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SNI Digital, Innovations in Learning, in association with the UCLA Department of Neurosurgery. Linda Liu, the chairwoman and its faculty are pleased to bring you the UCLA Department of
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Neurosurgery 101
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lecture series on neurosurgery and clinical and basic neuroscience
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A 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.
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This lecture is another in our Neuroradiology series and will be on the topic of the anatomy and pathology of the cerebral veins
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It is given by Noriko Solomon, who's a professor of radiology and neuro radiology at the David Gifford School of Medicine at UCLA in Los Angeles, California, USA. So good morning, everybody. I'm
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Noriko Sama from your radiology. So I'm talking about not me and pathology of disabled beings
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Today's lecture, I'm just going to divide it in another meat pot, which is part one is a superficial dip and posterior for surveillance. And
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I know the details of being as another meat
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sort of, you know, endless. But I just tried to show you the things we can see in the imaging And then so that you can understand what kind of exam to be ordered. And then I explain what kind of
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imaging findings can provoke the Venus program. And then what kind of study has to be explored next. And then there's a mimics, like looks like a Venus problem, but it's not. So those are the
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kind of purpose of the lectures today So the Venus anatomy is, if you say like Venus imaging is, it was super social sinus and then transmas sinus and then jugular brain and well deep in our system,
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cabinet sinus, and then what else? That's, you know, that's what kind of people's perception is. And then the Venus anatomy is relatively complex in a sense Like there are some
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very generous variations. So the - you can - see the super excited sign is embedded into the box. And so the Venus channel is the main channel, but also have a smaller channels next to it, as you
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can be maybe more familiar with. And then lots of arachnoid graduations can be next to it.
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And so this area of anatomy can be, before was it's very unknown and then invisible But eventually, nowadays, MRI, not only the flow-based imaging, like we talked about last week on already,
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there are many things it can be done to using a structural imaging, cross-sectional imaging to visualize the renal system. So then the inferences of scientists can be very valuable, and it's also
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embedded in the folks, and it could be very thin or hypoparastic.
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all these related to the deep venous system, to the straight signers to the venous conference, and then get to the transverse signers. And then while the transverse signers can drain in the
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skull-based structures, and then if you see this big flower-like of venous plexus here, and then this one is the temporal occipital drainage going into the transverse signers. And if you remember
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the anatomy lecture, until your occipital lodge, or temporal occipital border, is this where the venous conferences. So temporal-robinoxibular lobe junction is very visible because of this
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structure. So when you see this, and then the vein here to the transverse signers, that's where the temporal-robinoxibular lobe margin is, for example. So, and then if you're talking about the
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vein, not only the covering veins and cortical veins and venous sinuses, but also being a structuralist. from the skin surface to the ventricular surface and everything is kind of contiguous,
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right? So that's why you don't see it in the scalp band. You don't see that much in the diaphragmatic band and smaller medullary, transverse medullary veins. You don't see it in the regular basis
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but if you have AB fixture, if you have some
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intra-bascular lymphoma or something called pale vascular space process is developed, it can be visible. So it's always important to notify and understanding that's what the penis structure is
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supposed to be, right? So from the scalp vein, penetrate into the bone, go to the diaphragmatic band and the diaphragmatic band can be sometimes visible and it looks like a bone mass. So it's
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also important to notify that these things exist and then that's also penetrate the bone in a table and then connecting to the super-search assignment. and superstarsized sinus is drained by the
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cortical veins in the superficial portion of the brain cortex. This cortical vein were accumulation of the smaller veins within the cortex, right? And then from the cortex to the ventricular
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surface, like cell-truck versus, you see the perpendicular to the
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ventricular midrally veins exist. Then those are the things, often times visible, and then we, you know, wonder what those things are, but you know, those are the things. We don't see it, but
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it already exists. And then go to the ventricular surface. And then from the ventricular surface, you see the septal vein, or the cardiac vent, strata vein, et cetera, they all drain into the
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internal cell vein, or a base of an oral dental tube, then they go into the straight sinus, and then they eventually drain into the jugular vein. So this is a superficial to the deep, going
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through the scalp to the heart, And then also in the deep system, you have a tabina sinus, of course, during, around the seratorsica. But also, and the tabina sinus is connected to super
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petrosal vein, inferior petrosal vein. So this is how you can sample the
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ACTH hormones through the jugular vein to a period petrosal sinus and then closer to the tabina sinus and then you can see the gradient and right and left So those areas are also important. So, and
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then from the tabina sinus to the sphenoidal mesalubane, you have a terriboyed venous plexus. You can see the terriboyed muscles areas also has a prominent venous plexus. And those all can be used
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as a draining system. So these are major stuff. And then eventually, this is the
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example of, in a carburetium, then you see, oftentimes you can see the MRI. have a high brain density to sit in the ball. These are Venus lake. And then how do you know that? You see, you have
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to look at the continuation. Oftentimes you can see that little vessel comes out and then usually those are left on your shape. And it's very bright in tree too, and of course it's a Venus
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structure, so it enhances. And it's very well defined Don't be mistaken as a metastasis, for example. And the oftentimes you can see this sinus pecranine is the structure coming from the Venus
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surface to the superficial surface. Those are kind of congenital anomalies, and then you can see as a skull has this
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little defect into it, we would corresponding to the Venus system. And if you do a kind of 3D angiogram and you can create the Venus face, this one I did it for 20 years ago. So, you know, now
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you can look for this much. But you can see the old anatomy, you know, you can imagine. So there's a front door, core core bones, center core core core bone, and part of core core core bone.
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This is internal cerebral vein, brain, brain, brain,
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brain, and brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain,
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brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain,
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brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, brain, example. So the several veins have two main systems, very from the front of part and
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occipital regions, drained towards the super cytosinus. So if you think about it, if you are super cytosinus occlusion, you can have a edema or hemorrhages in the superpartum or sometimes
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occipital orbs, then from the inferior medial part of the brain draining to the basal vein and rose and top, then draining to straight sinus core to the deep system. And the Anastomotic Superficial
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Benzo, Beno Toran and Beno Palabere.
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which is superior and inferior anastomosis. Pain
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of the bay. So those are two French doctors. And Leon, the bay is a French surgeon who described, so
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you see pain of the
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bay all the time, but this is a large super-shore bane from the Syrian fisher to the transverse islands, right? So it's traversing the temporal lobe So if you want to go to the access to temporal
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lobe, you always have to kind of see the bay number of bay. It's called inferior nastomotic bane, and it's nicely seen from the Syrian fisher to the transverse islands. You see this in the MRV,
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you can see this on your observed penis face, right? And then again, the main of the bay, entering portion is the temporal lobe, an oxpero lobe junction. Bane of torrad is, pulling torrad is a
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French, I'm not a mist. I'm not a French. and it's a large superficial vein running from the superior fissure to the superecyzocyanus. So it's going to go into superiority and that one usually you
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can see this in the central sulcus regions from the superior fissure to the superficial bed. And then anything from the
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superior fissure to the superecyzocyanus is called the baneptorat. So, so classically this is a central portion, but oftentimes you can see the two in the frontal and bridal portion So, multiple
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these venous systems can be present. So, that's kind of, you know, you you hear about it and you just kind of see the real definition of those. And the vaso-benes, if you look at the brain from
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the the base of the temporal occipital lobes, you can see this again, all these occipital lobes and temporal lobes drains into this transverse sinus here and then from the top of the sigma. I'm
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sure you can see the bane of the rubber also comes here. So this confluence is very important. So that's why transverse sinuses are included. Then all this bane can be booked up and it can have a
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business edema. So that's the transverse sinus. That's the reason why transverse sinus can cause baby edema. And then trying to have a collateral pathway and then another cordial bane enlarges,
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which those are fragile so it can cause easily hemorrhage. So you can have these metoma in occipital robot temporal pole, even if you have to think of transverse sinus from both senses, one of the
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reason. So temporal occipital hemorrhage is the first thing I think, or you have to forget to include a uodeferential diagnosis, transverse sinus from both senses. That's one of the most important
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things, because if you see the humadomas, first thing you neurosurgeoned think is that it could be an aneurysm.
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could be a - well, you guys like to say a hemorrhagic mass, et cetera. So anything vascular. And then that's why you'd always do a CTA. But don't forget to look at the bang as well.
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And when you're looking at CTA, oftentimes you can see the very straight bang goes across the temporal lobe base. And that is the temporal basal bang, which is the severe bang to the - towards this
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transverse sinus conference. And then so this one is also draining into the transverse sinus. That's why if the transverse sinus occluded, this bang is bugged up and then can create a temporal
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hemorrhage sometimes. So those are the anatomical bends you can see. Transverse sinus - so talking about transverse sinus is you see this always those are asymmetric.
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The transverse sinus is the right side is usually larger and then the right side is the one usually drains most of the cerebral veins. And the left side is usually smaller because the left side is
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usually connected to the straight sinus. So the left side is taking up the deep system, the right side is taking up the superficial system. Of course, brain coverage in front of the right or
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occipital row is much larger, volume, so that's why the right side of the transverse sinus is larger Deep system is just in the center of the brain and the base of the row center comes in, so you
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don't have to have a very large volume, you see. So that's why the row is different, so that's why the asymmetric. So this one is relatively symmetric, but if you look, supersize the sinus
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drains directly to the right side and then left side, the confluence is towards the left transverse sinus deep, deep one is going towards the left side. So, If this Tokyo component is more
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separate, then you see this deficit is much smaller than the right side. So, Tokyo is this
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confluence of super-s that line that's supposed to be Tokyo. If the Tokyo is low, it's supposed to be a four-size small, so that's you can see the
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clear e-mail formation. Tokyo is high. That's what the clinical definition - the diagnostic definition of the anti-workout syndrome, for example.
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So now, this is the internal circle. It's a CTV, CTA,
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3D reformat, volumetric reformat I made. Internal circle, Bay and Bayon and the straight signers. And there is a big vein communicating from the straight signers to the supervisor to sign up.
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know what this band is.
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You know, this is a, well, this is
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for the processing science, so it's the, along the box. So this is one of the feet of the very known sciences. For example, sinus is also egg. If you don't know, sinus is for the cell sinus,
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you can see it around here. All right. So the processing sinus is a big to the superficial connections. Right. So that, usually this sinus, everybody has it in the feet of age Before, the
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leaders are obeying the stress and the scores. Right. But once this system forms, you don't need an equal to superficial connections. This is
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taking advantage of the superficial connections. So it's kind of aggressive, but some people have it. This is all take, you have it. But the people who have false sinus is dominant and doesn't
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have a strict sinus. But that's what the name of the diagonal form is
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and then so you can see pausing sinus, go to the sinus, that's it, and direct type of
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zero type of stuff, and if you do a underground, or you have a big pocket, and then kind of with bangles, this is the pausing sinus. So the pausing sinus is frequently sealed in those
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four-year-old type, both four-year-old type of the bangles here in coordination. And then those are the people who have very little, are not normally formed through sinus. So that no more people
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have through sinus, also have to have sinus. So that's not abnormal bang that people bring.
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And then so that the people who are in sinus, you pay attention but you have all the time. It's all the time that sinus is missing. Both sinus can be.
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actually, I've got to see the patients look up about the time that's very funny, and it's the same as we were saying, and then the field crossing time is considered to be trained to be trained to
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be trained. It's one of my favorite things. In terms of obeying, he runs underneath the forms, right? underneath the forms, and then you become and it's delineated the screening of the forms,
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right? So if you see
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them, then that's why the screening of the forms associated, right? And then both of these. And then, and that's where the interior side of the signs, right? because this is when the fox comes
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down.
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And the fox is very close to the corpse course, right? In crawl out, right? So, and then end of the fox, that's where the
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intragulcidous sine runs. And this anatomy is very important because that can mimic something, focus, you see? So something around the corpse course, there's something,
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some mouse or some disease process, something happens. A lot of corpse course, that looks like it's been the
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intracellular sine, right? So that when you have to be aware of the relationship, corpse course, and the intracellular sine, with what you see, intracellular sine, could be a part of the
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focus process, and then I'll show the example, right? So if you look at the CTAA, midline, de-format, you can see a lot of variations of the
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sine. See, intracellular sine, sine is very straight and normal, simple, not weak This one is beginning the story size in the living and life. So that's very common. And this one is very, the
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way it's vertical and vertically-organized research. This all kind of corresponding to shape of the tentorial, right? So tentorial can be very valuable. And the one of the common variation of the
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people all from the very worried about is, you can have some entertainment, focal engagement with those things. And then, so this is because you can see the conference And then this is because you
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have a big business system is kind of cut it off to these spiritual sign-as connections. And then, it slowly regresses and then some fails to this regression. Then you can have some questions. And
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in the same reason, you can see this
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beginning of the stress on this component is a very common location to have a big, a regular migration so that if you see the round feeling different. Most of the time, those are electromagnetic
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animations. It's not the strawberries. So that's also the importance. For the variation, I mean, active living space sciences is very common in value. So that's not the best part.
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And so you see the - basically, I color
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it on the screen. And this is what I cut down the dynamic assistant office over at the time when I was talking.
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This is a some stripe vein, join the internal strip of vein, venom guide, and history science. This is the base of vein rows. And so join the vein study, and go to history science. So it does
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have a little bit of tooth, hair. And then people mainly seem to join the internal strip of vein. So one of them is this serum Australia vein. The
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serum stripe vein runs from posterior to anterior And they've just got a very absolute envelope. So this is this envelope all the way.
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seamless angle, and then the era of
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new in several gram or angio around era. The
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riskiness angle was important in the shader. This is where the
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ramen model is. That's all, when you see this being a sample, this is where the ramen follows. Also, in terms of this being a sample for the parametric bank can join the international bank in not
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at the ramen model, but at the model schedule So that's what a direct survey. So that's very interesting. It cannot be used for inviculars, but well, it's just right now. So visiting the serum
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of striped bank is what kind of a kind of structure of the Spanish dream. It's what is serum on stripes, maybe scarves, but it doesn't. So nothing to do with the thumbs.
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you see the bank gonna run superior to the solace, draining all the strength of how the body falls through, drain the how the body falls through, and then turns into a joint that interacts with the
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body. So if you have this sort of straight bedroom, occlude and
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tapens, you don't have a on this ranking, option points, right? So, and then this is a non-observant, very clear, right? So, you don't have a bank account, so you have a straight bedroom,
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you have a sample here, and then fix the data actionable bank. Both of them don't have a bank account bank here, right here, and then
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you don't have to fix it. So, this is another medium-series all the time, and then this is a
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medium-seriesable bank, it's your NCA, there's a bank followed by NCA, basically, it does have a bank, and then, then become a bank surveillance center, right? Usually, this is parallel to
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the PC bank, and then, kind
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of, immediately, He's a good guy, and he's a good guy. Right? So, you know, many people say like, what this is like a mistake could be, think this is the key comment that you can see. But if
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you follow it, they're gonna go immediately. So, then that's a pain. Okay? So, it's always what you like. Right? So, that's the kind of surface.
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And then some straight vein, oftentimes you have this giant lateral vein called, you see this, usually you have to go until you eat and then join the internal super vein, but you're just gonna
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shortcut. So, that's gonna be short. And the physical diaphragm. So, I
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would just say that, and it's what, why this is
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important. But here is a case, so you see that, how it is, you've got it in the internet. So, you know, what's possible is partially, about the WN3.
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and it's super powerful and it's also, so this is something, it looks like a function, but it's not a teal. Tater is not done. And that's why this is happening, this is done with our disease,
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but it's
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not very asymmetric, very troublesome case. This is from the neurosurgery. And then why this happens is after you
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remove the shunt, right? Not that, you know, certain's wrong, but, so why this happens, you really want to know. And then so I just dig into a little, and then I look at the distribution of
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this. Well, this probably, this is something that would give me a system, an AC magic. So probably the right side of this system is up at all, right? So I just pay attention to this. And then
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you see here, this is the direct level of the brain, also the terms, right? The brain is shorter, it's going to become a intensive brain and join me in the brain and guide. And this side is,
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you know, short. So I'm gonna say this is occluded while it's going to prove that it's - you have to know the, you know, another bit well to see it, well, whatever you're saying, right? So I
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find the whole study and then all study shows, this is the right side of the bend, both doing it in the middle of the lower bend. This
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is three months ago. This was another variation that I wrote in. So the internet will remain in the conduction with a little bit different from the normal not the middle of the lower bend, but you
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see this vein occluded here. And then this is very close to the earring of the where the shunt was at his. So that's why I'm removing it. Somehow, of course, the hemorrhage or something, and
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then you can get the occlusion of that bend. They do this kind of thing.
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Patient gets better,
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right? So that we want to solve this. in Australian education. So, you have a superior portion of inferior portion that's
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different in the
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sickness or with superior pain for today in Canada, but it's very rare to come like that case. If you're trying to make it, you can have an international domain of inclusion, but usually the being
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a sign-as round, but it is much more distal. So, the being a gallium straight sign-as of inclusion. So, when you see the big, the, the inclusion, then you can cut entire time to give us
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a back goal. So, that's what the three being a
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system, but, you know, some would be in a drainage, nothing to do with the term strength thing. That's important to me Right. Now, based on Ben and Roden, though, it's the one who is similar
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path with a PCA, but it's going to go maybe a bit, right? And then, so just what were these
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things can cover the structure of the drainage? You have three compartments. So one is around severe pressure. Two is around the severe pitlock. Three is a chemical portion of the mid-brain
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component. And then each area has a different drainage system. So the 71 in around severe pressure is a big bit of severe vein And also three vein from the
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mid-media aspect of the base. And then stridal vein. As you
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can see, all these basal ganglia things can drainage. Why this is important? When you have a ABM in
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the basal ganglia thing, then drain into this one first component, the basal body. So that you have a basal ganglia in part, ABM,
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can be drained into the MCA territory. So what are the grains? Well, these are the systems of it. but usually they go into the base of a water bottle because the struggle, the inferior struggle
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then is the drain
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into this component, so you can do one of the base of the water bottle. And this particular settlement is the inferior settlement, that's the top part, and then if you take a big trigger bank and
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then around the resident bank, then drain into it. And then this telemedic portion here is called the
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lateral sympathetic bank, and it runs the lateral aspect of the brainstems, one upwards, and then drain into this way so they'll go down. This one is oftentimes this lateral portion of the bank is
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the one who always go around the
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trichinonop. If you do a trichinonuronia patient or some IAC, then always have a bank crossing around the
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trichinonop and then this is what seems to drain.
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And temporal vein of the brain, the bumble vein, also goes through the same, and the sleep. But it's a little bit more than I have a lot of things to do. Now, I talk about
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the inferior control of
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psychos, but if you have an ACTH, curiously some tumor, and then MRI,
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do a hydrazoration and dynamic and everything that you can't really see anything, and then so while you are doing the sampling, that I was, I don't know how often you order being a sampling, but,
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you know, so if it works if the patient has a nice, in-care picture of the sinus, and that is, so this is good, you see that you put the catheter here, you put the catheter here, you can see
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the cavernous sinus, see the cavernous sinus right and left is communicating, it's called the coronal sinus in the face of the
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surgery person, and so you see this is a communication, So it's not really your separate cutting. of measuring, but you can see the approximate portion of that, right? So, and then there is no
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communication in between here in this case, but many of the patient is distinct. So, which form in parapetrolosins? Then we just can't do anything, right? So, it's just there's no form vein.
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And then you see these veins going towards the other side. So, it's completely communicating and peaceful network. And then this is very dangerous. You just really wanted to go deeper, but you
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can just break and then it's a risk of positive brain symptoms, right? So, you really have to have a nice, you know, energy reaching to the successfully major part of the world. Now, first,
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there was a vein. So, this is but the bladder of the sense is
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very You see, this is where the trigonometer is. You see, always this vein runs near the
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broken mouth out. OK? So that vein
31:57
is going to the lower of the sense of the vein and then go to the base of the vein.
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And then
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the fundamental vein is for a lot of portions of the vein, depending on where you are. You have a vein of the vein, the fundamental vein, in the right of a pointy vein, and it's like vein simply.
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And then you have around the bromise, you have this superior, for a central vein, a superior bromine vein goes drain into the vein component. So what this used to be, these veins are very stark
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of the diagnosis, because if you see the displacement of this central vein, you have a brainstem mass versus severum mass And then that's what plays a very important role.
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you know, the brain, we don't want to do that. But oftentimes you have a, is this a tiny mouse or, you know, where it's coming from? And then I oftentimes just to pay attention to
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this brain where they have this brain, for example. And then the, these are the pointing being a sprexus. So the brain is being a sprexus surface of the pons and then, you know, the medulla,
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you have a death work of small brains So if you have trauma and
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then crunched to the cribus, then this brain can't believe, right? So that the news and conclusion happens that you
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can see a little graph. Can't create a focal sobripe and human. So this is my sensory sobripe and human, which is very benign. So if you have a certain hemorrhaging data, you have a system, you
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do angiogram and CTA and you don't have anything in there, you know
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So, I know it doesn't sound to be fun, that could be it. you know, benign venous rates of hemorrhage. So this is what those, responsible for those hemorrhages are, it's a network of venous
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venous rates, right? So the posterior forcides, either you just go superiorly to the base of a, or a vein of a gallon, or some of them go to a petals or sinus, to a cavernous sinus and drain
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into it. Ah, anteriorly. So that's usually the, when the venous sinus is occluded, they use this pathway to a drain into. And then majority of
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the cerebellum is super surface, and it's also using a transverse sinus to drain. So if you have a transverse sinus, strong vosses, or sometimes you can see the
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cerebellum as well. The cerebellum has a different pathway to drain. So, you know, it managed to not having the edema on the transverse sinus, strong vosses. But this is the case transverse
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sinus, strong vosses was happened And then you can see the temple.
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also had a severe surface of the failure. It's pretty much because of this and ran into the pain of the disease.
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Now, moving on to pathology to better understand how to use those kind of things. The being assigned as shown bosses, important thing to being assigned as shown bosses is you can see the cloth,
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right? So, through a cloth imaging, meaning you have to do a structural imaging. That's the key to make a diagnosis of the being assigned as shown bosses. If you do a vein of run,
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MRV was to be be, you know, CTP may be good, but MRV is like a just, you can see the vein and then it's kind of slow around the strongest and you may not be
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doing the strongest, right? So many things can cause venus and the shambles, so everybody, eventually they,
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kind of predisposed to a venous sinus rhombosis, right? So you probably have to send venous sinus
35:53
and expose it to one of the issues. Then the challenge is you have AC metric transfer sinus, AC metric, which I will be obeying, right? So that's the common hypothesis that everybody have it. So
36:05
if you have it, so happen to have MRB and then the main AC metric, you just look at the CT scan, whatever they have, and then look at the general problem. If the general problem is AC metric,
36:17
that's called generally AC metric. Then the smaller side may not be the stronger side. Maybe the smaller side is less flow, because the content is small. So that's always you have to be careful
36:33
about. If you have a MRB in front of you, the smaller side of this flow signal side is measured. This is not. smaller side of the thing and then you come how do you know that you compare the the
36:46
ramen you see at this level this is where the transverse sign is ramen is you see all always like I think the asymmetric right so if you see this you know that all these are just small to be in this
36:58
right so
37:02
either an algorithm or MRV you see always asymmetric thing and then if you see the asymmetry you just have to decide is this really the strong causing a non-visualization poor observation of the one
37:14
side of the several vein or this is just the congenital thing and then one of the things this is a non-contrast MRV and then flow intensity can be lost but if you do a post-contrast one post-contrast
37:29
MRV is you can see that if you do man is paid and you have visual rights so this is the hypoprostic side of the MRV
37:38
right so the brain is patent but you just don't see it in the flow related known contrast one. So always you have to have something contrast enhanced CTA or CTB or MRB with contrast. And then I
37:57
recommend to do an NP-H and then the contrast enhancement matrix scan to make a diagnosis of B-NOS-C. So this is a kid with a very high risk of B-NOS-C-NOS-C And then so it has scan, so patient is
38:14
asymptomatic. But so then if you do this, first thing you have to look at is a flow board, right? So that's where the transverse sinus is. OK, like nice dark signal. So, you know, this is a
38:25
flow board here. So it's patent, right? And then
38:31
if you do MRB, well, that side is - you don't see the flow signal. So well, that's odd because this is not the hypoprastic look you can see the flow void here. but you don't see the flow here,
38:44
right? So that's kind of strange, right? So then
38:50
continue exploring and indeed a couple of days later, I did a CT scan, oh yeah, there's a high density now, it just looks like a real cloth, maybe the MRB is right, and then that's just really,
39:00
but you know, how come that was a flow boy look? And then eight days later, you see that flow boy look on the high-point density T2 area, and finally get the high-point density to signal. So if
39:13
you see that, that's supposed to be the main areas, and then you have a high-point density, so that's maybe the cloth in the bank, right? So the T2 and then T1 can be high-point density, right?
39:26
So the key to this is MRB is the same, but signal intensity to is different So this was T1 is ISO, T2 is a high-point, and then become T1, T2, both high-point density. The important thing about
39:43
this is that if you have acute clot, T2 signal can be hypotenuse. So, this person, Binesana thrombosis is suspected, you see the transfer of sinus looks dark and the work looks patent, right?
39:59
So, very dangerous if you do only known contrast MRI, right? And then so if you do contrast MRI or you have a feeling defect, so you know, right? So the thrombosis in the vein is CT the acute
40:13
phase is of course hyperdense, but it quickly becomes iso to hyperdense. So non-contrast CT can be very dangerous, right? So the acute phase of MRI less than 3 days is iso in T1, so you may not
40:27
perceive, and then hyperin T2 you completely mislead, like as a robot. And then so GRE can follow the T2, so it's a hyper, right? So if you do non-con MRI only, you can completely miss it,
40:41
right? So if you have a high suspicion to do a course contrast study or you repeat after four days, you now become both hyperindenses, so nobody missed that, you see. So this is very dangerous
40:55
thing, so you just really have, if you do a CT scan that portion that time MRI was fine, you may have a hyperindensity in it, right? So you have to combine, so this person has an edema and then
41:07
so right or edema, so critical bang was the supecials, so you know, one of the differentia with the supecials of sinus rhombosis, so you just pay attention to the supecials of sinus, you have
41:16
hyperdense, right? But the same person, if you do only MRI, like UCLA does, then you just completely miss it, you know, oh, this there is a, the supecials of sinus have a hyperindense robot,
41:32
so there is no srompus, wrong, right? So,
41:37
if you do contrast, you can see this portion have a, you know, feeling effect. do a post-contrast study. It's extremely important, right? So this one is a, you know, the first one has a flare
41:52
hypo-intense, but later on you can become a hyper-intense. So now if this stage is everybody can see the plot, so nobody can make a mistake, but this is the stage people miss it, okay? So,
42:07
yeah.
42:14
So this is like a critical vein, one of the critical vein is just going to go into just a most intense crop areas, and then so that's what the venous solution happens. So oftentimes you can see
42:27
that asymmetric, or asymmetric humatoma, I think one of the things is that maybe even if you see the
42:35
venous, one of
42:38
the important solutions for that big humatoma, and then a big guy who comes out in the gym, and then a big humatoma ends up. It's got the same location, and then ended up in just a bit of a side
42:49
of a strong process.
42:52
So this is a partial brombosis where there's one cortical vein is deemed more, but for a full brombosis Plus brombosis is both
43:00
usually the bite, I don't know, but I don't know what it's called, it's more carrot. Yeah, but you see that one does the cortical vein, it definitely goes the same location.
43:13
you have a crop is considerably more, you know, stuck crop and then that's where that's got to obey those and right what the metals are able to drain entirely. So then right can be said. See, so
43:23
this asymmetric can be happened very often. This is like a banitrolar territory, more or less, right? Is this like the banitrolar territory? Yeah. Yeah. Same one like this too, similar.
43:36
There's like rhombus in the superior central sign. It's like almost sticking out of trolar partially stimulus, spiritual signs are very similar.
43:44
So those things can happen, you know. All right. And then, so let's remember that the scenario is
43:51
going to change. And then the pattern is, again, you say, I said like a small handwriting is really be marked in the temporal region. Always, in those cases, always pay attention to the
44:02
transfer sign. So the trigger sign is that it's definitely smaller, but eventually you can see the signal of the robot is missing on this case. And then so then you have to do a conversation
44:14
studies, right? This is a patient who have anti-attentancy that matters. And also how do you strike them? It's also divided by that, right? So when you see this, this pattern is, you know,
44:26
viral rotomics has many different types of infection and then in metabolic disease. But this is a little bit asymmetric. And then also happens this. Payment is not involved, but how that is
44:38
involved So that kind of pattern is how to see pay attention to the data gallon and then that's, you know, conclude that the given assignor responses, right? So normally you can always see the
44:50
straight sinus here. This is a role market. And in this case, we don't see the straight sinus, right? So that's what it's doing.
44:57
So if you have a transfer sinus, it's a temporal signal hemorrhage. Often times you can see the master of classification can induce or in a sinusrophosis induce the master. education. So you have
45:12
a massive obfuscation and being assigned to the same side is very common. And then this is a typical, as she said, the same term, but it's very radical, kind of hemorrhagic stigma. So let me see
45:26
this. We'll have to look at the second sign of some words. The differential for this is a press. Oftentimes this press and this better sign of distribution is very similar. So if you have a press
45:38
like edema in the posterior half of the brain, always pay attention to the cost of a sequence of the sign of signal intensity, right? And the big one is with the synthesis.
45:50
So right deep viral thumbs, you know, sign of strong forces, right? So you, you know, you, you heard this lecture and then for next day, you see this and, okay, well, here it's two viral
46:01
songs and that's how they do the matters and a little bit later of the video, right? Some of my grandmother is, well, I think this is the division of signational right? Maybe story sign is, you
46:13
know, so while in a T word, we don't have a signal identity. We don't have anything to do with it, right? So then, well, maybe this is like a good one. And then, you know, in a way, what
46:25
does the horizontal study, right? And then this is like a normal environment, and then you just don't see the story sign is here, but you just don't see the story sign is, but you just don't see
46:36
the plot here, right? So,
46:39
kind of strange, right? And then you see little this portion is a little busy, right? You just don't see any smaller surface, right? And then we don't have any flow more than anything. So,
46:51
this is kind of odd, and then certain CTB, so
46:58
CTX, CTA is good enough to visualize, after you're good enough to visualize all the, you know,
47:03
the structure so you can see, don't have to hold
47:08
a CT itself, right? So you can see the kind of straight. not to exclude there, but it's not really some double branch. And then you can see the
47:18
little vein or vessel going.
47:23
So this portion is really busy. So I just suggested to do a bunch of them. This is an arterial phase. You can see the internal phase. Meaning, this is the heavy fixture. So just firstly, how
47:36
the baby fixture And probably, the sign is attractive. And then not straining well. And then just doing the second, thirdly, the fixture. And then that's the reason why it's causing the
47:50
A, so
47:54
to
47:56
do. So this undergoes much more interesting than this, but then this is just ensuring that baby fixture can be
48:07
one of the potentials in those. This is a liver patient.
48:11
So, there's a state between a sign of trans-bosis and C-tissue high density in the neighborhood of trans-bosis. Right? So, in the MRI of the
48:20
GRE. shows like, Ooh, it seems like a looks at us, but it seems like a trans-bosis, trans-bosis, lots of being in a sign of
48:29
trans-bosis. Right? And then, so, then the clinician ordered it in the field, Well, that's not
48:38
enough. But they opened. So, this one is, this one is bigger than the right side, and so, that's kind of odd because this is, like, high density there, and then, Well, this is completely
48:44
odd, so, this is square mass. Right? So, then, you look more carefully. Right? So, then, transfer science lives here. Right? The bench is, this depth transfer science lives here. Right?
48:56
So, this whole, this whole is not hyperdense, and then, medial to it, this is hyperdense. So, that's not the transfer of science, this is medial to the transfer of science. Right? That's the
49:10
best way to do it.
49:12
So that was the subdural model. And then we created the result. And then, so subdural model can mimic because it's going to line up, at least. So you see this
49:25
in the occipital fracture. You see the subdural, and then it looks like a transverse sinusoid. No subdural, acute trauma can cause eventually subdural pushes the transverse sinus in force. Some
49:36
bosses, but you just don't see mistake and you see, you see that where they live, the brain is this small
49:47
thing. This is a blue shaker, which you can't control. Oh yeah, there's a killing effect, so this is what you get. Definitely, right? And after this blue shaker delta sign, the contrast can,
49:59
but this one is a, you see the early bifurcation of the
50:06
subdural sinusoid So oftentimes this Bye.
50:10
So this is also true stuff kind of mingled into it. So this is how we're going to be careful. And then a lot of the regulations, which are the graph structure, and then you can see the
50:24
inverse linear sense. So
50:28
this is the case of the stress sciences term.
50:33
This is very common to each. And then you can evaluate the linear analysis So in an inter-papartesian case, you can't have the analysis. So this is what the reason is. See in the things that they
50:34
want to do. One
50:35
of the
50:45
things that
50:50
the science can be about that. So when you see, you don't see the data in the sciences, of course, on the
50:59
skin. And then you can say, you're a bit stronger, so I go back. And then this patient has a problem in the - I don't see them on both sides of me,
51:06
so I'm sorry. This is a lot in the - because I can sign us, but this was indeed a light poem, right? So, GOE, the first piece of the poem, the very first piece of the poem, right? So, that
51:29
was a big thing, it was like, oh, and then it was one of the best words here. Yeah, and then the musicals, the three poems, all of them.
51:48
And then, before my show started, just, you know, sing or sing. So, it was a big thing, it's very interesting, you can't do it, right? So,
51:53
this was a classic case before him or I, and you should see this, you know, on the underground, everybody said, That's all right, it's like a time-winning case, but, you know, you don't, you
52:03
know, the family always does, so it's, that's the deal, but the Doctor of Events on which of the abuse of any orgy, rather people above, this disease can always be in a system. It's much larger
52:17
in the form than because they drain into those carrots. It's the study of the weather century. The study of a
52:26
syndrome is this political gene doesn't exist. So they all drain into the river system, right? So that's why you can see that many of your enhancements and then you can open them. You can see with
52:34
these major events, right? So all the way into the existence of that soil, the existence. So
52:42
that kind of comes back to that snow on the evening and then so on. So that I conclude. Thank you.
52:55
I have to go unfortunately today. So I will take the question if you want to give you a question. I always available for you. Thanks for letting me know. Thank you.
53:08
Thank you.
53:16
Thank you
53:23
You know, for Pernard surgery,
53:26
the venous system. All that comes out true. Can I take that vein or should I take that vein and that's.
53:34
Generally not take a vein, but there's certain things that. That you can take with some trepidation. Just in the way
53:46
That's it's really important to learn this and try to understand the venous anatomy for you. To do an operation.
53:54
Like those, uh, the flow of things. It's a funny example when you have a meningioma that has excluded the superior standard of sinus. That could be the actual flow. And if you do your craniotomy
54:09
and you take those things. You will Basically, you'll get it in part because your craniotomy took those things.
54:21
Have a. question to try and pull all this together. So Josh, you do a superior cerebellar, a protein poreal approach. Let's say it's like a superficial cerebellar met, take it out patient best
54:34
fine for a few days. And
54:38
then suddenly starts declining unexplained, and do CT scans, there's no hemorrhage. And then one day, just because I hope it goes kind of out of the list. And you do an MRI, and there's like
54:51
this penis appearing, a DMA, both hemispheres and upper two thirds third to two thirds of the cerebellum. So what happened?
55:04
Where's the lesion?
55:06
There's a vein you can take just a crazy looking crazy.
55:12
Sarah about cerebral hemispheres. So both cerebral hemispheres and the cerebellum, like the upper half of the cerebell. I've seen the case exactly. This was what I'm asking. But it's an case and
55:21
localization for cerebral venous anatomy.
55:27
Where's the one spot that if you block affects the super tintoral and imprinted for it? Where they come together at the - Yeah, so what's the name of that? The
55:37
Galen
55:40
and Rose are Rose are and Stray coming together. all all coming together and going down the straight sign as to where? The confluence of - The confluence wasn't on the name for the confluence. Work
55:46
it on. Yeah, so there's a case exactly like this. It's like a biopsy But there was like bleeding from what turned out to be the area of the porcula. And someone stuffed Sergacell in there. And a
55:57
few days later, it must have been stenotic in the porcula, just somebody eating whatever post-operative, the demon, whatnot, that included. And so we didn't even have any venous imaging, but I
56:09
was like a chief resident or something at a time, had done my vascular training and figured out that the location of the problem must have been the porcula. And then I talked to the attending and
56:17
they're like, oh, yeah, we stuffed Sergacell because it in that area. And so we took them back, took the surges out,
56:26
but that's like the only place you can get super-ininfant tutorial, like venous edema, like that. You make a couple of comments about Pi IH. Yeah, so IH is a tricky one. So we had a lecture
56:38
about it not long ago, obviously, about when to stand and when not to stand for IH. So people with extremely high intracranial pressure.
56:50
You have to decide whether the DC bilateral transverse sinus stenosis. You have to decide whether the transverse sinus stenosis is causing the high ICP or the other way around whether the high ICP is
57:01
there's like a pressure point where they kind of trans turn from transverse to sigmoid junction and that's like a pressure point where the ICP is transmitted to the transverse sigmoid junction and
57:11
secondarily narrowing the outflow tracks to cause of intracranial pressure from from other causes, right?
57:19
It's interesting that you see that much more in IIH patients than you do in other causes of high-entrepreneur pressure, but I think we just don't think he'd eat these in those weeks rather than they
57:27
live like that for a long time period of time. And there may be a point where this ICP thing causes the venousinosis, which then feedback loops back into higher ICP over time. And it's really hard
57:37
to suss that out. And so I don't know if you've made my lecture, but one of the things I do in IIH patients before I step is I do an LP, drain their
57:48
pressure to normal, and then do the venous imaging to see if with a normal ICP, they have stenosis. And if that's the case, and they add that gradient, the pressure gradient across that stenosis
57:58
with a normal ICP, then I say then you're at like, for sure, structural venous stenosis is the problem. And you can step them and they agree. Now, there may be another group of people that would
58:08
benefit some sense you're missing in that case if you strictly say only doing that if they have the stenosis without being this pressure being high or without the CSF pressure being But that's the
58:18
guaranteed way you step that patient when you drive them to normal. They still have the stenosis and they have the gradient. They're for sure going to respond. The downside of stenting someone with
58:27
high CPE, that stenosis is not the underlying problem, is that then they have to be six months on blood thinners and you can't shut them. They'll pee them to, you know, not to get out of these
58:37
administration to reduce their ICP. So you kind of commit them to a stent with blood thinners that call along with that, or at least to read about six months So there's, that's
58:47
a kind of a, like a lot of landmines of that determination, whether the stenosis is the cause or the result of the ICP issues.
58:56
So for these bleeds, so if we see a hemorrhage, it will rule out any arterial cause. And it said not most outpatient. It turns out that you've been a stromphosis. The treatments are in tight body
59:05
regulation. That's right. No question about it. Even sometimes in most medications that happen, it's like a big, spear central kind of trampersense.
59:15
You'll come back to treatment and seek a question.
59:18
Yeah, if I go like, like, people and, you know, post-profit everybody. So, like, a post-student boss, sort of, you know, being a senate bar, and, you know, it's an emergency to go back
59:27
in their good profession. Yeah. I agree. The, the, the spontaneous thrombosis, you see, it's no question, even if they have a hemorrhagic conversion, even, it's, it's a hard trip.
59:40
Post-operative is still triggered. And you often know what may be injured, like, if it's post-fossa. And and you have to be impressed with the area.
59:52
Spontaneous spiritual sinuses are mostly some transverse sinuses, if you can, obviously, safely anti-cardiation. And another thing is that I've seen a number of these patients that have
1:00:05
transverse sinus thrombosis in clinic, and they come in off-humidant, and it's really like a tritic transverse sinus. I don't think that necessarily in the community everyone's super adept at
1:00:14
reading these studies, so you have to always be a little suspicious of like transverse sinus thrombosis diagnosis
1:00:21
to make sure it's actually a problem with some of the tritic transverse sinus, because they're quite commonly sought couple cases of it. We hope you enjoyed this presentation. The material provided
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