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Neuroimaging Insights

Aug 25 | 1:30 PM

We have a really interesting and much awaited discussion on Neuroimaging with Dr. Deepak Patkar and Dr. Mitusha Verma where they will be discussing stroke, Dementia followed by a Turf expansion programme. IRIA, Kerala is delighted to extend an invitation to all radiologists from around the world to attend this conference. Conference Agenda- 7.00 PM: Stroke 7:30 PM: Dementia 8:00 PM: Turf Expansion P.S.: Certificate of attendance will be provided

[Music] good evening everyone welcome to the neuro imaging insights under turf expansion program of iria kerala under the leadership of dr mcj prakash kerala ira president dr rijo matthew kerala ira secretary and turf expansion chairman dr jose kuriwala this is the third program on turf expansion we have a few down-to-earth eminent personalities in radiology dr deepak parker needs no introduction he is the immediate past president of national iria and head of department of radiology at nanawati super specialty hospital mumbai i was fortunate to work with sir last year as an editorial board member of e-newsletter and also got got to know his team in his uh department welcome sir second first second person is professor dr chandra shekhar and keshavadas associate dean of the prestigious sritra tirunal institute for medical sciences and so we'll be joining later for the panel discussion on turf expansion welcome sir the other two mems are dr nitusha verma our second speaker and dr gauri ahuja moderator for this evening both are from nanawati super specialty hospital mumbai welcome ma'am before we move on to the session i would like to inform that the attendees will get participation e-certificate soon if they have watched at least 75 of the session we highly recommend attending today's session with headphones and in order to view images for better clarity you may zoom the image over the screen and regarding any queries please feel free to share in your questions at the comment box and we will bring it to the speaker's notice thank you now we will move on with the academic session for today may i introduce our first speaker dr deepak parker sir he is the director medical services and head of department in imaging at nanawati max super specialty hospital he is a member of who radiology advisory board in classification of tumors he is the immediate past president iria past chairman icri and leeds medical administration functions and instrumental in clinical team expansion he is the chairman scientific committee asia oceanic congress of radiology 2018 and has received best radiology teacher award for 2019 at radiology and imaging conclave 2019 delivered more than 1000 lectures and orations at national and international conferences including india meets at rsna at rsna 2019 and india meets ecr at ecr 2018. may i invite dr deepak parker to speak on the topic imaging concepts and recent advances in imaging of stroke over to you sir thank you judy uh thank you dr chennai and everybody else from kerala state chapter of ira for having me it's a great pleasure to be back with all my supporters during my uh tenure as president of ira uh judy and dr ramesh was a real great help in what i did and what i could yeah so i'll be talking on imaging concepts and recent advances in imaging of stroke before i do that i must acknowledge contribution to this talk from my curricular department dr mithusha gowri gayatri and harshad when we talk about imaging or stroke we must first understand the definition of stroke stroke is defined as reduced blood flow and confusion caused by thrombus embolus in the artery or hemorrhage there are three zones within the stroke ischemic core where the blood flow is less than 12 ml of blood flowing 200 grams of brain per minute penumbra where the blood flow is between 12 and 20 ml and oligarch tissue where the blood flow is more than 20 ml the normal blood flow in the brain is between 50 and 60. why stroke is so important to image and for us readers to understand a stroke can happen to anyone at any time and anywhere today stroke is the living cause of disability worldwide and the second leading cause of death but almost all the strokes can be prevented this year about one and a half crores people will have stroke and 55 lakhs will die as a result eight crore people have survived stroke worldwide and the main problem is disability physical communication difficulties changes in how they think and feel loss of work income and social networking there is a saying in english which says that what you want is what you get and evolution of stroke imaging is completely reflective of this saying for years together it did not matter when you image these patients because the role was limited to excluding hemorrhages and stroke mimics like tumors with thrombolytic therapy coming in about 15 years back and its efficacy proven over several years for now all of us as radiologist or neuro readers it is rest against time stroke imaging used to take 40 45 minutes before and now there are new generation devices where ct scan can reach the home of the patient and mri can be done in 10 to 12 minutes to understand the complete pathophysiology of stroke with that the role of neuroimaging change completely from just simple anatomic depiction of impart to identification of region at risk of infection try and detect the cause of stroke and predict the outcome in the same goal so there are several questions that we as readers need to answer the first question is is there an in fact at all if the patient is suffering from suspected stroke if it is so what is the cause if we find in fact whether it is reversible or not what kind of intervention needs to be done and can be carried out what is the outcome going to be if you treat this patient and if you not treat that patient can we prevent post thrombolysis hemorrhage in the given patient and can we assess the risk and predict the future strokes in the given patient in next 20-25 minutes we are going to answer all these questions so the first question is is there an in fact in the patient who is suffering from suspected stroke worldwide plane ct scan is the most commonly performed study because it is 100 sensitivity to detect parent chemical hemorrhage it is widely available it is very quick happens in a matter of few seconds and it's relatively inexpensive compared to mri problem with ct today is findings are very very subtle in the window period of treatment that is three to six hours two sixty percent of ct scans if you don't do ct angiography or ct perfusion are going to be normal in first few hours and in the era where you want to treat these patients aggressively a normal city is not good enough before we go on to anything else we must understand whenever ct scan is positive in first six hours that is in forty percent cases what are the signs you should be looking for and these are dense and say sign obscuration of lengthy form nucleus and insular ribbon sign on your left hand you have insular ribbon side where the insulin left side is darker compared to the contralateral side and your right hand side you have hyperdense mcsign equipped thrombus in any vessel appears hyperdense on clean city scan and that's the way to detect stroke on ct scan as in fact moves on cd scan from hyperactive to acute stage you get hyper density which is best shaped minimal mass effect in the overlying sunshine and engineering ventricles and if the effect is large you start getting mid line shift and infra temporal herniation of ankas mr today is considered as one stop shop to understand the tissue viability and vessel patency by doing mrnjo asl of perfusion imaging and diffusion perfusion mismatch even without all this eighty percent of the times you will find something on mr in hyperactive stroke also it is good for small acute cortical strokes or lacquering thoughts when patient has multi infrastructures it can also rule out hemorrhages and micro hemorrhages very accurately with new susceptibility weighted sequences there are four important sequences that we need to understand when we try to do mri in hyperactive stroke which can happen today in about 10 to 12 minutes diffusion is the stroke sequence and we'll understand about it this is later flare is required to identify onset of stroke when patient gets awake stroke so you don't know when the stroke actually started when patient gets stroked in sleep swi is required to identify micro hemorrhages and hemorrhages perfusion either with sl or without a cell is required to identify and differentiate core from penumbra and angiography a quick angiography is required for depiction of arterial anatomy and site and location of thrombus our stroke protocol which varies from about nine and a half minutes to about 12 minutes has diffusion of the first sequence predict off as the second sequence swan as the third sequence flare as the fourth sequence asl as the fifth sequence and and if required we do predict of nick and joe which many times is not really required differentiated sequence is called the stroke sequence because it picks up in fact very very early there are two gradients applied on a t2 address sequence first gradient is at least to acquire phase shift in transit magnetization in water the second gradient will refocus only the stationary spins phase changes due to motion prevent rephasing and there is signal loss this is a case of hyperactive stroke this patient came to us about 45 minutes from getting stroke he was never at our hospital if you look at the flare you do not see anything at all and if you look at diffusion then with 2000 b value you have a large which shaped area of restricted diffusion involving the posterior branches of mca so if you look at literature positive predictivity of diffusion is point 99.8 percent and that is the reason it is called as the diff the stroke sequence diffusion sequence is also very very important when you are suspecting posterior fossa strokes and here is an example of a patient presenting with lateral middle syndrome and what we see here is a hyper accurate in fact in the postural lateral portion of left half of medulla which is not seen on deteriorated images here is the concept of the wake up stroke you have two patients one on your left hand side has right iman territory hyper uh right emotionally accurate in fact which shows restricted diffusion and is brighter flare on your right hand side you have another patient with similar symptoms wake up stroke and if you see here you have diffusion abnormality in the m2 segment of high density flare is absolutely normal so patient on your right hand side is appropriate for treatment one on your left hand side is not a little bit about hemorrhagic infarct and hemorrhagic transformation of an infarct this concept i am going to explain little later which is important for us to understand and make neurologists understand how to treat these patients the second question that we need to answer is if the patient has hyper accurate in fact what is the cause for that ct angio and mrngo are equally good ct ngo happens fast contrast of course is required and the resolution is superior to mrngo it can detect soft flux and differentiate it from calcified plaques also amount of narrowing random lesions etc can be accurately depicted other important parameters using multi slice city is collateral scoring system so here absent collaterals as you see on your left hand side it means magnet profile and the outcome of that patient is going to be very very poor score 1 is diminished collaterals in more than 50 percent of territory score 2 is diminished collaterals in less than 50 of territory score 3 is collaterals equal to the contralateral side and score 4 is increase collaterals on the affected side which has the best outcomes if you treat them very quickly mrn geography as i said today the circle of videos can happen in one and a half minutes and make and you can happen in almost two and a half minutes basically this is used to look at thrombus in combination with swan images and also look at where the thrombus is coming from whether it is coming from carotid or from the heart we should do contrast mrngo few years back to reduce the artifactual increase in the narrowing of the carotid today this has been virtually given up so contaction and samara and geography is not really done in today's world the third question that we as readers need to answer is if there is an info is it reversible for that we must understand the concept of perfusion imaging ischemia is defined in the brain as ischemia when cerebral blood flow falls below the threshold of 18 to 20 ccs of blood flowing 200 grams of brain per minute because that is the minimum requirement to maintain cellular activity in the brain in fact happens when cbf remains below this threshold for enough time to cause irreversible cell damage and that number is four to eight minutes in different patients so ischemic core is an area where cell death has happened and there is complete membrane failure with failure of sodium potassium pump penumbra is marginally perfused metabolically unstable area in the brain where no cell death has happened and it is potentially salvageable with reperfusion using perfusion imaging with contrast or with asl you can have a look at diffusion perfusion mismatch and understand the salvageable penumbra so it acts as a complement to diffusion imaging and here are two examples first example shows a small area of diffusion abnormality and a large area of perfusion abnormality and this one has almost equal diffusion and perfusion abnormality so outcome of this patient if thrombolyzed would be much better than this patient because diffusion confusion might be mismatched in this patient is much larger than this also you can do post treatment perfusion scanning using asm to understand where whether the blood flow has returned back with presence of luxury perfusion in the infected area so repeatability of asl makes it superior to contrast enhanced perfusion imaging the fourth question that we need to answer is what kind of intervention needs to be carried out the concept is completely evolving as we talk and the management of hyper acute and acute ischemic strokes is changing from time is brain to physiology is brain and that's where diffusion and perfusion come into play so rather than going by clock which is three hours four and a half hours and six hours of allowing treatment to happen people now look at amount of salvageable penumbra even if the patient comes little later what can be done if it is possible mechanical thrombectomy is the best treatment followed by intraordinary thrombolysis followed by intravenous thrombosis and the time periods for these three are different here is an example of a patient who had right mca stroke thrombus was removed and post procedure on your right hand side you can see complete restoration of flow in right mca can we predict the outcome of the given patient when we image these patients there are several factors where outcome is dependent one is the involvement of a specific vessel for example basically artery stroke is worse than terminal ica stroke and terminal ic stroke is worse than mca stroke in terms of long term outcomes and mortality any major cva or large vessel occlusion will have poor outcome in terms of 35 percent recoverability versus 45 percent recoverability and 20 percent equality in mild and lacking in farms other concept that we must understand is alberta stroke program early city score which divides the mc3 into 10 different zones and whenever you see hypodensity on ct scan and restricted diffusion on mri scan you minus out that particular area so any score of less than seven has bad prognosis score of eight nine and ten has got good outcome the accuracy of aspects in super control compartment is so good that it is now being moved and used in posterior fossa also where thalamine occipital lobes midbrain pons and cerebral hemispheres are used to give score and look at the outcome there are multiple clinical variable impact outcomes which we must also understand the most important one is time to treatment so quicker you treat better is the patient's outcome post thrombolysis hemorrhage indicates bad outcome stroke severity age race weight and blood pressure are equally important in understanding the eventual outcome the sixth question that we need to answer is can we predict post thrombolysis hemorrhage for that we must first understand what are the types of post thrombolysis hemorrhages so small hemorrhages are divided into hemorrhagic infection type 1 or hi1 where you see particle hemorrhages at the periphery of the infarct hemorrhagic infection type 2 or hi2 where you see particular hemorrhages throughout the impact on your right hand side top ph 1 or parenchymal hematoma type 1 is where you have less than 30 percent involvement of infected brain with minor mass effect and parenchymal hematoma or type 2 hematoma or ph2 is where you see more than 30 infected area showing presence of hemorrhage and mass effect so there are several predictors which can tell you whether the patient will recover post therapy or even without therapy so massive cerebral infection has got poor [Music] of less and hence they are likely then the chances of hemorrhages are 25 if there are good collateral formation you will have chances of hemorrhage being 2.7 and here's the patient with terminal right left ica occlusion with stroke if you see contralateral injection right i say injection there are poor collaterals this patient mechanical thrombectomy was done and he has bled quite severely and eventually succumbed the last question that we need to answer is can we assess risk and predict the future in the patient if the patient is vulnerable for repeat strokes for that we must understand plaque imaging and block terminology american heart association has classified plaques into eight subtypes out of which plaques which contain lot of lipid or hemorrhage or have necrotic areas the type 4 5 and 6 plaques have higher chances of getting stroke so these are called as an these are called as unstable plot and they are likely to get get dislodged into the brain parenchyma using higher resolution color doppler or high resolution mri you can accurately image the quality and type of plot here is an example of a plaque in the left internal carotid artery which is diffused and has not accelerated so this is the stable block compare this with this unstable block if you see in the right internal carotid artery there is ulceration of the plaque and there are small areas of hemorrhages which are type six plaques so even if the narrowing is less than 70 in these patients you need to stand them because these are unstable parks before we conclude a little bit about advances and future of stroke imaging there are several new modalities which hold promise for further refining patients and classify these patients to improvise patient management and hence the outcomes asap is a new tool which allows us to do it repeatedly because it is non-contrast and it can evaluate the penumbra zone diffusion perfusion mismatch almost as accurately as contrast enhanced perfusion imaging it can also localize atom thrombus post-therapeutic hyperperfusion and diagnosis of stroke mimics here is an example of two patients which we published on your left hand side top you have small diffusion perfusion mismatch and right hand side bottom a large diffusion perfusion mismatch so outcome on the right sided patient is much better is going to be much better than the left-sided one here is an example of acute thrombus in the right mca which is seen as bright on asl imaging which is confirmed on swi imaging here is an example of post therapeutic hyper perfusion left hand side top you have hyper accurate in fact in left unsaturately post thrombolysis the posterior part of mca branches have got re-perfused quite well and not the anterior one swi imaging has really come as a bone in stroke imaging it was first described by hacking in 2004 and now it is an essential part of any stroke protocol across the world it can detect thrombus it differentiates hypoperfusion from delayed perfusion it allows better depiction of energy transformation and there are two new signs described which are called as susceptibility vessel sign and prominent vessel sign which are very very useful in hyperactive stroke on right hand side bottom you have acute thrombus in m1 segment of right mca which is seen as thrombus load as this susceptibility vessel sign indicates the hyperacute thrombus which is defined when you see diameter of the thrombotic vessel larger than the contralateral vessel prominent vessel sign is seen in the ischemic penumbra where you get prominence of veins in the affected area as the oxygenated blood rapid ai is an artificial intelligence based software which you started using which allows quantitative rapid assessment of penumbra volume the application is to decide mechanical thrombectomy for patients even beyond window period of four and a half and six hours here is an example you have a large hyper accurate in fact in left hand circular tree with thrombus in the left mca rapid ai shows the mismatch volume to be 142 ml and the core volume to be 11.9 here is the zoomed part of the core and penumbra it can also divide the given in fact into in fact oligemia and penumbra and post therapy you can see reversal of the mismatched area there are certain quality control parameters for rate of injection and for patient movement which allows us to improve the accuracy further here's the patient on your left hand side you have two images bsa and mrngo showing left m1 occlusion which is reperfused after mechanical thrombectomy and the pretreatment diffusion procedure mismatch has almost reverted to normal on this right sided image diffusion cartridges imaging over next three to four years will replace diffusion imaging completely it is based on non-gaussian distribution of the protons flowing in the infected area and using this rat in fact analysis people have realized the researchers have realized that the diffusion abnormality is not as accurate as diffusion cartridges abnormality and diffusion cartridges abnormality which is seen in the bottom second picture is the one which remains as the scar on this two weighted images post treatment six months so contributions abnormality is more accurate indicator of core than the diffusion abnormality ph mri is other area where a lot of research is happening because we know that disturbing metabolic activity and ph drop precedes the drop in cbf so ph will drop before the diffusion or perfusion abnormality will come up and these changes can be detected much earlier on ph imaging and here are examples in the same rat that we saw in the previous image so mismatch matter model with these newer advances is going to get revisited and you will be able to divide diffusion region into cartesian lesion and diffusion correspondence mismatch and perfusion diffusion mismatch will be further divided into ph diffusion mismatch which is oligemia and perfusion ph mismatch which is the area of ischemia so you need to identify the stroke image the stroke and treat the stroke as fast as possible so remember be fast that is my last slide and thank you for your attention so talk it's always wonderful to hear your lecture on stroke i'm sure judy you agree with me and especially covering those newer advances i'm sure those are really beneficial so i mean what i would just like to ask you for this rapid air that you mentioned in your advances do you need a machine injector or a handle injection is enough so a proper injector is is preferable but hand injection is good enough so if you're doing ct imaging hand injectors uh sorry uh the mechanical injector is must but if you're doing mri because you're injecting just six cc's or seven sissies you don't require hand injection is good enough and we actually do not do contrast enhanced perfusion angio we are conducting as perfusion imaging we just do asl imaging which does not require any contrast anyways thank you sir that was an exemplary presentation to our birding consultants and post graduates dr mithusha will be back online in two minutes with her presentation may i introduce and welcome our second speaker dr mithusha verma she is the consultant radiologist in the department of imaging at nanawati super specialty hospital mumbai a core committee member at the iria and state chapter rsna esr and bir she's a co-guide for post graduates dnb radiology she has been awarded as leading young radiologist radiology and imaging excellence awards the young iconic radiologist award 2020 and the welcome icon award 2020. may i invite dr mr varma to speak on the topic imaging approach to dementia over to you ma'am thank you for that kind introduction uh hope i'm audible yes ma'am okay so uh i think you can share my presentation from there and then you can start yeah doctor with krishna yeah i can see my presentation now so uh very good evening everyone and the talk which we are going to have now in next say 25 minutes will be discussing the role of imaging in dementia and in evaluation of patients who have complained of forgetfulness with imaging so uh dear friends we all know that natural aging which is a physiological process that also can cause forgetfulness so we should understand in this talk that how do we differentiate natural aging from dementia then we see the definition part of dementia how who describes dementia how the alzheimer's society describes dementia then we will understand the disease burden then we'll see the guidelines and recommendation whether we are correct in imaging patients with dementia or not then we try to classify dementia and then we see the future direction that is upcoming advances so as i said normal aging is a physiological process and everyone is going to experience the same during the lifetime so there will be slight decline in cognition we will call it dementia when the degree of decline and the rate of decline is much rapid and faster and the cognitive impairment is severe enough to interfere with the person's everyday ability to perform routine activities dementia per se will start as a part of preclinical phase then we'll go to the mild cognitive impairment phase and then to actual dementia so this is a busy picture slide where we see that there is a comparison between normal aging and dementia and the same thing we have tried and tabulated so a person's dependence on others will be what is seen in dementia but the person will remain independent in normal age in a person who is undergoing normal aging the person will not have complains about using the day-to-day appliances but a person who is dementing he will face difficulty in using even the simpler appliances at home the family persons will be worried and they will be complaining about a person's inabilities and inactivities in cases of dementia while in cases of typical aging the patient himself will come up with the complaints that i am not able to remember things easily and i am facing this problem then also us the person who is undergoing dementia will have a socially inappropriate behavior sometimes and will also lose interest in social activities while in typical aging this is not hampered so dementia the term has been defined by the alzheimer's society as a set of symptoms that may include memory loss and difficulties with thinking problem solving or even language and we say when we see the burden of the disease so if we see the burden of the disease then we can actually make out through the world alzheimer's report 2016 that in the asian continent itself the 2015 uh census of dementia was around 23 million people and if we extrapolate it this will go as i as 67 million people in 2050 so it's a huge burden and if we see the indian scenario as well we will find that uh this is an actual problem here we see that we might feel that diabetes and hypertension is something which is more common or which forms the bulk of morbidity in the indian society but 11.9 percent is because of dementia so if we go next to see the actual dementia india report 2010 then also because there is an increase in the life expectancy the number of patients who are coming up with the complaints of dementia or rapid declining cognitive functions that also is at a rise so when we try and see the proportion of various kinds of dementia in indian population we see that the most commoner as compared to the sensors is alzheimer's dementia but in a day-to-day practice we find that the vascular dementia is something which we find commonly as far as the imaging percentage is concerned the next common is vascular dementia next is dementia with lewis bodies and frontotemporal dementias now coming to the guidelines suppose we are recommending a person to undergo mri imaging or ct imaging for that matter if the person has complains of dementia are we correct in doing that so the guidelines have evolved over past few decades and if we see early 90s that is 94 there were guidelines suggesting that neuroimaging is not routinely recommended for patients for dementia worker but now the acr guidelines and all the current guidelines they are routinely recommending structural imaging and if possible functional imaging for evaluation of patients with dementia so if we see the acr appropriateness criterias which we have for all the conditions and we can always refer to them whenever we are at a doubt so here we see that mri is the investigation of choice when we are evaluating patients with complaints of cognitive decline and suspected dementia now let us try and classify because dementia is a broad umbrella term and lot of entities are a part of it so the classification of dementia can be made like on the basis of cause which could be alzheimer's dementia which could be cerebral vascular disease that is because of multi in fact state or because of sub cortical vascular disease that is binge vanguard neurodegenerative disorders like pigs disease huntington's korea parkinson's disease infectious diseases like cjd and hiv like aids dementia complex can be a cause of rapid cognitive decline then normal pressure hydrochemicals this is one of the most commonest treatable causes of dementia which we can identify with imaging nutritional causes of dementia are like wernicke corsica that is caused by thyamine deficiencies metabolic disorders like hepatic disorders thyroid disorders can lead to rapid cognitive declines and even trauma like head injury frontal trauma frontal area trauma and tumors like frontal meningioma can cause dementia if we go by dementia classification as per the site then we can try and identify the location or try and classify the type of dementia so if the person has the frontal pre-motor cortex involvement then the person will present with more of behavioral changes so like in cases of frontal temporal dementia then if the involvement is more of the parietal lobes like we see in cases of alzheimer's dementia then the person will present with more of cognitive function declines and behavior will be more or less preserved if it is subcortical involvement then it will be like poor ability to use day-to-day knowledge and skills if it is more of cortical it can be this fascia agnosia apraxia again a feature of alzheimer's so we will see how to apply this knowledge when we are interpreting our images again a way of classifying is based on reversibility of the dementia cause and when as a radiologist we can identify the reversible causes of dementia then that will be definitely helpful for the patient so it could be endocrine metabolic like normal pressure hydroquinous one is one of the reversible causes of dementia nutritional etc and even if we identify the irreversible causes of dementia the treatment plan can be modified and formulated as per the diagnosis so why this slide has been kept because this was a slide which we use which we were using for a tumor imaging presentation so all these sequences are used in brain tumor evaluation but now with the evolution of imaging techniques we can use all these techniques and sequences also in evaluating dementia so that's we are going to see how so a routine mri protocol for dementia imaging which we are using consists of t2 rated images that is a routine morphologic images actual d2s actual flare then we'll have a three uh 3d t1 weighted sequence this is very important that you should acquire one 3d t1 weighted sequence and this sequence will help you not only to identify which type of pattern that dementia is following that is what you are going to do is that 3d t1 we are going to reformat into three planes and then you can identify whether it is predominantly parietal lobe temporal lobe frontal lobe atrophy or if it is a global atrophy all those things can be identified the second important thing from this 3d sequence is that you can perform volumetry because in dementia evaluation brain volumetry and segmented brain volumetry are important that we will see in details other next sequence which we perform is susceptibility weighted imaging that is one diffusion will definitely be a part to uh evaluate for any hyper acute acute strategic influx but the advanced sequences which i was talking about was arterial spin labeling that is a non-contrast perfusion imaging that can be used mr spectroscopy from gray and white matter and if you see additional features like any meningomar tumor or features of normal pressure hydroquinous you can tailor make your study accordingly so let's see a bit about these sequences and how do we utilize them arterial spin labeling is non-contrast perfusion so here you will not be requiring contrast to perform confusion but what you are going to do is you are using magnetically labeled protons that is present in the blood and you are going to create this kind of perfusion maps and here we know that arterial spin labeling data set is very similar to what we have been obtaining through spec and neuropath data and a lot of articles and publications have been presented even the alzheimer's society has presented various literatures on the role of asl and the role of perfusion maps in dementia so various kinds of dementia will give us a different pattern of hypoperfusion or hyperperfusion in the brain's parenchyma and asl has the advantage that it is no additional cost to the patient and no additional pain to the patient it is just a four minute of mri sequence next is your mr spectroscopy this we are going to perform from gray matter and white matter so a single voxel spectroscopy provided to this patient from white matter one spectrum is obtained and from the gray matter another spectrum is obtained then we have the normograms or reference scales for different ages we are going to compare with this and then we are going to interpret so neuronal loss will lead to reduction in na which will be a common feature for most of the types of dementia myoinositol rise is seen with alzheimer's pattern of dementia so all these kinds of interpretation can be made through mr spectroscopy one thing to remember is that it is going to be a constellation of finding which you are looking at when you are reporting dementia rather than a single finding of spectroscopy or asl or any kind of volumetry so everything you have to bring together and kind of give a conclusive remark what do you think which kind of dementia is the patient suffering from next is the role of volumetry this is again important to classify a patient into one type of dementia so here we perform the 3d t1 sequence and when we perform the sequence we can use the sweet sequence to characterize the area which is involved by the atrophy and secondly we can actually do segmented as well as whole brain volumetry in segmented volumetry the most important area to segment is hippocampus because we know that in alzheimer's dementia there is specific disproportionate atrophy of the temporal lobes and that too specifically of the hippocampa now this image on screen is basically a report automatedly performed using a ai based software for volumetry so you can use semi-automated manual techniques or automated techniques the manual ones are little subjective they are operator based and they take little more time of the radiologist like if we used to do it we used to take around 10 minutes per patient if a junior resident or fellow is doing he may take around half an hour also to segment the entire brain and hippocampus and then again experience will matter but when you are using ai it will be robust in a way it will be providing you data which is quite robust and also you can utilize it in form of comparison with normograms so in this way you can actually try and utilize these kinds of automated softwares so in cases of alzheimer's dementia one marked feature will be rapid decline hippocampal volume so if you even follow up these patients you will see that as compared to what the hippocampal volumes were next year the volumes will may go half or even they can go further down as compared to a normal rate of decline of the brain points so now let us see each pattern of dementia specifically so one is your alzheimer's dementia let's see what we see in alzheimer's so besides that you will have your t1 weighted image and you will say that there is mild atrophy modded a trophy of the brain you will have to comment upon which area of the brain is showing more of the atrophic changes so you will see that the atrophy is predominantly cortical or white matter or global and then you will identify that the atrophy is predominantly involving the temporal lobes or the parietal lobes so in alzheimer's dementia it is more of temporal atrophy and more of parietal cortical atrophy and as i told you that hippocampal volume loss is definite features of alzheimer's so you have your visual scales like mta scoring which is just a visual scale you can google and get it and you have lot of references and articles which has this which have this image so you have to acquire this coronal on your c1 reformats and then you just have to compare the size of the temporal horns of the ventricles and depending on the size you can say that it is empty a score of two three four or one whatever and if with alzheimer's the mta score will be higher because there will be definite then as i told you that the rate of decline of hippocampal or volume also will be higher in cases of alzheimer's dementia next if we see what asl is going to offer in alzheimer's it will be hypoperfusion in cingulate precunious inferior brain prefrontal cortises and there will be asymmetric hyperperfusion initially in hippocampus amygdala and mental stride if you don't remember all this that is fine you can anytime refer to the standard articles of asl or bet and you can extrapolate the knowledge to your reports but that what is important is that you have to know that each of the sequence have some role to help you find the cause of dementia in a particular patient then mr spectroscopy will show elevated myoinos at all peak in cases of dementia due to alzheimer's next coming to the vascular dementia so vascular dementia is very commonly seen and this is as per the senses it is the second most common cause of dementia after alzheimer's so what we have here is a fosecra score which will help you quantify the degree of the vascular mighty impact damage to the brain again it's a visual scale and you have to compare your actual flare image for the patient with the skin and then you can give azekah score of one two or three somebody who has a record score of two or three that is a large confluent lesion they have a very high risk of disability and rapid cognitive decline risk so that is vascular dementia for you again you see an example where the patient has multiple uh flare hyperintense areas in periventricular and subcortical white matter but again if you see mta score is low so the hippocampal volume is very preserved unlike alzheimer's then even the vascular dementias if the impact is at a very strategic location that is those areas in the brain which are primarily responsible for the memory if those area undergo in fact again the person will have features like dementia or memory impairment so what are these areas it could be parietal temporal association areas angular virus paramedic thalamus inferior medial temporal lobe hippocampus or superior frontal lobe so that is also a cause of diminishes so if you identify strategic in facts you can explain the person's features of dementia asl will show you global hypoperfusion in cases of vascular dementia mr spectroscopy will not show any specific peak but there will be a decline in na which is a neuronal marker so that will be your there will be market reduction in n a values first in the white matter and then in the gray matter then coming to the third common type of dementia which is dementia with lower bodies so here you have a presence of intracellular cytoplasmic inclusion which results from abnormal alpha symmetry metabolism so that is thin nucleophages which when we see histopathologically but when we see this umbrella term the three things which it includes is parkinson's disease parkinson's disease dementia complex and dementia with fluid body it might not be very characteristic or patho mnemonic that you can actually point out that this is a dementia with lowly bodies but again there will be few features which will suggest that the patient will have dementia with double body so what are we going to look at uh we are going to see generalized decrease in brain volume with relative atrophy of midbrain hypothalamus substantial denominator and we will see abnormal swallow tail sign now what is this abnormal swallow tail sign so if you uh acquire high resolution swan sequence then what you want to see is posterior margin of substantia has a split appearance like two panel split bars so that is looking like a solo tape the tail of this bird and you can see that normally it should be present so presence of solar tail is normal while the absence of solar till is abnormal so with the features of parkinson's and parkinson's plus they might be blurring of the posterior margin of substantia nitro and that will lead to the absence of the solar pain so here you have again a visual scale so a lot of visual scales when you are reporting dementia where you can quantify the degree of blurry by using these terms like definitely normal solution probably normal solute probably abnormal solitary and definitely above the soil so this is one thing which we use asl uh will give you a distinctive pattern of occipital hypopathogen so all this pattern-based thing is uh usually seen initial phases of disease while in the later phases of disease there might be global hypo confusion uh this is an example where we have heavy control versus progressive supra nuclear policy and you can see how we can see that the mid brain is at trouble in cases of psp the upper margin of membrane is flat as compared to convex margin in led control and therefore the middle brain dupont's area ratio will reduce in cases of progressive policy so if you can calculate the emma parkinson's index there's a formula to it not going to the details but it is a simple formula and you can definitely calculate yourself and then you can characterize whether the person has features of parkinson's plus there is role of nuclear imaging as well in cases of dementia specifically if there are features of parkinson's then dota important and in cases of uh like corticobasal syndrome or in case of progressive supra nuclear policies or alzheimer's there might be a role of every breath to control the diagnosis there is something called as the hydrophilic variant of parkinson's spectrum where what you are going to see is combination of two things one features of normal pressure hydrogen fellas and second will be features of progressive sutra nuclear policy so this is a combination thing but the patient is like not going to show you features of shunt responsive nph so this is a known entity where you have more features clinical features towards psp but imaging features will give you a combination spectrum next coming to the front two temporal dementia and here you have a form of dementia which is genetically inherited and this is an autosomal dominant form of dementia inheritance and the usual age of onset in ftd so frontal temporary dementia is earlier as compared to the other forms of dementia so therefore it is more debilitating for the patient what you're going to see is a group of neuro degenerative disorders characterized by focal atrophy of the frontal and the temporal cortisos based on whether the frontal lobe is involved more or whether the temporal lobe is involved more you have variance so behavioral variant language variant so and in the language variant also you have a grammatic semantic and logopinic variant so when the frontal lobe involvement is predominant then that will be leading to a behavioral variant of frontal temporal dementia so a to a lesser extent the temporal lobe atrophy will be seen but if you see the 3d t1 carefully on the reformat you can make up then the frontal but trophy is the predominant feature there will be a symmetric involvement of one side of the brain and atrophy of the corded head whereas in language variant there is more of temporal lobe atrophy and very commonly the left lobe is involved so even like though rare if you carefully keep on doing dementia protocols in all your patients like we every year we might get one to two cases of this kind of pattern of frontotemporal dimension uh next coming to normal pressure hydroquinous in brief because this is a treatable cause of dementia and you should not miss this so even sometimes the patient comes for routine brain evaluation and you find features of nph and you can go ahead and perform the complete protocol so in nps what you are seeing is disproportionate ventricular dilatation that is one finding next important thing is scalping of inferior margin of corpus callosum next thing is a prominent fluoride in the region of aquila which is suggestive of hyperdynamics csf flow and also it will be an indirect marker that you can have a shunt responsive nph but the most important marker will be the calorie angle so people have given this most uh importance because it may also predict the shunt responsiveness of this patient so calories and angle which is less than 90 degree is suggestive of normal pressure hydroquinophilus which is shut responsive then uh you can also actually calculate the csf velocities performing the csf flow analysis studies and when you perform this study you get csf velocities across the aqueduct but what are the cut offs so initially there were articles by sir bradley talking about cutoffs of around 42 but those cutouts were not universal so same set of publishers and authors came up with another article very recently where they talk about creating one own normal gram based on one's own machine so therefore we also performed this is and from that study what we could formulate was that when we did 50 control patients our cutoff was 96 radar is 40. and when we were interpreting our data using this cutoff the interpretation was much more precise as compared to the earlier universal cutoff of 42. so it's better that you perform many studies at least 50 to 100 patient on your machine and create your own normographs this is how we report dementias uh so we give a comprehensive uh finding data set of what routine mri morphologic mri sequences are providing after that we give interpretation based on asl that is artillery spin labeling then we give mr spectroscopy and interpretation what we feed volumetry whole brain hippocampal and after all this we will bring together the major findings from everywhere and at the end we will mention that these features are consisting of or these features are suggestive of alzheimer's dementia or non-alzheimer's dementia and whichever variety you feel like various new things are coming up in the evaluation of dementia this is something which is really growing up and the utility of sequences like resting state fmri role of ai based tools like volumetric tools and role of sequences like dpi diffusion tensor is coming up in a big way so it is still under research but we can also try and contribute from rn because when we see in practical purposes as when we are dealing with actual patients of dementia let's see using these sequences and see how we can interpret these advanced sequences and help in interpretation also to summarize various types of dementia are there but we can try and classify our patient into one of these hippocampalatrophy is one market feature of alzheimer's dementia frontal temporal overtrophy is a feature of frontotemporal dementia multiple macular implants white matter changes pazeka scores of two and three are features of multi-part vascular dementia and all these features taken together like asl spectroscopy everything taken together with volumetric can help us classify our patient into one form of dementia spectrum so to conclude uh imaging is definitely a part of worker for dementia and management may vary with the type of dementia we diagnose therefore imaging with basic and advanced sequences should be performed mri is the modality of choice and we can definitely contribute to the treatment uh with this i would like to thank all of you for your patient listening and to my mentor dr patr for all the knowledge and ideology and shinoya for giving me this opportunity so thank you everyone if there are questions we can consider them now thank you ma'am that was a wonderful presentation with excellent uh points uh curry ma'am yes [Music] so that is measured in the coronal plane so the middle cerebral peduncle is measured in the sagittal plane and the superior cerebellar peduncle is measured in the coronary so it's a very basic measurement so as i told you 3d t1 will be very useful so if your patient is moving or something the first sequence in dementia you can perform is 3d t1c so that will almost 50 60 percent of your reporting can be done with that sequence thank you so much there was one question which was asked for here uh has diffusion or does diffusion but also imaging having advantages yes a diffusion kurtosis is something which is coming up new we are not routinely using it is still a research tool but it will be like defining the margins of actual in fact more precisely as compared to the routine diffusion so if you see that we see that there are phenomena of diffusion reversal by the person with hyper acute impact if you symbolize in time and you repeat the scan you see that the area of impact is lesser but our understanding was the area which is showing restricted diffusion is dead so it cannot be reverted or safe but the area which is hypoperfused is something which is salvageable but when we see that after uh treating or thrombolyzing the diffusion is also reverting which means that there was something which could be saved from that diffusion restricted area as well so the margins of diffusion are not the actual margin of the dictation so this will define the actual dead tissue even better than this so that will not be replacing diffusion perfusion mismatch but that will be improvising the diff mismatch ratio if you use diffusion instead of just dwi thank you so much now we move on uh to the panel discussion with dr deepak parker head of department of radiology at nanawati super specialty hospital mumbai professor dr keshavadas associate dean of the prestigious sri citra tirunal institute for medical sciences tiruntapura and dr mithusha varma consultant radiologist in the department of imaging at nanawati superspecialty hospital mumbai the moderator for this panel discussion is dr gauri ahuja who is also a consultant radiologist from nanawati super specialty hospital mumbai over to you sir yes discussion on dr expansion in radiology so we have with us dr um thank you so much for joining us [Music] and we need to increase awareness [Music] has been very successful in researchable planning and decision making for delineating the safe surgical culture according to you what needs to be done to make functional mri and gti uh first of all i thank podcaster dr mithusha and dr gauri heard the talks and it was so good that i also learned a lot regarding the questions that you asked regarding fmri and dti the the main thing that we have to see is we have to get more reference for fmri so if a radiologist has to get more reference first he should have enough reading in fmra and dti but unfortunately what we are seeing is in most of the medical colleges today they have mri machines but what is being taught is the routine mri techniques they are not actually doing fmr even in very good medical colleges with large number of radiology seats they are not doing fmri and dti so they are not trained because they are not trained when they go to hospitals they have to then talk to the neurosurgeons and the neurologists and the doctors they have to sit in the multi-disciplinary meetings like the tumor board the epilepsy meeting or the stroke meeting and when they sit in these meetings they have to show the neurosurgeons and the neurologist the capabilities of these techniques the fmri technique for example you can save some part of the brain we have been doing fmra since 2005 2006 but even now if you see the number of reference if you see is quite less and i understand that it is basically because we have not been able to actually uh tell the neurosurgeons they they know that fmra is good um and but we have to actually show them more cases and show them that this is a useful technique so once we start doing that i am very sure that they will refer more cases to us and the same is for dti also you have to show them it is useful and then you you have to develop a skill the radiologist should try to develop they have to go to centers where it is being done get some small training maybe one month training in that and then go back to your hospital get the fmri tools and start doing the procedures similarly both these techniques have a lot of software involved in it so you have to learn this software how the processing happens you can can't leave everything to the technologies you also have to learn some amount of this so basically it is a training and to canvas to get more uh reference so these are the two main things that you have to rely i'm sure podcaster will have his opinion on this i'm completely angry yeah i am horrible right yeah i completely agree with you basically it's more you see more you use more you see the applications and unfortunately in medical colleges it doesn't happen people have so much numbers that they want to do the minimum sequences to get to the diagnosis without getting into intricacies the culture of research does not exist in our medical colleges unfortunately i should not be generalizing it i am talking in general uh initiation like yours demands they take real care of going to the depth of the problem the issues research etc in typically in a typical medical college that does not happen people are trying to cover uh the waiting period waiting to let us at least in mumbai waiting for that for a routine mri and medical college is six months eight months etc just just pull out numbers uh 30 40 50 whatever they can and still will have a waiting period of three to six months ct scan with monthly slice coming into two cities can be available in a medical college the waiting period has dropped but still it is eight nine days and nobody really wants to get into adding sequences or trying something new they do run-of-the-mill kind of kind of studies research gets a backseat again because of resources being limited and so typically i mean when i i was i was a medical student the city was not happening everything was happening the barium's ivp is [Music] [Music] so what changes do you think our basic education program structure needs so that we radiologists so it's kind of extension of what uh casey said basically uh our education system requires a complete overhaul uh our time when i did my pc uh doing a clinical pose was a must so we had no choice but to do one year of either six months of medicine six months of surgery six months of gynac etc now if you look at what has happened over the last 20 years the most sort of the branch in field of medicine is radiology so the best talent in medicine comes to radiology but the program has not been tweaked at all if you look at europe or america radiology has become six years to eight years specialty we have remained three years we have to learn everything in three years which is just not possible uh if you look at the american board [Music] with four years of rotations and then two years of subspeciality so my fellows who pass md from here and go there would have to know another six years of radiology which includes four years of generated energy and two years of specialty can be neuro it can be msk it can be body it can be density it could be molecular imaging you have lots of options and also they have clinical rotation so i have a couple of friends children who have gone there they do almost two or three years of medicine before getting into radiology or surgery i know somebody who's done three years of surgery and then got into radio so their clinical acumen their decision making is so much better than our post graduate who has passionately but knows nothing about clinical side radiology is now become integral part of management it is not diagnosis it is management and we don't look at it like that we look at radiology as a picture either on a film or on your backs and that's not radiology at all literally unless we do that we know nothing of stroke we know nothing of uh embolization we do not know pathophysiology we do not know outcomes we just know diagnosis so patients are not supporters patients are patients and they have to be treated wholesome which is not taught to us that is one point that i would like to make clinical training is the second point third is we must talk language whether it is fetal medicine neurologist neurosurgeon then they will respect us and again as soon as their saturation happens they have a proper way of doing the dms etc now we last year i'm sure asa remembers we fought a case in dnp where neurologists and neurosurgeons were allowed to do neurodiverse dna neuro radiology interventional whereas we were not alone that happens because one our lobbying is probably who our training is probably i'm sure has something to add on there and also okay yes so i just would like to add like i said like if flight has a faculty or from like the regulatory bodies which we have so for a neuro or neurologist per se it's very easy to do interventions go into intervention radiology or but at the same time if radiologists want to handle patients who are like a neuro or neurology patient and it is a difficult path to follow so if the pathway can be simplified for even the radiologists either yeah i also agree and i just wanted to add the point what partners are told that many of the bodies national bodies they have the when the decision of the is being taken the neurologists and neurosurgeons take over and they because they are closer sometimes to the political this thing are and they then take decisions and they say that look radiologists we just want the images we need not have the training which is required but we manage the patients much better than the radiologists these are the points that they always raise and they say that we have enough training and it is we who can manage these cases much better so we have always had these problems in institutions like nimhan's reciprocal india instituted all these institutions pga where the neurologists and neurosurgeons always uh tell that you see we have better understanding of the about the patient care and therefore we are the best people suited to look after all these whether it is interventional or diagnostic here is what partnership told the correct point we have to get involved in clinical apart as much as the neurologists and neurosurgeons we should be talking uh neurological terms with them we should understand those things and once we start doing that then they they will understand the value radiologists can give to a team and we should also start understanding to work in that team in all these bodies we should try to project a project we should first of all try to enter these bodies where decision making is done whether it is from the national national board or whether it is a medical council we should also try to get into these things and have our voice that is very very important and i am sure father when he was a president of god we were all trying to do that and we should continue the ira has to play a very important role in that also the subspecialty organizations also should play an important role in this it all goes down to how you can mess yourself yes thank you so much all of you really very valid points i'm sure uh slowly changes will come into place and probably in the future we'll have a slightly different discussion over this thank you so much now let's move on to our very young and the dynamic radiologist what challenges do you think young radiologists face while establishing themselves in their respective fields so there are various challenges but just to point out a few uh is that once we are doing our post graduation which is three years of course we feel that after this is done everything is sorted and we will get a good uh job maybe in a government or a public or private setup and everything is set for us and we can go ahead but what we are facing is there is lot of competition so only doing your post graduation is not enough you have to know that sub specialization is the way ahead because uh if you are just a generalist kind of radiologist you can be easily replaced by the upcoming generation so maybe in two to three years somebody new will come and replace you so that is a quick process so you should always try and do sub specialization like sir said like neuro radiology what i was talking about was that subspecialization is the way to go ahead that is one thing that only doing post graduation is not enough so once we finish our dnb or mb we should know that we will have to get trained for say three to four more years and sub specialize and therefore the best would be skill building so if we can build some forms of skill like intervention ideology that will definitely strengthen the terms because the then the most important threat that all of us are talking about and i'm sure we are going to discuss now as well is ai so ai can easily replace somebody who is just reporting or creating reports but as some a person who is performing intervention or who is using skills will definitely have way ahead and ai will not easily replace that person and even the turf will be more stronger as we are talking now with the skill building so we should be uh aiming to subtraction lines to build skill and also as said and we must agree that we have to be a part of the clinical care system so we are not just reporters or we just not people who are creating reports like we are not giving them some values or something we are a part of management team so we should understand that so we should also correlate we should try and guide the physician and the treating person and once they know that your guidance is important for the treatment of the patient they will also see you as a part of the team so that are a few things which i could point out thank you thank you so thank you for your sharing your experiences [Music] yeah i i just i totally agree about that term is about skill you need the skill you have to get md just gives you a basic foundation after that you have to skill certain things for example in interventional neuroradiology you have to get the skill of by doing more mechanical thrombectomies first you have to assist somebody and then you have to get trained uh you have to do something independent and then once you have done this many number of cases then you become eligible to do mechanical thrombectomy for stroke but how do you get that in india unfortunately we still do not have guidelines if you ask the nmc also who is the person who has enough training to do mechanical thrombectomy nmc is the controlling agency but they don't have it in fact we have even put an rpi now we want to know the kerala area has given an rti to understand this particular thing who is the person who should do it so we have to put this many number of cases have to be done so that you get training the point that once these guidelines are put then the person who gets the skill only can do it in the country anybody cannot do that is point number one the point number two is radiologists should design interventional neuro radiologists and mithusha was talking about interventional radiology just doing the procedure is not enough after the procedure the care of the patient should be under that radiologist because you give it to somebody else and that person then we will have to totally depend on other that person so but rather why can't we start doing the clinical care of the patients and that is why we should have our own bed some one or two or three beds for our interventional radiology cases and we should be treating these patients these are important things the skilling part which dr mithusha told is very very important [Music] [Music] imaging is been becoming an increasingly common tool in modern radiology practice advancing from research styles to the clinical living rooms could you elaborate on the bone of quantitative imaging in neuro radiology yes so um uh dr mitocha also touched upon quantitative imaging in our talk the importance of that now when a patient comes for dementia imaging in most of the centers in india and what i am telling is both private medical colleges everywhere wherever they go we report their mri we look say that there is an atrophy then we write that there is a mild atrophy moderate atrophy or severe some words like this is used mild moderate severe more hyperintense less hyperintense these sort of words are being used now once i was given a talk in a neurology forum on dementia imaging and then after the talk the the many of the neurologists there especially those who were treating neural dementia and all they asked why don't you give an information which is quantitative so from their side from the neurology side itself there are telling because when we do images over a period of say six months once done in that dementia patient after six months the patient comes again then we do another this thing so we actually should be giving them a quantitative information how much of atrophy is happening in the frontal lobe temporal lobe hippocampus and what is the normative data now there are fda approved tools for that why can't we use those things so when we start using quantitative data this is not only for dementia i would say that it is for many other conditions for hippocampal sclerosis for example many other conditions quantitative even tumor volume multiple sclerosis what is the relation load for all these things now quantitative methods are available the neurologist wants to actually understand how much of uh over a period of time how much of damage is happening in the brain and whether it is correlating with the clinical this thing so we should try to adapt it just like artificial intelligence quantitative imaging is something which we should start trying to adopt it in our practice and in our reports also we have to give it probably we might have to increase the charge a bit because we are using this tool fda approved tool and all for which we would have paid but it is always useful for location so these are all [Music] that's the way to progress further and if you don't do that we'll be observated [Music] so thank you so much unless we can provide what customer wants uh yes so thank you once again now partners are coming to a very hot topic in the current scenario artificial intelligence some might consider ai to be a potential threat to water but if handled efficiently it might document our field so what would be your opinion so simple answer is the bottom of the pyramid will get wiped out somebody who is just reporting a run of the meal kind of reporting those people will get wiped out they will become like pathologist the machine is doing everything you have to just sign and you will be paid accordingly so your payments are going to go down so if you're going to report lacking in facts and might cerebral atrophy and small disc bulge and protrusion and strain of acl and my policy strategies and multiple calculi you will not exist because computers will do all that where we will be useful is one interventional ideology to somewhere you where your skill really matters when you are integral parts everything boils down to the same point whether you exist in the circle which is important to the patient if you outside that circle you do not exist because then the computer everything is going to take over you so i always tell everybody what will exist after 10 years we don't know what will not exist the drivers will not exist pilots may not exist radio race may not exist if they keep reporting this what will somebody will exist is who makes difference to this ecosystem so ai is going to come whether you like it or not it is going to do the bottom of the pyramid work whether it is counting the in fact whether it is counting the severity of atrophy whether it is micro calcification that you are looking at whether your account is definitely abnormal what is going to cause the problem to the patient that is where the returns will be useful if you use ai properly it will definitely optimize your workflow it will definitely improve your productivity so if you are reporting 30 40 mris today with ai you'll be able to report maybe 100 but do those hundred matter to you do those hundred matter to the society is what will be important so it will optimize the out workflow of the radiologist it will facilitate the quantitative and quantitative work that we are doing so your productivity will definitely increase so it will be more like uh how you have siri or alexa helping you in your day-to-day activities but everything else you need to do so auto segmentation 3d printing all those things ai will take care but core reporting core skills if you improve radiology will remain with we used ai quite effectively whether it was diagnosing it whether it was detecting it people were doing three four four hundred cd scans per day and it was not possible virtually for the radio or this to go through the whole thing so ai really played so that kind of hasn't the way we use ai we have what is called as ai rapid uh which i showed some examples so that has really improved uh the way we work improve the way we work in the night when recent is reported so errors will go down accuracy will improve but if you don't add up and flow with it you will get outdated yes sir i think you have told everything very nicely the the the quality of your mrs and your cts also are being improved in a very short period so you take a two minutes sequence but the quality of that mr or the the contrast to noise ratio really improves by i am very sure that this is going to improve the radiology workflow and we should accept it and go along with it once we start going along with it we will never feel that okay this is a competition and our job is going to go better better to accept it that is what would be better that it is like augmentation of the radiology it is radiologist radiologist will definitely replace a radiologist without ai so that might be the case so definitely like this volumetry etc where there is all this uh something which is based on algorithms that ai can do much faster though the radiologists can save their time from there and lose the time in keeping like things together and keeping their logic to come into the interpretation of the condition [Music] [Music] so [Music] so thank you so much [Music] think the discussion already we have discussed the important points and uh for the sake of planning for this bringing to this that the sub specialization is the way ahead so neuro radiology is a very good branch to go ahead and there are so many institutes in our country all as well like sri chitra where we have some dedicated courses for neuro radiology so one after we finish our mds and dnps we can target these courses we can be a part of it and in neuro radiology we should always try if we can learn intervention because as i told that ai will not be able to replace that skill set of radiology so that is one thing and also if we can make a point that during our residency itself the newer advanced sequences in mri legs are said like functional dpl asl and all perfusion and how we interpret them is a part of the curriculum so it's not like that only the consultant knows how to do it and resident is like i don't know how to open asl or how how to open dtif at least so they should learn all these things so it will be easier for them to interpret and this will be like a basic skill set they will have when they are coming up after dndmd and then over a period of time say two to three years because neuroradiology is something which even a general radiologist is doing so if you ask somebody that which is the easiest part to report they will say brain we do so everybody like does reporting of brain so that is not neural ideology person so you should go ahead you should learn something it is difficult like metabolic disorder could pediatric neuro ideology so something little more focused so that people look for your opinion for those reports so then you are a neuro radiologist so on a pediatric something you should focus specialize onto it and go ahead with neural networks so practice her and uh if you could add yeah same opinion your question was on perfusion imaging so um yeah perfusion imaging okay so the thing is that you see when the techniques of diffusion imaging came when the technique of aswi came we adopted it as a routine technique in our brain protocols but when profusion is there for the last several years we still are not doing perfusion of course every mri may not be able to do asl but any way we are going to give contrast why don't you do a perfusion also which will give you an information so here why i am telling this in our institution we get a lot of mris which have been done outside where dwa swa and all other sequences would have been done but perfusion is not done and then this patient has to pay again for getting the perfusion done and contrast charges also that is an adding to the patient i think we should make it a routine protocol whenever we are doing uh our mri brain and you you see a lesion whether it is a demyelinating uh lesion if it is of course i am what i am telling is tube effective demyelination versus a tumor or whether there is a infection versus a tumor similar conditions whenever you think that this is required always do perfusion also any of you are going to inject a contrast you need a pressure injector that is the only thing you start doing it and if you have an asl in such cases while dr mithush also showed very nicely the use of asl we always do asl in a flip c dementia and all these cases where we are not injecting contrast where we do asl so perfusion i think should become a protocol as a part of our protocol and this should be a message which should go around in all the radiology circles so that we use it isn't it sir what do you think yeah yeah the information that it gives accidentally also i'm so surprised to see asl being used accidentally many times why did you do it and you the amount of information that it gives oh situation a lot of situations even um there are several situations where perfusion is absolutely useful and i mean i we virtually run it as sequence of choice in every situation yeah it just adds three four minutes [Music] the amount of accidental information it gives is phenomenal [Music] [Music] for joining us and all the delegates out here and uh [Music] thank you [Music] thank you

BEING ATTENDED BY

Dr. Sasikanth Reddy & 825 others

SPEAKERS

dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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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. Gauri Ahuja

Dr. Gauri Ahuja

Consultant Radiologist,Nanavati Max Super Speciality Hospital, Mumbai

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dr. Mitusha Verma

Dr. Mitusha Verma

Consultant Radiologist,Nanavati Max Super Speciality Hospital, Mumbai | Recognitions- Leading Young Radiologist, Radiology & Imaging Excellence Awards by ELETS 2020 & Young Iconic Radiologist Award 20...

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Deepak Patkar

Dr. Deepak Patkar

Director, Medical Services and Head of Imaging, Nanavati Max Super Speciality Hospital,Mumbai | Immediate Past President, IRIA | WHO - Radiology Advisory Board

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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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. Gauri Ahuja

Dr. Gauri Ahuja

Consultant Radiologist,Nanavati Max Super Spe...

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dr. Mitusha Verma

Dr. Mitusha Verma

Consultant Radiologist,Nanavati Max Super Spe...

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Deepak Patkar

Dr. Deepak Patkar

Director, Medical Services and Head of Imagin...

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