between subcarbon artery and common call to the artery, or very close to the subcarbon artery origin. So it was also the common variations. The right
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body of origin can be very variable. So body of artery is usually arising from subcarbon artery, but oftentimes arising from what pretty much arise, you can arise from anywhere. So you have a
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common origin from common call to the artery or even arising from the external or internal call to the artery. So that's the tricky part So this is the example of. right about already arising from
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the common colority origin or right about already arising from the Arctic
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origin. So this almost looks like a
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left by the already origin, but left by the already origin is arising from the cervical, the subscribing already. And then so those variation is, this is a rare variation, but those variation can
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be seen The
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internal coated artery can be very tortuous. And then so this is called kissing artery and those can be mediaization of the common coated artery or internal artery is very common. So the problem of
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this is this kissing artery can be passing around the oral pharynx or hyperharynx. So if you do a ENT procedure or you're just gonna approaching to the intra oral procedures then you may have a.
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in the main brain. So, you can just poke it and then you just reach the artery very closely. So, you know, tonsillectomy used to do, you can hit the artery because of this anatomical variation.
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So, internal caught the artery is the one who is reached to the brain. So, if you look at this is the lateral view, you see that I'm going to talk about the intracraniality rate So, you see that
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I'm going to talk about the intracraniality later, but you have three branches AC, AC and PCA. And then, if you look at this lateral view everything is kind of spaghetti shaped everything together
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but PCA has a certain shape
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you have a little
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line down Y shape. If you see this Y shape structure, this is a PCA. And then ACA has this until you to poster your moving can copy shape. So if you see this car B shape, that's where you are
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looking at ACA. And then MCA is kind of fun shape of spreading - finger spreading around. So that's the basic shape of the ACN PCA. So if you're looking at the lateral view, that's how you orient
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yourself. And the sub-ego segment of the internal culture already go to the how it determines has a distinct name, of course And then sub-ego segment, entering the bone, become a petrosal segment,
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and then rest room segment, and then entering into the cabinet's sinus. And then here is so you can see the cavity siphon. And then mid of the siphon, you process the dura, and then become a
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sugracrinois segment. Sbracrinois segment has a somic artery, peacom, and
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antiocordal artery, those three branches, arizes And so that's very important component. of the internal coated artery, and then coated terminus, and just arising through the anterior and middle
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cerebral artery. So the, again, the dissection happens in this high cervical petrosal junction because this portion is not protected by the bone. Once you get to the petrosal segment, it's
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protected by the bone. So you have a, some traumatic force, the injury can happen in this junction. So this is where the, you know, from a magnum level. So when you're looking at this location
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is the first slice of the axial plane of the MRI. So if you're looking at the dissection, you pay attention to the first slice of the axial MRI and then you may see the
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dissection in there So the chemina segment is one of the One of them. locations which protected within the cabinet signers. This is also the common place to have
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aneurysm. This is also common place to have aneurysm. So here's an example of the dissection of the high cervical segment. So if you look at here is a code bifurcation level, and then you see that
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this right side is very tortuous, left side is also very tortuous, but if you look at this high cervical segment, the right and left side have a different caliber. So this narrow, narrow the
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segment is this is a patent lumen, and then unpatent lumen, this is where the pseudo lumen is. So if you look at the first slice of this patient axial plane, you can see the interlocutor is
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enlarged, and then so dark area is a true lumen, narrow the true lumen, and then this is the pseudo lumen with the neurothrombus in it. So that's how the dissection look like. And then that's a
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high cycle segment. And once you get into the cabinet signers, in the cabinet signers, you have a posterior genial of the, how it already has this meningal hypophysial trunk. The meningal
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hypophysial trunk is meningal and
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hypophysial also one go to the meninges, the tentarium, the dura. So you have a tentarium
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meningioma. This is already, who just gonna feed the tentarium edge of the process And the mening of hypophysial component is the other one goes to the posterior pituitary, right? And then you can
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see there's these two layers of the dura. So we still can't visualize two layers of the dura by MRI, the MRI, but you can just imagine like if you have a curve of the called deciphone kind of
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passing, changing the direction, this is rather pressing the dura. And usually the stomach artery arising after forcing the dura in this prokonossegment.
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So that's the normal anatomy. And in the carotid segment, you have a carotid cave. So if you do ask of a surgery or aneurysm surgery, then
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you may see this anatomy, familiar with anatomy of the optic chiasm here and then the side of the cranial nerve here. And then this is where the sprokina are repressing the two layers of the dura.
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And then coming out to the sprokina segment, here is the ophthalmic artery origin That's the common origin of the cranial nerve here. And then so this component, video to underneath, dispersing
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the dura component have a little cave space. So the medially projecting
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distal cabinets, segment of the internal call to the artery, aneurysm called the call to the cave aneurysm because of this is like a Michael's cave, some cave, the space you can find and then just
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aneurysm can glue there So if you look at the angiogram. This is a medially projecting aneurysm. It's nicely shown. And then you can even see that in the CTA. So that's the carotid cavernous
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segment called the cavernous sprochronous junction aneurysm, right? Ophthalmic segment is a, this is the super-coronoid aneurysm.
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Sprochronous is the most common thing is in the, of course, it's a PCOM, and then until corridor artery. But ophthalmic segment means you can see the ophthalmic artery here. And then after the
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ophthalmic artery origin, between ophthalmic artery origin to the peak of origin ophthalmic segment. So called, that component is ophthalmic segment's percolated ICA is
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aneurysm is usually superior projecting or inferior projecting. So this is a superior projecting most common type of dislocation and aneurysm. And then if you look at the CTA, aneurysm is here for
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a kind of portion. so you can see the aneurysm right here. So that is a common place to herbal aneurysm as well, right? So the anatomy important thing is you can see the petrosal segment to
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cabinet segment and then pressing the tura, ophthalmic artery, and this is plecoranal segment, and this is called deterministic. This is a small antiquator artery, this person does not have a pea
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comb, right? So, ophthalmic artery origin is, as I said, this plecoranal segment just after pressing the tura, that's a common location, but oftentimes, ophthalmic artery can be arising from
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the cabinet segment. You see this person needs to be further called this siphon. Origin is way under, so that can happen, or you can have a duplicated origin, so either you have both plecoranal
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segment, one is cabinet segmenting, the other is plecoranal segment. So I've seen a couple, it's rare, but.
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It's all incidental findings, and then but those things may exist, right? So that means ophthalmic artery program is usually, you see sprocorinoid segment, but oftentimes you have a big cavernous
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sinus program, then people may have ophthalmic artery program.
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One of the important variations of the ophthalmic artery origin is the middle meningial artery origin. This is about 145
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And the most common is sinus on the right side. All this variation is somehow happening more often on the right side than
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the left. The middle meningial artery is we now, it's very trendy things to do a subdural humatomas treatment and the middle meningial artery embolization. And then it works very well, I think,
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but middle meningial artery, before you go, If you improvise, you may be improvising the ophthalmic artery in. one percent of the patient. So you have to be very careful. And then if you do a
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more A, of stomach artery usually arising from this sprochronous segment and then this portion, medially then go into the optic now. But middle menu artery origin aneurysmates, arising from this
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sphenoid wing portion and then entering from this small farming and then in the optic, in the orbit So it's easy to find by MRA as a variation if you look. And then, so that's maybe the important
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point that before you're doing an embolization, of course, angiogram you can see it if you see the stomach artery arising. So that's an important thing to, before you go to a middle major artery
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embolization of any kind
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And there are other important branches for the - the counterclockwise segment. So, intercoidoidity, aneurysm can often happen in the same distribution of the hemorrhage as a PCOM. And the
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intercoidoidity is 76
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of sprokerine that ICA origin. But as you can see, here's a PCOM. And just distal to the PCOM you have intercoidoidity originated. So, it's very close to the MCA origin, very close to the PCOM.
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So, you have a common origin from those two things. And then, or you can see more distally oriented, ICA bifurcation component origin can happen. So, the problem of intercoidoidality arises not
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only for the
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aneurysm for the neurosurgeon, but also you have an ICA terminus occlusion of the construct patient oftentimes intercoidoidality infection can be seen. So, it's important to know where the
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intercoid already fits, right? So, this is a good drawing to understand the one of the intercoid already engagement for the basal ganglia. So this is intercoid already arising from the distal ICA
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and then they go around towards the ventricle because croyd already so they just give the
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croyd praxis but in that trajectory you can see the coated tail and then so that's how the tail is I mean it's too small and coated nobody cares about the coated tail but coated tail and then it
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follows around the coated tail and then just on the passage you can give the branch to the posterior portion of the posterior intercoid and posterior portion of the abdomen. So if you see that that's
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a nice drawing to conceptualize where those things goes And then of course you go to, if you look at, this is superpyromco here and then this is chiasm, so oblique tract. This is anterochoid
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artery goes along the cerebral pylongol. So the feed oblique tract, feed the brain stem. And then also here is the anchors on this side. So the feed the medial temporal lobe. So if you look at
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which anterochoid artery goes, there are so many structures being listed, but if you know the main just structure trajectory, of course you go along the oblique tract And then people come post
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structures and medial temporal lobe structures for the hippocampus p-home cortex in the middle. There is a medial temporal lobe. And the brain is the midbrain, cerebral pyranko,
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substantia-neganial nucleus. And then they go to the salamis, of course, superior lower portion of the salamis. And then the tero-cardia, the internal capsule, and postopetamin. So those are
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the areas. Goes within those, only areas being fed purely by until Kojga already is a mental health. So all the rest is PCA helps, or other artery helps. So if you have an ICL cruigion and then
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one area, it can be mostly affected by - we see an MRI is the
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amygdala. So when you see amygdala infection, you have to think of anticoidodal arteries affected.
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So I will just talk about the antipostal communication as other variations So the PCOM is one of the important antipostal communication. And we know where the PCOM can be found. It's a distal
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portion of the
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sprochronoid ICA. But if you can see this, this looks like a PCOM. But eventually, if you look at the cardiac siphon, PCOM is a distal end of the sprochronoid ICA. So this communication is a
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beginning of the cardiac siphon. So if you see that communication, This is where the trigeminal now passes. persistent trigeminal artery. Persistent trigeminal artery is one that was a very common
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anti-opposterior communication. And then so these are the potential anti-opposterior circulation communication. So the p-commm trigeminal artery persistent otic artery,
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hypogrossal artery, pro-attrental intersegmental artery. So each cranial nerve levels, so five, eight, 12, and you can, you may see the vessels going through communicating with either baudible
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artery to internal courtid artery or bazur artery to internal courtid artery. So that's the
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common, most common thing is of course, p-commm, but the next most common persistent communication is a trigeminal artery, right? So here is a p-commm, this is a persistent trigeminal artery So
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this one usually goes to the bazida artery communication, but persistent trigeminal artery also goes to the bazida artery, to SCA, also go to PCA. So if you go to the cerebellar arteries, it's a
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little bit complicated look. But most common communication from the ICA to
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persistent measurementality is directly communicating to the basilar artery. So you can see the basilar artery distort to it. Because ICA is taking care of all these posterior circulation, proximal
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basilar artery can be very attractive or very thin. So don't be mistaken as a basilar artery stenosis. If you have persistent measurementality, proximal
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artery can be very small. And then persistent measurementality can be associated with a big aneurysm. So this is a big one, so it's easy to find. But you may have a small aneurysm. So if you have
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a persistent measurementality, you look for other vascular malformation or aneurysm This is the incidentally found. persistent regimen already, we see this incidental persistent regimen already,
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maybe I see this once a month. The, so this though, but it already is a normal size as I see a, but if you go to down here is, but it already is very thin so old is this a problem, but if you
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look at the in between you can see that I see a to the bus already is communicating So, you see this portion is seen
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proximal to this communication of the bus already to the internal court start.
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Right. So, and then persistent audio gallery are the IAC level is very rare, but you can see a little bit lower side of the communication also go to the
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bus already Also already is you can see this in the CTA or more a and it's a hypoglossal canal you have a big already from body body to the CIA communicating through.
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Hypogrossal, persistent hypogrossal artery person is ICA gives the battery, this about the battery, so proximal about the battery is not existed. So that's one of the, if you don't see the
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vertebral artery from the origin, you may see a persistent hypogrossal artery, right? So this is also the, you don't see a, this person has a this side of the vertebral is very thin and you just
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communicate it here. And then this side, you don't have a vertebral artery. And then I internal call to the artery gives the vertebral artery from here. So this is also important variation to know.
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Protonanto, protonanto intersectional
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artery is much more lower than sort of subcommigatory junction areas and either internal call to the artery go to the vertebral artery So that's the one. important to know if you do a cervical
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injection or cervical spine surgery. That's variation can be important because you just you just injured the entire hemisphere already if you just make a dissection on those. The basilar already has
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a one of the common the variation is a fenestration because the basilar already has two other these fuses from the top to the bottom. So you can have one fenestration or multiple fenestrations so the
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fenestration the one with one to two percent we see this in MRA in very common and then you know if you have a simple fenestration that's not the problem but oftentimes fenestration is associated with
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aneurysm so you can see the small aneurysm or bigger aneurysm kind of arising from and then kind of
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See, you look through the fenestration hall, you have a big aneurysm kind of passing through the hall. It's very strange, but I've seen many of those examples of the fenestration with aneurysm.
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Usually, most of the fenestration is just stays as a fenestration, but oftentimes the aneurysm can happen here.
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So the bachelorette is a fusion. So it's a failed fusion You can see as a duplicated bachelorette, or bachelorette fusion is like a very high. So you look like a two bachelorette, and then the
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icar can arise from each one of them. So those are the interesting variations. And then the bachelorettete perforators goes to the thalamus. And the partial aneurysm one of the variation of these
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perforators So the patient already you can see in. MRA, sometimes with CTA, you have a nice reformat.
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So you see this is a proximal. This is a viscera proximal PCA, and you have a big artery coming and then go to the dividing in both sides. So this is a partial artery variations. So if you have a
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proximal PCA occlusion, then you can get a lot of ophthalamic infection like this So this is a diffusion, where you will be showing a bilateral dose of median nuclei restricted diffusion. So if you
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see this, that's the variation you have. And this person has only one PCA proximal PCA occlusion.
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So the ophthalamic artery is a - you have a mostly the posterior circulation is going to the Samus So both entericoid artery is one, only to enter your circulation for participation in all the rest.
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is the baziratip power raiders and pea comparators and the PCA
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branch. One of the PCA branches is the semi-geniculate artery directly coming from the PCA
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or posterior cordial artery. So the posterior cordial artery goes to the superior lateral portion of the thumbs. Power raiders from the baziratip and then pea come goes to the more anterior and then
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the medial portion of the thumbs And then the lateral inferior portion of the thumbs is the PCA branch goes. So if you know where that infection is, you know which portion of the artery is a problem,
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for example. A CA icon PC, a pica is also have a lot of variations. You see the SCA can be duplicated or triplicated. So multiple SCA
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can be seen. And then if you do a microsurgery, you may see that lots of more extra best source than MRA,
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The ica can be duplicated or triplicated and then all ica is not exist and then pica can take over the ica territory. So this person is a big icon on this side, the left side doesn't have aica,
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left side is pica is taking over theica territory, right side isica is taking over the pica territory, for example, so one pica can go to both sides
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So theica pica has a lot of variations, I think they are helping each other a lot.
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And then so this is a poster for the vascularization that the simple fact is, you look at the poster first side and you go to the middle saber pylonco level so that's where the first magical is
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largest So this saber pylonco is vascularized byica,
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this orange isica, and then anterior portion of floculus is also vascularized byica.
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are the provolus. So inferior slices to the middle saber pyronco is all pica. So bear to this is SCA. So that's just like, you know, dividing half at the middle saber pyronco above and below is
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SCA above pica below. And the middle saber pyronco and the provolus are the icon. So it's a very simple
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and a meteor. So now going into the intercranial vessels. So the ACA goes covers the meteor half a portion of the
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brain. And then the lateral margin is a
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superior phantosalka. So superphantosalka. So superphantosalka, ACA branch goes to traverse is the superphantosalka and ending in the superior phantosalka. So the lateral margin is superior
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phantosalka.
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So and then posteriorly they go
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to the pre-cunels, about half of the pre-cunels. So depending on the patient who have PCA, dominant person versus AC, dominant person pre-cunels can be a once or two, you know, half of either PC
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or AC. It can be vascularized. And then sprenum the copascrosum. Copascrosum is mostly vascularized by the ACA.
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And the sprenum portion is shared by ACA and PCA, right? So these are the ACA,
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vascular tateries. And then either you have
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a pericarous or already giving all the branches, or you have a pericarous or ends cross-emerginal artery, both. So these are the two variations of the proximal branching.
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And then when you look at the AP view, oftentimes ACA originated from the ACA terminus and then go directly to the next slide. perpendicular orientation and then going upwards to the A2 segment. So
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this orientation of the ACA A1 segment prevents cloth to go to the A1 territory. So that's why the most of the
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stroke is MCA and then ACS stroke is rare because of the orientation is more perpendicular or inferior oriented. So it's difficult, has to go to the cloth to go from the heart to a cervical artery.
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If you have a much more straight orientation like this, then you are even even chance of going to MCA or ACS stroke. So who have this type of variation of the
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ACA angle is the younger person So if you have a younger individual like a baby or you know
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like younger than 15 years old, so this angle of the ACA can be much more straight. So it's a particle orientation, then you can get the more even chance of between MC and ACS stroke. So don't be
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surprised that a younger person has a ACI-E function like this.
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Until coming again already is a important artery for vascularizing in the one side is occluded. So this is a short communication artery, but it has also variations again. So you can see the single
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ACOM So the ACA is also one already dividing two. So you have a lot of communications at the end of the ACA, but eventually ended up in a one communication. So single ACOM is most common or
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duplicated ACOM.
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You can see it like this or prick C-form ACOM. So that's the problem. So when you have a prick C-form ACOM like this, that looks like an aneurysm. And you may have an aneurysm, you see the very
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conglomerate component of this anatomy and then it's very confusing but that's the prexiform acom and then that's what you're dealing with. A1 can be hypoplastic one side if the one side is
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hypoplastic the other side the takes over both frontal hemispheres so that's why that's a higher flow so ICA can be asymmetric. A1 hypoplasia side of the internal courtyard it can be smaller because
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they're carrying a small amount of blood volume which makes sense so therefore the contourateral side of the A1 hypoplasia oftentimes you have a higher flow so A1, A2 junction can more often see the
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aneurysm so if you see the A1 hypoplasia which is not big deal but you have to look for the aneurysm in the contourateral side.
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Recurrent outer cubinum is
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the until your coat is headed. and an internal capsule that's until your portion. So post your portion of the internal capsule and then containment is until called the artery. Until your portion of
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the containment internal capsule is the
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recurrent arterial humanor, so the ACA takes care of. So this is important for the neurosurgeons to know where exactly it is and recurrent artery because they arising from the A1A to junction or A2
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segment and then just kind of go parallel runs parallel to the ACA A1 segment and then recur. Turned over, so
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that's why it's called recurrent artery of humanor. And then, so when this is a problem is a pituitary surgery because you just engulf the A1A to junction, right? So you see the A1A to junction,
39:26
they engulfed. And then so, well, you know, it's slowly progressed, so you're just not occluding and then human artery is still alive But the neurosurgeon goes in and then you may have a program,
39:38
right? So this is a big pituitary. tumor and then nicely taken out. So it's a very successful surgery. And then looks, no, residual tumor and then you can leave it. But if you compare to the
39:52
pre to the post, you see the high in T2, high intensity here. So this is where the hubena artery territory infection. So you see the hubena artery
40:04
is right here and right here, that's the hubena artery territory, which nobody really takes, you know, pay attention to. So when you're looking at the cardiac head, where the hubena artery
40:14
territory is, you see the coded head is like, well, this is the coded head you may think, but this coded head is too high coded head. So this most more inferior portion like close to the anterior
40:28
area. So this is where the coded head component of the hubena artery. So hubena goes to here. It's more anterior inferior portion of the coded head. And then your familiar how they'd head here is
40:44
little high. So this portion of the coded head is the MCA powder that goes. So that's why after
40:54
the skull base surgery, you can see the coded head infection. That's human artery. That one is part of the MCA infection. You see, when you see this coded head is all this human artery, no,
41:06
this is too high for the human artery, right? That's one thing I want you to understand.
41:14
So ACI have some, this is a triple ACA, which is common variation. And then as it goes ACA, you have a one A2 segment dividing data into, so in those are oftentimes associated with aneurysmata
41:30
bifurcation double MCA. So
41:34
MCA, the M1 M2 is always people have a confusion So M1 is a horizontal segment.
41:42
sphenylis segment of the indesibular fissure along the sphenoid wing no matter what you have a
41:48
bifurcation vessels you have that's M1 segment and then M2 is the peri-inchular segment so it's kind of hidden in the you have to elevate the operacrum to go into the M2 segment so that's M1 and
42:03
that's the M2 segment so that's the you know M1 and M2 is first delineated by the angiogram the AP view so the M1 is this angiogram horizontal segment and then get into the insular so peri-inchular
42:22
branch of the dashed and vertical segment that's the M2 and then they're going to come out through the opercogram so that's again horizontal orientation in AP view with angiogram that's the
42:32
peri-inchular branch
42:35
and then coming out to the Corcor surface so the 1, 2, 3, 4 was a angiographically in an AP view was very easy to see. So that's how the originated from, it's nothing to do
42:51
with a bifurcation. And then MCA goes to a different territory, which if you know that, which are able to see this, then this is how
43:01
the pre-CTP people identify the brain cortex using angiogram So if you look at this, this person has a
43:13
hypoplastic A1. So if you do ICA injection only, MCA can be seen. So it's very convenient for the anatomy. So one branch goes posterior. So that's the angular artery, which delineates the human
43:26
vision. Papenjukular to this is the
43:30
carnivore artery, which is the prefrontal artery. So that goes to infarifontal gyrocere areas. And in between, you have three branches, Pre-central, central, central, central, central,
43:40
central, central, central. So there's these five branches
43:44
you should identify. Then you know the - and then inferior to that is the temporal branches. Temporal branches are so small that it's very difficult to see. But then you can kind of see each south
43:59
side of the three south sides. That's a present or center and post-central sulcus. And you can delineate the isra. So now you can kind of see through the brain, just looking at the lateral view of
44:10
angiogram. So using this to integrate into the MRI, so MRI, you can see the isra nicely, right? So that if you see the isra, most anterior portion of the isra passing already is a prefrontal
44:24
branch. Most posterior artery is angular branch. And then in between, you have three branches, right? So if you look at the MRI, so this is always a prefrontal branch, this is always angular
44:36
branch. And then you can kind of divide it in three So that's a central surface already. pre-centro-circusoidal rate. This is anti-apartic branch, which is a post-centro-circusoidal rate, right?
44:46
So then, for example, this is a patient who have infarction or, you know, vascular, this is a perfusion delay. So T-max is delayed in this opecular portion, right? And then, so it's a distal
45:02
MCL occlusion. Well, this MCL occlusion is always hard to tell. If you have M1 is occluded, yeah, everybody can see, yeah, those right and left of M1 is occluded, right? But if this M1 is
45:15
open, then you just say, oh, I don't know, I have to go to the NGO, right? But no, you can see it. You can see further the distal branches, how you can do that if you see this. So this is
45:27
how I see it. So if I see this picture, so this is a parietal operogram. So it's front operogram, center operogram, meaning parietal diagram is here And that means this is
45:38
a post-central sulcus branch. Right, so I pay attention to the post-central surface branch, which is going to be in this. This is a prefrontal branch. This is an angular branch. So post-central
45:51
surface branch is going to be around here. And then I go to the sagittal.
45:57
Right, I go to sagittal. This is an angular branch. This is a prefrontal branch. And then so there's one, two, three branches. And oh, yeah, there's a little bit something wimpy here Right?
46:12
So then - so I'm going to say, I went waiting for the angiogram to see that post-central surface branch is not visualized. And then you can see it here. So that's the pre-central surface, central
46:25
surface branch. And this is a post-central surface branch. It's pale. So that's the angular branch. This is a prefrontal branch. So then you see the obesity, as CTA sell can you, see can you
46:36
And expected data.
46:41
central circumstances occluded.
46:45
Right? Easy. The basal ganglia. So again, I said, like, an anticoagoid artery goes to the cardiac tail, and the cuban artery goes to the most anterior inferior portion of the cardiac head, and
47:00
then all the rest is MCA power radars can take scale. So, MCA power radars, if you look here, this is a power radar. So, lateral portion is longer than the medial portion. The medial branch is
47:12
short, and then more you go to laterally, this is what covers the attainment, continue to
47:19
the internal capsule, and then reach the coded body to the head, right? So, oftentimes you can see the infection along this artery, right? So, those are the, see the power radars are not the
47:34
same length, that you, more you go more distally to the MCA then that's longer and then that can cause more. problem, right? PCA. PCA is very easy because about the tip, you can see the,
47:48
around the silver pionco, you can see the PCA. And then important thing to remember is PCA has a cargo official branch and a pre-cleanse branch, but also have an important branch covers this entire
48:03
inferior portion of the temporal occipital lobe, which is free from gyrus, in parypocompromal gyrus and lingo gyrus. This is
48:11
where the face recognition and color recognition and the naming and all this stuff is important things are in there. So you don't want to lose this branch. And then so this is an inferior surface
48:25
branch and then this is a cargo ring branch and then this is a pre-cleanse branch. And then of course they give small branches to the sprainium. So the sprainium have these smaller branches arising
48:33
from the PCA. And the
48:41
So if you look at the angiogram, so this is an inferior temporal branch, which is called covers the inferior surface of the temporal spiral of fish from gyros and lingual gyros, et cetera. And
48:51
then this is the calcary feature. So that's the major prayer for the, you know, visual loss. And then this one goes to the protoxo-fisher areas and then go to the pre-cunuous, right? So, and
49:04
then this inferior temporal branch is always go laterally. So you always pay attention to the lateral branch, right? Again, lateral branch is kind of hard to go because you have to cut up a
49:14
nuclear orientation. So that's, you know, analytically protected. So temporal row is laterally anteriorly MCA and then inferiorly surface is a PCA. And then if you look amygdala, it's nobody is
49:29
taking care of amygdala, right? So
49:34
amygdala is a anterior chord of R, right? So also, so the spenium is a tiny area and then I sent it, he said, Boss goes. but it can be infected. When you have a spreading infection, either in
49:46
one side to the other, it doesn't go to central, you just always have always one side, because the side of the PCA can be affected. So it's always like a lot that arise, right? So those are the
49:58
tiny spreading infections, and punctured spreading only infection
50:04
is rare, but it happens. And then often associated with the PCA infection So here is the left PCA territory function with the sprainium. So what kind of patient symptom may have is, of course,
50:18
you have a hemianopsia because the left PCA is, you know, curry curry branches occluded, right? But not only curry branch occlusion. So you have a contourato side is still alive, so they can use
50:32
this cortex to see things, right? That's the hemianopsia but you have the
50:38
sprainium of the corpus call some small infactions. is also present. So if you have a dominant hemisphere of PCA infection, plus premium, what happened is you have a, trying to use this cortex to
50:54
read the thing, but you have to, this video cortex has to communicate to the language zone so that you can recognize as a language, right? When you want to read a book, right? But you can't pass
51:09
this explaining because same is injured. So this visual information can be interpreted here, but you just, you don't recognize as a language because you cut the communication to the language zone,
51:24
right? So that's why you can copy, but you can't read. So that's Alexia without a graph here So that's the 1880, like a didgerine described that, you know,
51:41
this phenomenon of the patient with the PCA plus spreading the coralsome, you cut off to the communication to the language, so you have this very peculiar symptom. So, you know, that's how the,
51:56
a little chip for the, if you have a spreading main function that can be a very drastic thing can happen. Okay, so when you look at the CTA now, you may see more things, I hope And variations are,
52:12
you know, there, you just don't see it if you don't know it, right? And then some of the variation can be very fatal and then important, like me do many already origins of stomach artery, for
52:22
example, right? So for that, thank you very much for your attention.
52:38
for Dr. Saltz.
52:43
Actually, I have a question. So, um, the point about the anterior croidal and the perforators, the superior thalamus, not been for anterior temporal lobe X, but the campactinase, they always
52:53
talk about after the croidal point, you can take the anterior croidal and it's safer. And we don't often see in parks related to that. Is there a lot of collateral? Or supply of posterior croidal,
53:06
posterior circulation?
53:09
For the thalamus. For the thalamus. Yes. Yeah. The anterior croidal rotator is mostly covered by the posterior croidal artery. If they go to
53:18
the same, we can share the same location. So the
53:26
That's where the sonic infection, the most common thing is also media and Ontario, but
53:33
how in our component. The dorsal superior nuclei is. very, very infected.
53:41
Yes. What's the incidence of the chloroclimatol? Prodontol,
53:47
cemento. Yeah.
53:53
be more of your depression and no CTA, by the way. So it's not only governmental already, that's rare on your personal communication, but you have lots of financial situations. So that's what
54:07
more you have to be careful about, because you see that both of already goes and the C1 action and kind of simply goes out. So you just only pay attention to the C1 component. You see, if you are
54:19
tortuous, both already can be careful But oftentimes you go to the both, you know, the big finistulation there sometimes, then you have like an entire, you know, multiple body is, you know,
54:32
superior. And if you imagine can be covered by the body, those, luckily, those are
54:38
also not that often. I got less than two percent, but still,
54:46
still you really have to be careful about.
54:50
Yeah, maybe you just, maybe you, maybe, occluding one of the, you know, finished rated, but apart. Yes. There are times where you see us order CTA when we should order an MRA advice first.
55:03
So, you know, CTA is the, this is one of the cities where you have radiation and the people are just very, you know, but CTA can give you a classification, you know, kind of soft plaques and
55:16
then, you know, bone information So that's a very good anatomical orientation. And I, you know, value a lot on CTA. And MRA is a, you just remove the bone. If you don't need a bone information,
55:31
you just really wanted to see the aneurysm better, especially for the scar base, we don't have enough sinus areas. MRA, the strength of the MRA is like a, or it's kind of surrounded by the bone
55:42
areas, which is kind of difficult to see sometimes in CTA but you know, but about already or internal court is already. you know, you're looking for dissection, CTA is better delineation of
55:54
things. You have more information about, you know, classification you don't see in MRA. So, you know, both have advantages, but I'm, I prefer CTA.
56:12
All right, thank you so much. Thank you.
56:19
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