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Radiology Spotters

Aug 03 | 1:30 PM

With this very first session of Indian Radiological and Imagaing Association, Kerala we bring an interesting radiology spotters for the radiology residents and budding consultants. With this we can brush up on some amazing concepts and learn some new things with Dr. Gomathy Subramaiam

[Music] good evening to all this evening iria kerala opens a new chapter a new platform by netflix and only mobile platform presenter speaker audience all are using mobile thanks to the efforts of doctor m c j prakash dr matthew for taking iria kerala to newer heights this evening we have dr mcj prakash president ira kerala for the opening remarks welcome sir good evening thank you for the nice introduction emcee dr judy man you're not able to see secretary general doctor and the man behind the total scenario dr shayna i am very happy to be in this platform along with our wonderful kerala team our favorite teacher and academician and president-elect ira dr gomri mam i heartly welcome you this program she is the officer behind this whole academic program of airlia we are we have been very relentlessly and very meticulously taking up so many teaching and academic programs and training programs for the practicing radiologists and residents as well our i am very thankful for him for his help and guidance and support all in all the challenges and the night he is a man behind all the rules in thankful to her also at this at this point i have to inaugurate this exporter's section of erie welcome to all the participants and wish them all the best and do take in courtesy and don't be disappointed once again i thank you all thank you sir now may i invite dr richard matthew secretary of kerala iria to felicitate welcome sir thank you miss judy the state president dr mcj pagasa the speaker of the day dr gamadi subramanian she is the president-elect of ira kerala and all the delegates have joined into this new platform offered by netflix the ira kerala the chris has been associated with plexus md for a long for for last four six to seven years and this platform that has come from them i'm happy to be part of this inaugural session academic session avaya kerala in this platform called medifix ira kerala has been the forefront of academic so and social activities for the last few years and this year the new team under dr mcj pragash has once already started last in the last two months a lot of activities on the academic front lot of webinars a lot of case discussions a lot of exam mock exams and as you all know for the last 30 years radiology has been the most sort of specialty branch especially from the for all the post graduates who have been preparing well for the entrance examination and the red two and the radiology today with all its imaging armamentarium uh has got lots and lots to study there are 15 sub-specialties the academic and in the social friend also radiologists have shown a lot of taken up lot of projects that helps us to unders show our social commitment or rickshaw project the saving the girl child subjection to reduce the perinatal mortality in india and there are n number of activities going on under the social wing of ira of which the national coordinator dr bamadi subramaniam is here along with us today she is not she is not only an academician excellent human being excellent person has been doing a lot of charitable activities for the ira caroline the last three to four years ever since i've associated with her and i'm extremely glad to have her academics so she said she was a professor of radiology in manjari medical college and government medical college corridor and now in the malabar medical college a teacher with such a passion i must say she has got a passion in teaching and compassion in her social activities and that's what makes her different from many of the other persons in the academic front so today we are blessed to have her session uh to have a session of radiology spotters maybe this is the first time the radiology uh spotters have been shown or maybe a first radiology session in this netflix platform and i'm happy to be part of it and ira kerala will be associating with this platform with more debates more academic platform more academic sessions and also on health education friend we will also be coming up with our radiologist talking to the general public as well as to the other specialists to make them understand our position on many of the subjects like radiology radiation safety quality and standards so that is how we are going to plan the sessions in this platform and i all i congratulate dr remy chennai who has been the person who organized this session who has put in a lot of effort for the ira kerala and national ira and chris kochi for the last so many years and to put bring together many academicians in the forefront for the benefit of the postgraduate students as well as the junior consultants so there has been a significant number of activities i am sure that will continue i congratulate all the team here the dr judy is the master of ceremonies who is also moderating this session everyone who has joined here to put in their lfoods i congratulate all of them and wish them all the best thank you thank you for your good introduction now we are into academic session we have the most sought after faculty this evening for doing spotters for radiology residents at a very apt time when the final year's practicals are about to begin in kerala it's none other than dr gomez president-elect and professor head of department radiology at malabar medical college corey poda we have two radiology residents dr sandeep prasad and dr ashwathi to answer the supporters i welcome professor dr gomathi subramanyam and both the residents over to you ma'am thank you i had a very nice introduction by dr mjj prakash and dr vijay and judy thank you so much i just want to tell the distance that i have spitted my spotters into four series today i'll be showing the first series because i thought i'll start the spotters from the upper story to the lower story so today i will be dealing with the upper story nearly the head so i will show some of the spotters which will be very helpful for all the residents so today i'll be dealing my spotter series one dealing with the head okay so i'll start my uh spotters uh i've given my email id in this first slide with my mobile number any queries can be sent to this mail id and to my mobile number in the whatsapp any query if there is lack of time okay so i'll start my uh first slide so you can start sandi uh yes madam uh uh linux rave is called frontal projection and a lateral view but they're showing a fusion of all the sutures there is diffuse uh enlargement of the skull there is evidence of a mental peritoneal shunt which is notre dame uh this is evidence of hydrocephalus how do you say hydrocephalus uh there will be uh uh there will be uh erosion that doesn't sell it there will be a widening of the sutures uh there can be uh elongation in the skull what happens in uh hydrocephalus to the sutures you gave you told me sutures are fused isn't it uh yes madam here they are uh here is the winding of the deploying space normally in a in a child whose switches are not fused there will be widening of the soldiers uh which is one of the earliest signs of intellectual hypertension what are the sutures you see in the skull vault uh the sagittal suture corona suture and the lymphoid okay so when does this fuse uh the sagittarius uh suture by uh 18 months no no metopic suture which is followed by uh the coronal yeah the meterpix suture will close by two years it can prolong also it can be seen in adults unfused also but the sagittal corona lambda suture will fuse after the age of 25 years already understood so there'll be a gap of 2 mm okay so now you are saying the sutures are fused isn't it yes matter so what made you say the soldiers are fused uh i can't visualize any of the switches in the front alone very good yeah so what has happened to the shape of the skull i've given you two views the ap and the lateral view uh the shape of this curl appears in last in the ap view uh in any specific shape any specific shape uh tower shapes very good yeah wait when do you get tower shaped skull uh in yeah yeah sorry okay so what are the syndrome uh granosinosis there can be multiple syndromes upper syndrome roseanne syndrome and carpenter it's carpenter isn't it yeah so uh how can you divide the cranial stenosis how will you classify it based on which suture uh is going to fuse we can divide them into sagittal uh fusion which is uh dolichosophaly uh the coronal suture fusion which is uh or yes very good coronal and lamboid suture on one side which is plagiocephaly or yeah yeah very good so you have an anterior and posterior plagiocephaly when one half of the suture fused so there will be enlargement of the other skull that's why it is called as plagiocephaly what is trigonal kefali when the lamb when the when the meat topic suture fused early you get trigonometry why there was a vp shunt in the first slot you saw that why there was a vp in as there is a hydrocephalus to drain the hydrocarbons yeah why why there is hydrocephalus uh because uh the soldiers have already fused [Music] they can be a chronic race intracranial hypertension uh chronic waste yeah what will happen then there'll be suture will be closed very good there'll be microcephaly the supernova space all will be adherent the foramen that is central canal also will be narrowed so there will be obstructive hydrocarbons and also you put a vp shunt tube understood okay okay very good that was a tava skull otherwise called as acro kefali of the brain this is the ap view uh which is showing uh a grossly enlarged uh skull uh the sutures are apparent the sagittarius suture can be seen there is mild widening of the saturated suture very good yeah so this could be hydrocarbons very good so now you understood the difference uh yes madam yeah so what has happened to the eyes what do you call that eyes now uh sunset sign yeah very good sunset science isn't it so what are the features of hydrocephalus there will be uh by uh whitening of the sutures uh there will be erosion of the dawson cell probably in a skull x-ray you can see a cockpit yeah you said there will be erosion of the cell doesn't that you have four types of erosion starting from the initial raised in an intracranial tension to high intracraniation there will be different phases of cellular erosion understood so what is the finding what will happen to the frontal angle how do you say it is hydrocephalus how do you say this uh we have to measure the b by its uh angle uh ratio and if it is uh more than point three percent we can say there is a hydrocarbons basically look at the frontal at the same level we can measure the width of the biblical diameter and if it is more than point three then you can say there is a hydrophilus when do you say there is early hydrocarbons uh when this ratio is more than point three or when there is opening up bilateral temporal horns yeah when when it is when do you say it is enlarged what is the measurement uh for what matter temporal horn measurement that the first horn to open up is the temporal horn isn't it so what is the measurement uh measurement i'm not sure madam seven more than seven six to seven mm it's more than seven mm definitely sometimes you can see opened up number one you have to measure it if it is less than seven mm it is normal understood okay okay what are the different types of hydrocarbons uh obstructive and non-obstructive hydrocarbons is how we basically classify them and we can also divide them into extraordinary intraventricular hydrocapillaries okay very good um what is optic hydrocophalus uh when there is uh [Music] when there is chronic mastodox when you have abscess formation that will lead to rattle sinus thrombosis which cause obstruction and that will lead to hydrocarbon that is ortic hydrocarbons understood okay what is the type of edema you get in hydrocephalus sandeep you're gone offline i think sandeep has gone offline i can see him adam okay i can see what is the type of edema you get in hydrocarbons there where do you get cytotoxic edema cytotoxis is usually seen in the case of infarcts gastrinitis commonly seen in the case of tumors yeah what's the difference between cytotoxic and uh transfer genetic uh cytotomy cytoskeleton is basically because of the inability of so what is the main difference there will be in which uh edema the blood bearing is lost blood brain barrier okay very good thank you so that was about that now what is this uh uh here there is a uh mr image which is sagittal e2 and axial t2 which is showing uh diffuse um there is no cerebral hemispheres noted in the um superintendent of brain panchema however the international pressure is noted we can see the cerebellum when do you get hydrogen what is the cause uh because of interacting with pollution of the i mean [Music] it has to be bilateral yes very good so that was hidden very good now what is this uh here there is a mono ventricle uh yeah with uh the interest ratio is partially formed uh this is a hollow you must process specific uh here there is the monometrical however the industries is partially formed semi-dopa type no no how do you say it is semi-robot type uh are you able to see the uh cerebral or hemisphere uh no madam you're not able to see you know yes you're seeing only a mono ventricle there you're not able to see any other structure dynamic efferent structures also in this it may be fused isn't it so semilover is partially fused yes this is completely visible yeah yeah so about this additional feature you're seeing here uh there is a fluid level within the uh yeah ventricle it could be uh blood within the ventricle yeah yeah very good that was a blood child had intraventricular hemorrhage that does hold on this is a low bar hormone what is this that oh the answer is given there it's actually semi loba are the different types of polar present carefully it can be low low bar adobe and similar holo processor valley depending on whether the ventricle is fused when the ventricles are interesting visible or the lamina yeah yeah which is more uh lethal uh the aloe vera one is more lethal followed by semilover followed by low bar lower okay so how do you differentiate hydrogen and cafali from hollow present carefully aloe vera in hydrangea valley there will be no mantle of uh the brain surrounding the ventricle when it will occupy the entire hemisphere however the internal fissure will be visible whereas in the other uh in holocaust valley the intensity will be lost and there will be more ventricular and a surrounding brain oh very good very good now in i showed you so many conditions now in which conditions you get this type of skull uh this is madam is a copper patent skull which can be seen in uh chronically raised intracranial tension yeah very good yeah uh the other differential diagnosis would be a lacunar skull which would be seen in less than six months of age yeah very good very good how do you get this type of appearance it is because of the prominent convolutional markings uh which are as a result of the chronically raised uh interconnected tension yeah what is called as yeah it's called appearance appearance isn't it so in those conditions with raised integral intention you get this convolution monkeys which are the gyral impression on the inner table of the skull which will be seen throughout it that is prominent convolution markings okay so what is this now uh here there is a bracket calcification around the central loosen c which is midline uh in its height it could be pericles what is this line called bracket classification very good that is bracket sign now what is this now with the peripheral calcifications how do you say it is a lipoma uh it has fire density uh it is in the midline and there is peripheral calcification surrounding the lymphoma what is the attenuation of fat in ct uh minus 50 to minus 50 hu uh of air because both appears black minus thousand will be the air at you and minus 50 to minus 50 will be the fat uh hu now you are seeing the you said it is calcification now how will you differentiate calcification from blood uh calcification will be as dense as compared to the bone so it'd be somewhere near the bone whereas uh the blood won't be as much as that it'll be around 70 to 90 hu whereas calcification will be uh in the region of the bone so 700 i mean around 500 thousand uh calcification will be less than more understand will be less uh here there are serial radiographs which is showing uh um a conjugal convicts hypertense collection in the left frontal and parietal hemisphere uh it's evidence of a subdural hemorrhage which is actually crossing the sutures and it is uh exerting mass effect in the form of a mild midline shift and diffuse replacement of bilateral sulfide subdural hematoma would be the when do you say it is acute when do you say it is chronic subdural hematoma uh acute is when uh we can the mhm will be hypertense in plane ct and in the case of active bleed we can visualize a swirl sign which is hypotenuse within it's commonly seen in extraordinary hematoma however it can be seen here also whereas in the chronic subdural hematomas the adoration will progressively decrease and it will become iso to the ventricle eventually in which patients you get subdural chronic hematoma chronic subdural hematoma uh they can be bilateral bilateral non accident injury is a cause where there will be uh different hematomas of different ages non-accidental trauma uh in the case of adults bilateral subdural hydromas is seen not hygroma hematoma enraged hypertension okay they'll develop bilateral subdural hematoma what is uh suppose it is iso dense bilateral subdural isotonic sematoma you are not able to differentiate between the brain parenchyma what is the sign in the brain to say it is subdural hematoma you are saying in the sub-acute phase not in the acute phase uh in the sub-acute phase there can be a fluid level where there'll be hyper hyperdependent blood density i said brain parenchyma you can see all this in the peripheral in the hematoma in the brain any time yeah what will happen when you they can be having herniations yeah very good there will be mass effect on either side squeezing the ventricles and you will get a rabbit horn appearance of the frontal horn whenever you are looking at the image you have to look careful isn't it any other finding do you think you have missed here look carefully look at the first two look at the third one i have enlarged look at the first the top one on the right left side and look at the what is specific what is striking at you what is striking at you yeah your answer was there in the previous slide [Music] what has happened to the occipital horn of lateral ventricle the hospital on the left side is completely obliterated on the right side it is paradoxically directed okay this is the same appearance whatever you are seeing here is the occipital horn only because it's a higher not higher cut when it gets dilated what do you call it what do you call it okay it is parallel now only you got it this is tear drop appearance and send it so what is your finding now corpus callosum genesis so you see the third ventricle where it is gone it's hydrating hydrating high raining what do you call that appearance uh moosehead appearance or a viking helmet sign helmet sign isn't it okay what is the syndrome associated with corpus callocalogenesis uh there can be icardi syndrome very good xenon females yeah it's seen in females icardi syndrome usually seen in females isn't it okay very good then is this complete or partial uh it looks a bit complete because when you see parallel ventricle it is complete isn't it yes otherwise you have partial agencies of the genome or the splenium of the copper scalars understood so this is often associated with lipomas understood in the specular lipomas so this was a case of corpus callosulogenesis with subdural hematoma okay okay now uh madam here uh there is smoothening of the brain very good [Music] with with calcifications in the bilateral uh frontal frontal lobes in the cortical regions uh with the subarachnoid space appearing prominent in the frontal surface uh the possibility would be of uh lesson capability smooth shaped smooth appearance of the brain why there is calcification uh the heterotopia by heterotopia uh it's commonly associated with uh the it's a migration anomaly in which uh there can be uh uh um in the yeah it can be what is the typical appearance of listen carefully uh figure of each appearance appearance how many types are listened to fairly you know uh type one and type two matter very good type one and right okay it's given in the textbook can read it so this is listen carefully type two now uh here there's bilateral basic angle calcifications and the classifications involving the uh subcortical white matter in the bilateral frontal lobes [Music] there is no other evidence of uh any other calcifications or sub endemic nodules so it could be fast disease which are other tds you would like to put uh any other picture will get so much of calcifications fluorescence yes then any poisoning um carbon monoxide poisoning isn't it then all the hypoparathyroidisms okay so this is a power syndrome okay uh here there are bilaterally symmetrical uh calcifications involving the basal ganglia [Music] with uh the x-ray of the hand with the showing dominant evacuations of the hand look carefully look carefully you gave the diagnosis in the previous slot hyperparathyroid pseudo hyperparathyroidism very good you look at the meta couple yes man they're short fourth and fifth are short what is metacouple sign uh when the fourth and fifth uh metacarpals are shot in pseudo hyperparathyroidism do you know how to draw it uh and you have to measure the distance if it is more than 5 to 10 mm it indicates turner syndrome or soda so you have to go clinically with the biomechanic by chemical parameters okay so the pseudo hyperparasite uh these are the mri uh brain sections which is showing uh bilaterally symmetrical uh t2 hyper densities uh involving the uh putamen and the base of ganglia which is having a uh hyperextending t2 hypothesis uh diffusion restriction which is the last two one last upper and lower one is diffusion images [Music] is any other thing you can say some syndromes would be uh when there is bilateral basically involved in crabby disease scrappy syndrome uh you know you can see this atrophy you said when there is neuronal loss yeah it is okay you are nearing it this leaks disease yeah very good there will be neuronal loss due to spongy form degeneration what is the marker for this uh csf analysis of uh oh very good csi herself lactate isn't it yes how do you get this hyper densities what happens why do you get there all do you see this hyperintense signals uh they're predominantly seen in the putamen in the coordinate nucleus and in the periventricular white [Music] mainly around in and around the brainstem and very acutely white matter isn't it and can be seen in the basic other regions also okay this total spongy form neuronal loss there will be atrophials so neurogenerative atrophies and needs disease okay now what does this know they all are diffusion images just to give a striking uh here there is a intense diffusion restriction involving the uh uh uh [Music] so the possibilities would be of a diffusion restriction here it could be msud very good how do you how do you get this increased deficiency signal what is the main pathology behind it a branching amino acid accumulation is the pathology yeah why do you get this signal uh because of the what happens will be mainly the splitting of the myelin and this is the edema and accumulation of water between the myelin isn't it that's why you get this signal so water from edema is there two types of edema this ah signal increase signal is due to deposition of water and pathogenic edema understood oh the answer is here sorry it was animated actually this is the first slot is you can see what do you see in the first slot uh there is uh uh um in the it's a ct image which is showing bilaterally symmetrical uh hypotensitis involving the white matter in the uh frontal and in the bilateral parietal lobes however there are multiple air forces yeah actually the first slide you can see that was a newborn baby taken on the third day then the last three city was taken after seven days see the difference in the developing air pockets yeah so bodybuilding asked the page because the answer is given here uh it was a contra study also uh what will be asked in the history of the patient to the mother this is very important isn't that always a history is very important for a radial we should go as clinical radiologist rather than a radiologist we should be clinically oriented yes madam uh [Music] uh we can ask for uh congenital thoughts infections uh no rather than torture infections when you say torch infection what do you look for actually microcephaly calcifications yeah you are not seeing that isn't it no matter when the initial ct was taken you saw the air pocket in the parietal region on the right side later we can see diffuse which organism causes so much of hair uh pseudomonas um very good yeah so what is the history of last it is photomonas infection any mastodite is any year related no no you're one child how can she develop masteritis [Music] actually you have to look for in the ultrasound also some anomaly is there or not i've given you a clue okay yeah look for any shunt congenital anomaly that is cyanotic heart disease you should also history but the cyanosis is there any cardiac problem because most of the child with congenital heart disease will have septicam body leading to brain infection understood yes so this was a brain patient expired after seven days oh it came from yeah no [Music] uh there is diffuse atrophy of the brain parenchyma with the predominant involvement of the parietal lobes uh there is expansion of the civilian fisher on the left side it could be directed i have given you only two images no okay you cannot say no something which you eat some vegetable not a vegetable also that appearance is like that you typically tell that what has happened to the brain you can see you said the sylvian features cortical cells are violent so there is neuronal loss here again so there is atrophy appearance yeah very good so where do you get mushroom appearance so it is understood mushrooming is typical finding in this case now structure which is there in the posterior fossa which is extending to [Music] yeah actually there is venus shunting here uh along with that there are at the level of the third ventricle there is a obstruction so yeah actually this uh was an aneurysmal vein of gall and dilatation or the straight side of the base when everything was dilated understood so actually this was a vein of aneurysm a gallon aneurysm okay uh i just want to know which vessel drained to the uh straight sinus uh both the internal cerebral veins are joined together to form the vein of the vein of galen no before they interrupt any other vein uh thalamostriate beans and the perforating veins oh uh together and they from the international remain we joined to form the great survival state service uh this is the needle which is used for sending this technique for the puncture yeah what do you call it uh female sheath females very good well you used for sorry one second yeah so our tv sheet isn't it yes so which which artery do you usually puncture uh the confirmer artery on the right side how do you palpate for the how will you look for the performer artery uh so we measure the distance we look at the anti-superior spine and the difficulty and we draw a line between these two and we can look at the maximum pulsation and that is where we will uh put the needle how will you know whether your uh needle has entered the femoral vein or femoral artery uh so if you enter the femoral artery there will be the blood will spurt out in in the pulsatile manner whereas it will be just low flow very good okay uh this is what is the size size the board size usually used for aminograph angiogram and length of the computer yeah fourth french length of the catheter now 6200 okay so that is the head hunter which is the other kathy which you can use for uh for vessel angiography [Music] no no no no not cobra cobra you can use but not usually no pigtail is for global injection from the iota you can use manis catheter and you use simon's catheter for tortuous vessels okay okay okay so you are using the former cell and what is this uh there is a you can do a intervention yes there is a well defined uh structure which is there in the midline which is at the level very good so what is this technique uh this is a digital subtraction image a digital engine no look properly with a reconstruction i mean i mean it's a yeah surface rendering image which is uh yeah uh showing the eco manufacturer okay what is the size to say it is an aneurysm in the brain what are the size you say what can you say the size to say it's an algorithm in the brain i mean in the intracranially anything more than two centimeters of giant aneurysm what is called asberry aneurysm when do you call it baby aneurysm yeah anything in and around the art in a circle of villas yeah size yeah three to five okay now here uh here there is uh in the plane image uh there is a well defined uh hybrid solution in the uh right frontal lobe which is at the appending the incremental fissure uh in the contrast images we can see uh an aneurysm like structure which is there in the right mca and the ac with uh in the left i mean in the right parietal region abiting the international fissure there is a well defined needless which is having multiple feeding arteries and training veins malformation with multiple floral aneurysms so it is what is the diagnosis avm with multiple flow animations okay very good so it was adrien with uh so there's a well-defined hybrid installation in the right temporal lobe uh which is showing uh intense post contrast enhancement uh it could be a uh and you listen from the mca why do you see him here or it could be a uh right no no yeah what made you say it's mca you tell me uh it's in the right temporal lobe and it is so which branch supplies the temporal lobe of mca m2 will be specific what are the branches can you name at least few branches the m1 m2 m3 m4 are the main branches from the uh from the m1 from the m1 there are two branches very good which is uh one to the of um anterior coronal artery and very good and [Music] yeah good very good from the m1 yeah then from m2 m2 multiple uppercut branches yeah very good uh sylvian uh then at the level of the cylinder it will divide i mean it will become the m3 and follow and into the cortex multiple info branches cortical branches the when which branch applies to the anterior part of the temporal lobe the anterior coronal artery no it has come from the m1 segment so naturally it will go to the fischer that is to the ventricles actually it is an anterior temporal artery the temporal lobe has got two supplies in it one from the pca and one for the mca anterior temporal is from the mca and posterior template from the pca isn't it so the location wise because it is large it's difficult for you to tell so it is actually a pca aneurysm it was from the posterior cerebrum okay understood this is last night for you this is the last slide for you okay um [Music] [Music] [Music] uh the anterior um the what is striking at you something ending blindly i see it's not getting i see it's getting ending like yeah yeah very good now if you can see the external characteristics isn't it no no table so what has happened uh it could be a complete occlusion of the ica very good say complete occlusion of the icf so what as a radiologist what will you do uh we have to do a skeleton standing yeah very good okay that was it i see a complete occlusion as a result you can do sending image [Music] so what is it tumor blush possibly why is it why do you say this tumor blush what is this vessel there is a vessel which is draining down see the caliber of the vessels it's a artillery venus malformation yeah very good it's an arterial vermont malformage you suppose you get an mri how will you look for the electric and non-eloquent areas functional mri bold technique mra okay so there's an amy by the way what is the eloquent and non-eloquent areas speech areas are control of speech [Music] that directly controls the speech function then motor areas primary motor somatosensory cortex okay very good now what's your finding here [Music] can you have a look more sharply uh you may be correct but still if he looks look uh look at the cortical branches look at the cortical terminal particle branches what are the branches i have sandeep also what are the main branch which is going above the corpus callosum periclosal artery yeah very very colourful artery what is seen anterior to medical cell artery you can see here two vessels are winding around the corpus callosum one is anterior one is posterior and there is a third one also yeah hello so marginal pericalor cell isn't it okay so at the terminal end of the very calorie what are you seeing you can see multiple small aneurysms can you see small aneurysms okay because microorganism aneurysm of the in mca territory okay what's the finding [Music] there's a direction of the terminal i see what are the what are the uh segments of ica same uh cervical segment c1 then segment then the uh so which segment do you say this is okay so uh in your department if you get an undo some legs what will you do as a intervention you're all you're a radiologist and you receive coiling yeah very good do you know the size of the coil the coils are length size is made up based upon the length of the coil the diameter of the wire that is used yeah very good yeah very good final size support final size [Music] okay so you saw so many aneurysms very good very good so what is charcoal aneurysm i have given it here because most of the time in your department you get patients coming using commentary stage with basal ganglia hemorrhage isn't it so these are the charcoal moisturizers which are the end artery aneurysm which are very small which rupture in chronic hypertension when the bp suddenly raises usually seeing the basic thalamus bonds and cerebellum so you should know all about the aneurysm anterior circulation and user and posterior circulation anterior circulation is 90 percent of which 30 to 40 percent is what aca and econ 30 for supra clean on icn ica and mcl is only 20 to 30 posterior circulation is only ten percent mainly in the basilar tip in superior silver and fiber understood what are these agents used for embolization very good so these are the umbrellas agents what is this now you use this here um so what are the embolizing materials it was shown before the embolus commonly used is pv embolizing agents can be temporary or permanent agents permanent yeah classified as a distill and approximately yeah very good and commonly used permanent approximately coils and um plug yeah and the commonly used to distinguish us are the polyvinyl alcohol particles and then we can use glue the n-butyl cyanoacrylate blues onyx agents also very good very good well done so that was dna this is the patient who presented with vomiting and headache just see the sequence of images i've given the t1 the t2 the flare diffusion adc which is uh centered in the lateral ventricles uh which is a hyperintense on t1 hyperintense on t2 the clue is the chloe's in the diffusion image that's why i didn't put the contrast shows a diffusion restriction very good um patient and headache because of heterogeneous isn't it patients are vomiting because of raised intracranial tension i told you the clue is in the diffusion restricted images and adc very good oh there's a case of giant cordy journal epidermoid cyst with obstructive hydrocarbons very good now look at the site look at the site and look at the serial images again you will get the clue i put the contrast also uh mr images show uh signal intensity lesion which is a cortical based with the peripheral cystic areas just evidence of a heterogeneous uh post contrast enhancement even so you just locate the site first look at the site look at the site look at the mass effect and look at all the serial images t1 t2 see the intensity signal signal intensities then you will come to a diagnosis what is the signal is t1 t2 flare is it bright even it is a hypointense and see the site is it uh what is the age of the patient can you look and say tell me what is the age of the patient [Music] the common side it is in the frontal region and yeah typical appearance you can describe for this lesion so you are getting a signal in terms of variegated appearances in it both hyper intense signals and hypointense signal showing no much of contrast enhancement seen in the frontal region on the left side with mass effect younger age group your diagnosis is p n a t understood child always a child you should think of this neuroectodermal tumor okay okay very good be louder don't be always bored be bold when you answer what is not eclipsed it's an embryonic remnant ah off of what those hyper visual canal where does the pituitary develop from both the are you know hypophysis and neurohypophysis um that it's an embryonic coaching from diarrhea very good okay and uh so there's a step sister okay so now i'm just coming to a case now just tell me the finding this patient i'm not going uh to give you the detailed history but presently the child the i mean presented his age is 20 is a male patient with 21 years of age who presented with headache he had a long history the history is different but now he is present with a headache any findings striking at you here 21 year old male 1 huh just diffuse brain edema very good uh the posterior horn of the right lateral ventricle appears uh um appears a faced it tastes very good when you say brain edema any other added finding you're getting in this very good very good pickup to the occipital home um okay oxford horn or which part of the brain is very close to the angular capsular region you can say isn't it yeah now that is the hinge there's a part of the calcification mercedes because of that cut it is a hyper translation broad based to the dura which is why there is edema on the left side do you think that relation yes now you can summarize you can summarize be little faster there is uh two well-defined hyper dense lesions noted involving both sides of the force broadband with the so what is your diagnosis meningiomas calcified tumor i said he is a male patient a 21 year age do you think he is an adolescent or an adult i mean 21 means adults but still younger age group isn't there when when do you get uh many germans commonly fourteen to fifth decades females so do you think still it is a meningioma if it is a meningoma in which group of uh nephacomatosis you will see if it is neurofibromatosis very good okay so do you think this is uh mendoma still if it's a meningioma will you see so much of edema meningomas the perilation radium is due to expression of vascular endothelial growth factors yeah so the edema [Music] you mean calcification yes none because of calcium okay my dharma should produce so much of edema [Music] you will see fat density you know thermite will have more of a density so what is attenuation of fat in ct if minus negative yeah it is negative it is not negative the attenuation was about for for 500 to 700 800 was ranging i've given you a clue now a brainless little casper cats uh it will you see such a well-defined smooth calcification oligodendron what is the pattern of calcification oligodendroglioma coarse calcifications so uh and will you see multiple oligodendroclimas and what is the common sight of involvement in oligodendroglioma frontal temporal cause yeah from the parietal temperature common is frondal isn't it yeah now i told you it is calcium densities so we are rolling out meningioma meningoma will not have so much of calcification it won't go up to 500 600 you will have some bodies or cellularity which shows increased density but this is calcific isn't it so young boy so i have ruled out meningomoid any of them striking your mind with so much of edema any dds you want to give other than many german pink thing tb2 uh tby bilateral so much of calcium it can be irregular not smooth isn't it this is a plain city only anything strike you might sandeep you also can answer if you want help eurocustomer metastasis uh he's 21 years no why neuroblastoma should come at 21 years of age uh you have reached the uh somewhere near the lake yeah matter what type of metastase it is yes yeah very good so it is case of osteoarthritis now what is this finding now here cannonball metastasis in the multiple pulmonary nerves ah multiple very nodular densities what is the what is the opacity what is what do you how will you describe these opacities cannonball metastasis is it cannonball about this striking at you here what is striking so many things are there findings here one two three four high elements yeah what has happened to the highland look at the highland so dense so much dense and look at the right atrial region and look at the peripheries much calcific densities isn't it bilateral hyaluron calcified lymphadenopathy isn't it can you see yeah then what is striking about anything striking at you here anything done to the patient left right humerus there is yeah the prosthesis so where do you think the lesion would have been the right humeral humerus very good right humerus anything else in this patient any tubes because you have to know about some tubes also any tubes you can see look at the left lateral to left high alarm you can see a tube isn't it can you see listen yeah what is that yeah very good that's a chemo port because this is a case of osteosarcoma you give neoadjuvant chemotherapy after surgery and before surgery isn't it so this was a case of osteosarcoma so what type of hostess are committed yeah so what is the finding you're seeing in the social sarcoma periosteal reaction yeah why do you get this periosteal reaction sharpie swipe uh tumor spread along the sharpies fibers produces the sun those periosteal reactions yeah yeah very good so it is lifting up of the periosteum of the tumor cells isn't it which caused the soft tissue swelling and the periosteal elevation giving the cord man triangle isn't it okay what is the type of periodicity reaction is this interrupted or continuous appears to be most of the malignant neoplastic cases you have interrupted very periosteal you get continuous periosteal reaction uh hypertrophic osteoarthropathies yes in osteomyelitis also you get instantaneous okay uh why if you get a x-ray and radiograph like this what is the next imaging modality you will ask for looking at the bone but mra is more essential you do a ct of what in this patient ctf what shoulder ctf shoulder as well as ct of the chest because before starting neurogen chemotherapy you have to look at the chest to see whether there is any metastatic deposits okay that should be done for all the ocean sarcoma patients before the chemotherapy this is the mri why do we do mri the confirmation of diagnosis staging because now previously ocean sarcoma was a very mutilating diseases and there is to amputate but now new newer techniques have come for the limb saving procedures so to know the marrow involvement you have to give the marrow involvement that the correct position of the marrow environment the epifacial involvement by the involvement the joint also that's why we do mr and look for the soft tissue involvement understood so that was a case of osteoplastic osteocytes any other morphological classification you know angioplasty osteosarcoma also is there and a companion case what is this now uh there is a high increased density at the uh which bond is it the head radius crystal radius is it radius or ulna what do you think it is it is radius very good very good very good so it is a 12 year old child involvement of the metaphysis yeah yeah what is paired it is meta differential involvement so it is again osteoplastic so always you have to know the details whenever you look at the msk case what is stamps stamp stands for s for site understood always look at this whether there is epi facility involvement whether it is metaphasial metadiaphasial or difacilion because it is very important to come to a disease protocol you should know which site is involved because uh suppose meta diffusion you can go look for osteogenic sarcoma if it is diffusive you look for ailing sarma and the age is also very important so this stamps if you remember in your mind you will come to a conclusion and your diagnosis s stands for side p stands for transition white means malignant narrow means benign a stands for age and aggressiveness understood then ma m for margin of the lesion and look for the matrix that is marrow and periosteal reaction p for periosteal reaction and s for stock tissue so this time should be in your mind whenever you report a case of msk understood listening yes number seven yeah now can you believe it be faster uh the frontal and the lateral projections of the skull shows um so swelling on the outer and inner aspect of the skull on the left parietal bone with the expansion of the deploy space very good very good so that's circumscribed deletion with the narrow zone of transition his age was 22 again same age group the lateral axis shows the lesion has a well-defined border with a narrow zone of transition well defined what border sclerotic border mud very good yeah [Music] younger age group when you find such a lesion what will be a diagnosis age is younger uh you said narrow zone well-defined borders introspection [Music] what will be the appearance of as you said fan burst appearance yeah sun bulb there is no sunburst appear isn't it focal involvement focal involvement this shows uh increased density involving the right left with the expansion of the deploying space the matrix of the lesion appears um fluffy amorphous densities high density 601 high density matrix any typical appearance in your mind ground glassy and yes yeah there is specific name for that when you sleep you use your pillow what is inside the pillow not nowadays previously yeah cotton ball appearance isn't it and when do you get this cotton wheel appearance with you eat something you peel it off you eat something and you peel it off [Music] so orange rind of orange wind of orange appearance with cotton wool ground glassing in fibrous distribution very good the case of vocal fibrous what the different types of fibrous dysplasia monostitic type poly very good yeah so now what is this now it's a companion case mri abdomen and pelvis shows uh well-defined uh cystic lesions and uh extreme abdominal pelvic um [Music] with the peripheral post movement [Music] yeah it's down is a contrast suppose contrast enhancement very good uh the right iliac blade shows uh signal intensity which is appearing very good yeah yeah i'll give you the elac braid i'll give you the brain also it also shows don't say ground gloss in mra but in ct you can say very good there's expansion with multiple experiences involving both the skull vault and the appendicular skeleton bilaterally symmetrical so what is your diagnosis now very good very good well because endocrine abnormal diseases make you an albright syndrome understood very good very good now this is a rapid firing okay now we are going to rapid firing what is striking at you yeah you have very good left eyeball what has happened to the left eyeball [Music] left eyeball is elongated you're not seeing the left eyeball isn't it you're able to see the right eyeball but still right eyeballs also elongated it it has buffed almost but what are you seeing adjacent to the left eyeball there is no eyeball isn't it there is no eyeball but that is replaced by csf density area and there is some soft tissue what is a diagnosis what has happened to what is the bone which is so much folded there what is that bone related to that area so you know yeah so what has happened to the phenol bone remodel what has happened to the orbit what has happened to the sphenoid bone i'm giving the clue so much of soft tissue [Music] orbit understood neurofibromatosis type one or two type one type one okay now today i'm dealing only with the head excluding paranasal sinus and temporal bone understood permeating changes motor involving the mandible yeah very good you get the mandible on the right side very subtle finding is there very subtle finding you can see some erosions but you can see permeative pattern as she said okay so this was the lesion when we saw the i said clinical radiology is very important i just want all the residents to take history of each and every patient's because if you don't see the patient you will miss the diagnosis so clinical radiology is very important nowadays so all of you all the residents who are uh seeing my lecturer hearing my lecture should take history of each and every patient you are reporting understood this is the clue for you okay just keep in your mind this picture okay this is the ct picture plane and contrast [Music] um very good cystic and solid component both heterogeneous lesion with cystic and solid component involving the mandibular region extending to the maxilla understood and you can see level one two lymph node also level one a and b lymph nodes okay that is the finding here with destruction of the mandible and maxilla this is a coronal cut this is a clue for your diagnosis of false calcifications are you able to see the fox here you are able to see part of the anterior focus so it is yours you're just seeing a heterogeneous mass lesion the area of mandible and maxilla seen in previous slide with some contrast enhancement in the region of the frontal bone now are you coming to diagnosis see then [Music] very good yeah this is a contrast showing a heterogeneous lesion in the region so can you give me the diagnosis now tuberous sclerosis only tuberous sclerosis yeah what is association of tuberosis yeah one association is odendogenic fibroma in this case you can have destruction of the mandible and maxilla usually seen in the jaw region and you can get ah one more lesion that is desmoplastic fibroma these two conditions can be associated with tuberous sclerosis understood listen okay you're happy yeah no we are nearing the end i will show two or three uh spotlight cases this is one case discussion where are you seeing the lesion just tell me what is this picture radiograph yeah you know how to take it how do you get this view the mandible the seed recep image receptor and [Music] the x-ray tube rotates around the patient very good yeah in an arc like fraction which other imaging modality moves in this arc like function the cone yeah one is conventional tomography which is used previously and and and now condem ct which we use for dental then cbt that is computer stromography for the breast understood that is the arc length movement is like that okay okay the arc like series goes on even though the tube rotates you are not able to see the rotation of the tube we won't be able to see the arc moment but the tube will rotate inside to get the slice okay here where are you seeing you're seeing in the upper uh maxilla or in the mandible look carefully yeah mid line very good you know you could catch it it is in the mid line region expansion lighting lesion isn't it involving the involving the maxilla yeah this is nearly a young child i think uh about uh 15 to 20 i think 10 to 15 years came with the swelling so what all you look for now what there will be a diagnosis so [Music] this is bulging into there's no break so much of break but still you can see it's merging into the maxillary sinus isn't it what will you look for if you see in a young age group like such expansive light equation which is bulging what do you look for inside you look for an under erupted tooth isn't it but in this case you are not able to see the under but it is very close by now existed so uh two things should come to your mind one is that the the density within it was not like a soft tissue it was like an uh infected fluid like unless if it was a soft tissue you could have said it is ameloblast amyloblaster but this was fluid because it is infected so this was a case of infected dentitis because you could see the tooth under to the very close to the margin of the expansive light equation understood this was the infected dangerous system now what is this is a rapid firing tell me that name the procedure three more slides what is the volume of contrast you use for cylon b specific what cylogram it does submandibular cytography look carefully and tell me whether it is yeah what is the name of the duct tension step strength what is the volume of contract you use [Music] two himalaya one to two ml what precaution you will take before doing a cylogram here [Music] you're not able to see the opening fly lemon setting give the less i love gog isn't it so that you can see the open you can see the saliva pouring it out what is the finding in this case there is you know the different types of phallic cases you know what is this cylogram submandibular cytography what is the name of the duct work what is this cylogram any finding in the cylogram ah you can see the branching pattern it is dilated isn't it in both the cases it is it is silectasis isn't it yeah now what is this what is this procedure name the procedure the ct cylography the patient came to the department with stab injury in the region of the parotid gland okay the region of the parotid line you can see the sensor duct normal but what has happened to the parotid gland this totally destroyed and is filled with contrast when we did a ct that's why you're getting so much of density total destruction of the parotid gland it's called as global destruction so you should know the types of the dilatation of the uh salivary gland so it is described in different patterns known as punctate type globular type cavitatory type cylindrical and fusiform type okay this should be in your description if you are doing a cylogram but nowadays nobody does this procedure because it is invasive all go for mr silogram okay this is a spotter supplemental yeah submandibular very good you're correct the first size image is plane but x2 is contrast abscess peripherally yeah very good submandibular abscess lapses is due to what a silent stone obstruction yeah you can see the calculus along the along the what else duct isn't it can you see the calculator large calculation causing obstruction and has led to submandibular abscess formation because it was ignoration did not show the concerned surgeon for this because he left it like that so the submandibular axis the last case is an ending case for you the first two images are ct the down the three images are mri i have given you t1 t2 and the flare it's a very defined sophistication age of the patient is nearly 78 years 78 years [Music] patient just came to the department of some weakness just weakness of the upper and lower limbs [Music] the clue is in the picture itself i have given you t1 t2 and flare so what is it and the ventricle is so so clean clearly you know so what is the density and intensity of the fluid hyperintense on t2 so what is it be bold enough to answer nothing so much serious i just i can suggest what to say radiology [Music] query it's a magic angle so nothing serious in this once you see here when you when you see high point and hyperintense signal what is it actually the fluid [Music] is it similar to the csf yes name so what is atleast what is the lesion eric narcissist yeah where very good why it takes a lot of time is it intracurrent primal or is it extra parenchyma extraction because i'm not able to show you here i don't know if you can use my hand here you see the sag image you can see a ring of parenchyme around it isn't it can you see the sagittal image but the sad image also you can see actually it is an intraparenchymal electrons it's very rare usually you get in the extraction resistance or the suburban space isn't it this is intraparent chemical erythrocyst that's why patient did not have much of symptoms after the age of 70 to 80 years understood what are the different types of organizations do you know of hello yes ma'am yeah [Music] different types you know type one type two type three [Music] and this is which type type one type two type three common only one percent of two personal cases will get intra paragraph electron just okay most common advances are extreme type 3 or type 2 most common you get type 3 archangel understood usually you see in the temporal fossa region we can see in the cisternal region usually in children you get in the quadrigeminal system or in the posterior fossa in temporal region understood we can remove what is the complication of the removal of arkansas if it is in the temporal region i had one slide but i could put it i'll put in the next quarter subdirectory [Music] you can get hygromas and one of the complication is arachnoid ossificans i'll show you in the next class okay so thank you for your patience listening and very good answers both of you did very well i am very happy with both of you you will come out in bright colors all the best for your exam sandeep and ashviti thank you so much thank you man that was an excellent session not only for radiologists but also for consultants to brush up the knowledge i see that they do not have any questions so we will go ahead for any doubts they can be asked to gomati madam by sending her an email to dr underscore gomo gomu at yahoo.com after this program for all those who attend who have attended today's spotter's webinar e-certificate will be given within three or four days by email we have come to a concluding session of this event we will be back again with more supporters and more exams for residents watch the groups and social media for further intimations

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dr. Aswathi P

Dr. Aswathi P

Consultant Radiologist, Calicut

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dr. Sandeep Prasad

Dr. Sandeep Prasad

Radiology resident , GMC Calicut

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Kerala

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Gomathy Subramaniam

Dr. Gomathy Subramaniam

Professor and HOD, Radiology, Malabar Medical College, Kozhikode

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dr. Aswathi P

Dr. Aswathi P

Consultant Radiologist, Calicut

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dr. Sandeep Prasad

Dr. Sandeep Prasad

Radiology resident , GMC Calicut

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dr. M.C.J. Prakash

Dr. M.C.J. Prakash

Consultant Radiologist | President - IRIA, Ke...

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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Dr. Gomathy Subramaniam

Professor and HOD, Radiology, Malabar Medical...

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