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We are honored to welcome Dr. David usum for

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a spine Imaging border view an interactive

0:43

and Rapid review of as many cases as possible.

0:46

This is a sneak peek into the upcoming neuro quiz

0:49

Bank of 100 brain a hundred spine and a

0:52

hundred head and neck cases that will be offered for the purposes of

0:55

Board review for the Diagnostic Radiology certification.

0:58

and neuroradiology subspecialty certification

1:01

exam

1:02

sign up to be the first to know when it launches using the

1:05

link provided in the chat.

1:07

Dr. Yusum is a neuroradiologist and professor of radiology at

1:10

the Johns Hopkins University School of Medicine.

1:13

He's the author of 350 scientific papers and several

1:16

popular books and radiology and is a series

1:19

editor of the case review series.

1:21

He served as the president of the American society to

1:24

give neuroradiology and was awarded the outstanding education or

1:27

educator award from rsna. We are

1:30

grateful for Dr. Yusum and his support of MRI online and for

1:33

serving as our newer Imaging subspecialty advisor.

1:37

At the end of the lecture, please join Dr. Yusum in

1:40

a Q&A session. We'll try to address as many questions as you have

1:43

on today's topic.

1:45

Please remember to use the Q&A feature to submit those questions so we can get to as

1:48

many as we can before our time is up. And with

1:51

that. We're ready to begin. Today's Board review Dr. Yusom.

1:54

Please take it from here.

1:56

Thank you very much. Well my goal today is to

1:59

get through a lot of cases as main cases as

2:02

possible and pull the audience for their answers

2:05

and make an interactive and fun

2:08

if we can so we're going to take off here with

2:11

spine case of you. These are all new cases that

2:14

I just loaded up recently and they are in

2:17

addition to the 100 spine case of

2:20

U cases that will be available for Board review. So,

2:23

let's Dive Right In and see what we got. All right

2:26

here is case number 101 again the first hundred or gonna be

2:29

offered through MRI online. I'm letting

2:32

you see a T2 weighted image a post-gadim

2:35

enhanced axial scan

2:38

and then A sagittal T2 stir

2:41

image.

2:43

case 101

2:45

and I'm going to start the

2:48

polling. So what do you think is

2:51

the best diagnosis for this case? Is this a Pancoast tumor?

2:55

a neurofibroma a schwannoma

2:59

a lymph node or a synovial cell

3:02

sarcoma. So those are your choices one through

3:05

five number one pankos tumor number two Norm fibroma.

3:08

Number three schwannoma number

3:11

four lymph node, and number five

3:14

synovial cell sarcoma.

3:18

So we've once I hit a hundred answers, I'll

3:21

stop the polling so you can

3:24

see what people have said he got be.

3:27

Fat in your answering the majority of

3:30

people put in Choice number three, but the

3:33

correct answer was by 39

3:36

people answer number two. So

3:39

this is an example of a patient

3:42

who had a norfibroma and you should know

3:45

that this is a lesion that is associated with the brachial

3:48

plexus. This is the anterior scaling muscle anterior to

3:52

the lesion posterior middle scaling muscle behind it and within

3:55

brachial plexus lesions nor fibromas

3:58

outnumber schwanomas.

4:01

Most of the time schwannomers are much more common than neurofibromas.

4:04

And this does have what we call the target

4:07

sign of lower signal intensity centrally

4:10

with periphery that is brighter. So the

4:13

distinction between schwanomas and neurofibromis is

4:16

very hard to make when Imaging and as you know, we rely on

4:19

a few of these findings including the target sign as well

4:22

as if there is Central enhancement, it's

4:25

more likely to represent a norfibroma if

4:28

it's a cystic lesion more likely to be a

4:31

Schwannomi, you have the vesicular sign which is

4:34

small little ring-like structures within the lesion. That's more

4:37

likely to be a schwannoma. But most importantly we

4:40

see neurofibromas in the setting of neurofibromatosis type

4:43

1 a good follow-up question for

4:46

the boards ask you what are

4:49

the seven major criteria of norfibromatosis type

4:52

one. You should know these six or more Cafe Olay

4:55

spots axillary freckling English nodules optic

4:58

pathway glioma a plexiform

5:01

or fibroma family history of

5:04

norfibroma and a skeletal dysplasia.

5:07

So those are the seven major criteria of neurofibroma again,

5:11

Cafe Olay spots actually freckling English

5:14

nodules optic pathway glioma

5:17

skeletal dysplasia family

5:20

history of family member with it and

5:23

plexiform nor far more two or more norfolio. So

5:26

let's move one from this case correct answer was neurofibroma. I'm

5:29

going to stop sharing.

5:31

Can get ready to re-launch my

5:34

poll. So here we have a T1 way T2 weighted

5:37

postgettable name enhance T1 weighted and axial. This

5:41

is actually a T2 weighted image looking at the lesion

5:44

at l45. So case 102.

5:47

What do you think? This is going to be? What's the best diagnosis

5:50

here? Is this a protrusion?

5:53

And Extrusion a sequestrated disc

5:56

an epidural hematoma, or

5:59

does this represent lymphoma? So go

6:02

ahead and start answering the questions. Would you say that this is

6:05

most likely a protrusion Extrusion sequestration

6:08

sequestrated disc epidural

6:11

hematoma or number five lymphoma.

6:14

So we're pulling for those options

6:17

behind the L5

6:20

vertebra. So we've got our hundred answers and

6:23

the most common answer is

6:26

sequestrated disc and that is indeed the

6:29

correct answer.

6:31

By virtue of this lesion this

6:34

piece of disc no longer

6:37

communicating with the parent disk. And that's probably

6:40

most obvious on the postgad scan sequestrated

6:43

discs, these disc fragments often have a little

6:46

bit of a peripheral enhancement. You can see that

6:49

that peripheral enhancement separates it from the parent disc identifying

6:52

this as they sequestration. So in

6:55

the North American Spine Society American Society of

6:58

Norm radiology and American Society of spine Radiology, we

7:01

have agreed to the nomenclature of protrusion for

7:04

that lesion that has a wider base than it's

7:07

peripheral per portion the Extrusion which kind

7:10

of looks like the mushroom cloud with a narrow base and

7:13

a more wide peripheral portion and then

7:16

a specific type of Extrusion where the

7:19

disc is no longer communicating with the parent disc

7:22

and that is the sequestration or sequestrated disc

7:25

the importance of this is that if you were to consider chemo

7:28

nucleolysis to

7:31

Of the disk, that would not work with a sequestered disc

7:34

because it no longer communicates with the disk space

7:37

at the in this case the l45 level. So the

7:40

correct answer here sequestrated disc.

7:43

Let's move on to case 103. I forgot

7:46

to share the results.

7:48

Stop sharing. Let's relaunch.

7:51

Okay case 103 we have

7:54

the CT scan and the Mr. Scan. This is

7:57

a stir image. And this is a postgutominium T1 weighted

8:00

image case 103.

8:04

The question here is the patient has prostate cancer. What's the

8:08

most likely diagnosis of this lesion is

8:11

it myeloma?

8:13

Is it a metastasis from a second primary?

8:16

Is it more likely to

8:19

be a chordoma a giant cell tumor or

8:22

is this a prostate metastasis again

8:25

our choices in a patient who has prostate cancer is this

8:28

going to be more likely myeloma?

8:31

a second primary not prostate metastasis

8:34

chordoma giant cell

8:37

tumor or prostate metastasis

8:40

so the audience is

8:43

Feverishly putting an answers will end

8:46

the pole and this time I actually will share the results with you. It's kind

8:49

of split here and appropriately so but

8:52

the most frequent answer was

8:55

Choice number five, which is actually the correct answer and this

8:58

was biopsy proven prostate cancer.

9:01

Why is this a difficult

9:04

case because it's a lyric lesion

9:07

which is a little bit unusual and I

9:10

have some numbers for you for lyric lesions

9:13

from the standpoint of political lesions

9:16

56% of breast cancer metastases

9:19

or lytic

9:21

14% of prostate

9:24

Cancer metastases or lytic 64% of

9:27

lung cancer metastases or

9:30

lytic and 91% 91% of renal cell

9:33

carcinomas metastases are lytic

9:36

when we shift to blastic metastases 20%

9:39

of breast metastases are are plastic

9:42

62% of prostate cancer

9:45

metastases are elastic 33%

9:48

lung and only seven percent renal

9:51

cell carcinoma. So if you had to say of what

9:54

primaries has the highest rate of

9:57

a lytic lesion, it would be renal cell

10:00

carcinoma and the same thing asked about

10:03

primary tumors with

10:06

blastic it would be the prostate cancer. But

10:09

this ended up being a prostate cancer metastasis. Let's move

10:12

one two case 104 and he's not sharing relaunch my

10:15

poll.

10:16

This is fun. Okay.

10:19

Case 104 so I'm here.

10:22

We have the axial CT scan We Have A

10:25

sagittal Reconstruction from the axial

10:28

CT scan and although this might

10:31

be a crazy orientation. This is actually the coronal reconstruction

10:34

through the

10:37

Posterior elements here.

10:40

So axial

10:43

sagittal and the coronal reconstruction.

10:46

So what is the best diagnosis

10:49

for this lesion, would you call this a hemangioma?

10:53

A giant cell tumor a chondroid neoplasm.

10:57

Is this just djdrome?

11:02

and disease related to the ligamentum flavum

11:07

or none of the above. So our

11:10

choices here are number one Hemangioma two

11:13

giant cell tumor three chondroid neoplasm

11:16

for djd.

11:20

Or none of the above.

11:23

So our poll is we

11:26

hit our hundred.

11:28

People and number three,

11:31

which is chondroy neoplasm was

11:34

the most common.

11:37

Answer this turned out

11:40

to be biopsy proof Hemangioma. So only 16%

11:43

of you got that one, right? But why

11:46

is it Hemangioma? This this bubbly

11:49

bone lesion could be from a number

11:52

of these options the Hemangioma. It's

11:56

much more well defined and benign if we

11:59

had done a T1 weighted scan. I think we would

12:02

have settled this as a bright on

12:05

T1 weighted image. So the correct answer here was

12:08

indeed a Hemangioma very common spinal

12:11

region.

12:14

But let me ask the follow-up question. So I'm gonna

12:17

stop sharing.

12:19

Okay, so at the boards the majority of

12:22

the cases will just just be cases on Imaging

12:25

and then diagnosis but there are

12:28

follow-up questions on a minority of

12:31

the cases. So with regard to the the term

12:34

Hemangioma, is that the right term for this

12:37

lesion? Yes. It's a

12:40

spinal Hemangioma. No, we should be using the

12:43

term cavernous malformation. No, we should be using the term Venus vascular

12:46

mouth formation. No, we should be using the term Vino lymphatic

12:49

malformation or no, we should be using the term Barracks

12:52

is hemangioma the

12:55

correct term for this lesion.

12:59

This is the terminology of the of the

13:02

case. So we've hit our hundred. Let's share

13:05

results.

13:06

So Choice number three?

13:09

It's actually true, you know, we all use the term

13:12

Hemangioma of the spine, but we should know

13:15

that this is not in our you know

13:18

classification. It is

13:21

not a neoplasm and you know, the the hemangiomas

13:24

with the Mulk and

13:27

classification are supposed to be glute one

13:30

positive. These lesions are not good one positives and

13:33

they're not related to the infantile hemangiomas. For

13:36

example, these are capillary or

13:40

Venus vascular malformations. They're not

13:44

that truly neoplasms despite the fact that their Eugene

13:47

classified as such and we use the term Hemangioma. So

13:51

there has been a movement to change our

13:54

terminology on these lesions, but the common vernacular is

13:57

just a calm hemangiomas and as you

14:00

probably know one that the differential diagnosis often is

14:05

just fatty infiltration of the of the vertebral body.

14:09

And you know, when you see enhancement on

14:13

a postgard that's that skin kind of cinches the

14:17

diagnosis of a Venus vascular malformation AKA

14:20

Hemangioma of bone.

14:25

All right.

14:26

Sure. Okay. Stop sharing.

14:30

All right. We're moving one to case 105. Let me read along

14:33

the pole. Okay case 105.

14:36

So we're looking in the cervical spine. I've got a T1

14:39

postgad. This is the same as the T1 post

14:42

guy. Just magnified it for you.

14:46

and

14:47

let's see what the question is. All right, this this patient

14:50

is prostate cancer. What's the best diagnosis

14:53

in this patient with prostate cancer? Is this a prostate

14:56

metastasis? And he man geoblastoma is an

14:59

ependymoma is an astrocytomo or

15:02

most likely a multiple sclerosis plaque so which

15:05

do you think is in this patient

15:08

who has prostate cancer?

15:10

What's the most likely diagnosis prostate metastasis hemanagioblastoma

15:13

appendimoma astrocytoma

15:16

or an MS plaque?

15:22

All right, we've the hundred we got 333 participants

15:26

and we're doing pretty well with getting over a hundred

15:29

results and choice number

15:32

three was a penduloma and that is

15:35

reasonable.

15:36

But incorrect so this

15:39

is in fact a hemangioblastoma and

15:43

why is it a hemangioblastoma rather than

15:46

an eponymous? I have to say that it's certainly

15:49

looks like it's a cyst with the nodule here.

15:52

If we go back to the previous and look at them magnified view

15:55

here. You have the cystic portion

15:58

as well as the Niger portion when it's this small

16:01

insist and nodule I'm much more likely

16:04

to call this hemangioblastoma.

16:07

When it's a larger lesion more extensive

16:10

with larger area of enhancement.

16:13

Then I would more likely to call an impending

16:16

moment. So if it's under one vertebral body segment,

16:19

I think you should really go with hemangioblastoma. Even

16:22

though it is true that he means you blastomas are

16:25

less common lesions than a penduloma

16:28

and astrocytomus also can

16:31

have solid enhancement. We just don't look for it to

16:34

be quite as small and quite as well defined as with

16:37

hemangiblastoma and the occasional

16:40

ependimala.

16:42

So which of these?

16:45

Five items. Well, let me stop sharing

16:48

here.

16:52

Which of these?

16:53

Five items does not fit

16:56

with the other ones. Okay, one of

16:59

these doesn't fit with the others.

17:02

Is that he means you by stoma?

17:05

Renal cell carcinoma pancreatic cysts

17:08

endometers or

17:11

adenoma Sebastian which

17:14

one of these doesn't fit with the other?

17:20

items

17:22

So he made your blastoma renal

17:25

cell carcinoma pickaxe and then I'm backstack tumors or adenoma Sebastian.

17:30

Okay. So this one y'all did pretty well with

17:33

it is indeed Choice number five the

17:38

Numbers one two three and four all are

17:41

all associated with bonhiple in

17:44

down disease, right?

17:46

So you remember that vulnerable lindau disease is an

17:49

autosomal dominant disorder with the

17:52

vhl gene, which is on chromosome 3 you have

17:55

associated with them brain and spinal

17:58

hemangioblastomas within the

18:01

retina. You may have hemangiblastomas or

18:04

angiominus lesions as well. They may

18:07

cause retinal detachment. For example in the

18:10

abdomen. I don't usually talk about

18:13

but you may have your pancreatic this

18:16

or tumors in a

18:19

clearly you have your renal cell carcinomas and

18:22

your kidneys associated with one down disease.

18:26

And no one facts act tumors. So and then in fact act tumors

18:29

about 10 to 15 percent of patients with

18:32

one HIPAA lindau disease will have an endomexic tumors.

18:35

For those of you are unfamiliar with the this these

18:38

are tumors in the temporal bone. Usually along

18:41

the plane of the Petrus portion

18:44

of the bone, even though it's more in

18:47

the mastoid portion and they are unique in that

18:50

on pre contrast T1 weighted images.

18:53

They are bright on the pre contrast t

18:56

one way. It's game a very fluffy ridiculation. They

18:59

do enhance and they

19:02

in fact obviously the vestibular Aqueduct or

19:05

end of in fact

19:07

you should also remember that Von hippo

19:10

lindau disease is also associated with field chromocytomas and

19:14

other cyst adenomas the criteria

19:18

for making the diagnosis is if you have a family

19:21

history of bunnympa lindau and one

19:24

of these tumors

19:26

That I've mentioned that's sufficient. But

19:29

if you have don't have

19:32

the family history, but you have two or more of these type of lesions, then

19:35

you can make the diagnosis of

19:38

people and now disease so I have another question about Von

19:41

hippo Lindo disease. Let me stop sharing.

19:45

Again, a follow-up question, which probably about

19:49

20% of cases at the boards will

19:52

have follow-up questions to just the diagnosis.

19:55

So which is not true patients with vulnerable endowed have a

19:58

25 to 35 percent chance of having a spinal hemantoplastoma.

20:02

patients with a spinal hemangioblastoma have a 25 to

20:05

35% chance of having fun it but lindau

20:08

Number three 25 to 35% of cases of unhippalindo or

20:11

curse sporadically number four all of the

20:14

above are not true.

20:16

Or five none of the above, which

20:19

means that all of them are true. Okay, so

20:22

tricky wording. Be careful. Um,

20:26

I'll let you think about that but which

20:29

is not true patients within now

20:32

have 25 to 35% chance of a spinal hemangioblastoma. If

20:35

you have a spinal blastoma, you

20:38

have a 25 to 35% chance of having money now.

20:42

25 to 35% of cases of unhimple window

20:45

occurs sporadically as opposed to through the genetic

20:48

autosomal dominant root. All of

20:51

those are wrong for number four or

20:54

one two and three are all correct. And therefore the

20:57

correct answer is none of the above.

20:59

All right. All right, see whether I completely

21:02

confused everybody I did indeed. So

21:05

I answer number one is

21:08

correct. We usually say the one third

21:11

rule of Von hippo win down and smino to

21:14

bless them as that one. Third of vhl patients have

21:17

a but I know him and your blastoma and one

21:20

third of patients who present with a spinal hemanager by

21:23

stoma end up having the diagnosis of unhippalina

21:26

disease.

21:28

Answer number three is actually incorrect only 20%

21:31

of cases of vulnerable window

21:34

occurs. Sporadically. Most of these are

21:37

genetic 80% occur through that vhl chromosome

21:40

3 Gene. So the correct

21:43

answer of something that's not true is

21:46

number three. It's only 20% of cases

21:49

upon him now occur sporadic.

21:57

Our case number 106 so every

22:00

once in a while to put in a case, that's not perfectly obvious

22:03

visually and try to see

22:06

whether you can make the diagnosis. This

22:09

is what we call an eye case.

22:12

What is the mechanism of injury for this lesion and we're not identifying the

22:15

legion yet. Is it acceleration deceleration

22:18

injury. Is it a high energy rotation injury?

22:22

Oh, I guess we pull sorry.

22:26

Okay, what is the mechanism of injury for this lesion is it acceleration

22:29

deceleration injury is it high energy rotation is the

22:32

high energy axial compression. Is it hanging or

22:35

is it an assault so for this lesion is

22:38

depicted and I'm not pointing out for you.

22:41

What what is the mechanism of the

22:44

injury for the region? So this is

22:47

not diagnosis question. It's a mechanism question.

22:50

Is it acceleration deceleration injury is a high

22:53

energy rotation injury is it high energy axial

22:56

compression? Is it a hanging injury or is

22:59

it status post assault?

23:03

So lots of people putting in their answers as

23:06

if they know something is correct, and the correct

23:09

answer here is number three.

23:13

High energy axial compression. This is an

23:16

occipital condyle of ocean

23:19

injury.

23:21

Let me see. What a previous. Oh, I only had one

23:24

image. So this is the region here from the occipital condo.

23:27

I have to admit that in the

23:31

25 years of doing noradiology twice the

23:34

resident on call picked up

23:37

the occipital condo injury on the spinal CT and

23:40

I was like, oh man, I'm missed it.

23:43

So good for the resins for looking at this and this

23:46

is something that you will see with motor vehicle collisions as well as

23:49

Falls and it is considered a high-energy axial

23:52

compression injury. It's not rotation and

23:55

it's not a back and forth injury and

23:58

it doesn't occur with hanging or assault. There

24:01

is a classification and I

24:04

think that asking question about

24:07

the type of occipital condyle lesion might

24:11

be something that could be asked in the nerve Radiology

24:14

subspecially certification test, but it

24:17

would be I think punitive for the

24:20

residents. I'm taking the Diagnostic Radiology boards, but

24:23

nonetheless here are the different types by the

24:26

Anderson Montesano.

24:28

Classification type 1 is comminuted impaction

24:31

fracture, which you see the combination here type

24:34

2 is associated with other skull

24:37

base fractures and/or a linear

24:40

fracture. And then what we saw was type

24:43

3 here it's a vast

24:46

off of

24:48

the off of the occipital condyle

24:51

and it may or may not be displaced. So

24:54

in aulsion factor with tension from the AR ligament

24:57

is one of the mechanisms here.

25:01

Okay, we're moving ahead.

25:06

case number 107

25:08

right on target here with where I want to be.

25:11

Okay. So you're seeing a post myelogram

25:14

CT scan. This

25:17

is with the kind of a bone window the media

25:20

the the middle image is more

25:23

of a soft tissue window and this

25:26

is a coronal reconstruction through

25:29

the

25:31

fecal sac

25:33

case 107 you can see the patients already

25:36

been operated on but that's irrelevant to the case.

25:41

and pull

25:46

Real lunchable, okay.

25:48

These images demonstrate. What a

25:51

pseudominingacl.

25:54

arachnoiditis

25:57

scoliosis

25:59

root of ocean

26:01

or cord atrophy

26:04

What are you seeing on these three images a

26:07

pseudominingocele?

26:11

arachnoiditis

26:13

scoliosis

26:15

root of ocean

26:18

or cord atrophy what is being demonstrated

26:21

here?

26:25

So we've hit our magic number.

26:28

Indeed the correct answer is root of

26:31

ocean what you see are the normal nerve

26:34

Roots here and here but if you notice on the right side,

26:37

we don't have any nerve Roots.

26:40

We've got the anterior and the posterior rootlet here.

26:43

Nothing on the contrail side

26:46

and the cord looks a little funny here. This is a not

26:49

such a great coronary reconstruction. But here we

26:52

have a nerve root and here we have a nerve room and here we have a nerve it

26:55

on the other side. It's not just that we're not in pain those nerve

26:58

Roots have been evolved.

27:01

So the correct answer is number four root of

27:04

ocean with absence of seeing the nerve

27:07

roots on the right side, which is the pathologic sign.

27:15

So here's the follow-up question

27:18

for

27:20

root of ocean injuries

27:23

clumpy associated with cat1 which

27:26

is correct clunky associated with c81 com

27:29

key absent biceps reflex.

27:32

herb palsy and triceps reflex

27:36

herb palsy and c67 injury or

27:39

dubercy paralysis and c5c6

27:42

entry. Which of these is correct

27:45

Clump key associate with cat1 injury kumpke

27:48

absent biceps herbs.

27:51

absent

27:53

triceps reflex

27:55

herbs c67 and dubercede paralysis

27:58

and C5 C6, which is the correct.

28:04

So a little bit slower on answering this

28:07

one as everyone's checking the internet and doing the Google

28:10

search for what? Oh, what is

28:13

a clumpy paralysis?

28:16

All right. Well, it looks like it's a little bit slow down. So share the

28:19

results and the most common answer is

28:22

indeed number one and it is the

28:25

correct answer. So come Keys paralysis is

28:28

a root of ocean of C8 and

28:32

T1 nerve Roots. It's an injury of those nerve Roots

28:35

at c71 and T12 and as

28:38

such it is most commonly

28:41

associated with intrinsic muscles

28:44

of the hand weakness. So they talk

28:47

about the claw hand of clumpy paralysis. This

28:51

most commonly occurs that we

28:54

see it with shoulder dystocia around a

28:57

birthing process. However

29:00

in young adults, we

29:03

see it most commonly cycle injuries where

29:06

the motorcyclist goes flying over the handles and

29:09

reaches out the arms to as they

29:12

land and that kind of

29:15

Yanks the shoulder back and you get root

29:18

of oceans. So there's two different types. There's the clump

29:21

key, which is that c811.

29:25

And then you have and that that

29:28

may also be associated with Horner syndrome. So the the abortion

29:31

It's associated with the Horner syndrome is come

29:34

keep browses the herb whoops. The herb duchenne

29:37

palsy is

29:40

a c5c6 palsy where you

29:43

lose the biceps reflexing you have served this

29:46

waving hand characteristic. So it's

29:49

it's not the intrinsic muscles of

29:52

the hand, but it's I'm sorry, it's more the

29:59

More the the limp arm

30:02

rather than the hand so biceps

30:05

reflex is lost with with the

30:08

herb palsy.

30:11

Okay, dubercy paralysis. I made

30:14

this up. Thank you for the five people who went with

30:17

one. I just made up some term, okay?

30:22

Let's move on. So this is case 108.

30:32

This is a patient who had abrupt onset of

30:35

quadriparesis.

30:45

He relaunched a pole here. Sorry about that.

30:48

So what is the best diagnosis is this

30:51

most likely to be multiple sclerosis?

30:55

normalize Optical spectrum disorder

30:59

managedenders like glycoprotein disorder

31:02

mug

31:03

spinal cord stroke or acute disseminated

31:06

encephalomyelitis abrupt onset

31:09

of quadriparesis in the patient

31:13

best diagnosis multiple sclerosis. Nmo nor

31:16

my latest Optica used to

31:19

be called devex syndrome MOG disorder

31:22

against the algodendrocyte protein.

31:26

stroke

31:28

or acute disseminating encephalomyelitis

31:36

All right. So, let's see share the results here.

31:39

So the most common answer is

31:42

stroke. You should recognize that. This is a diffusion weighted

31:45

Imaging. How do we know this is diffusion weighted Imaging really

31:48

bad. Look at the spine. It's not you

31:51

know, the vertebral buys here don't look anything like

31:54

a T1 or a T2 or a stir image.

31:57

What you're seeing is A sagittal DWI

32:00

DTI sequence. You

32:03

got this these bright areas within the spinal cord.

32:06

So this is a spinal cord stroke and

32:09

the history of abrupt one set should have led you

32:12

to that most of the other things multiple sclerosis and

32:15

all the other demonating disorders or not presenting

32:18

like that adem is

32:21

the post viral or

32:24

post-vaccination although immune

32:27

demyonating disorder that can occur in the spine.

32:30

Those are long segment disease remember

32:33

that we talk about long segment.

32:36

Is when we're talking about nmo. These are little

32:40

You know Dots here, which would not go for multiple vertebral

32:43

body segments of either nmosd

32:46

or MOG. It could be Ms. But

32:49

this is a DWI suggesting

32:52

that this is ischemic injury.

32:57

Which is the let me know stop sharing

33:00

here.

33:03

Which of these is the least likely etiology

33:06

of a chord stroke not necessary

33:09

saying the one that I showed you but of all chord

33:12

Strokes, what's the least likely ideology

33:15

aortic surgery aortic dissection

33:18

genetic causes vasculitis or

33:22

trauma, which of the five of these

33:25

is the least likely source of a chord

33:28

stroke. Is it aortic surgery is it

33:31

aortic dissection is a genetic causes. Is

33:34

it vasculitis or would it be trauma? So

33:37

what?

33:40

Okay, so vast majority of you got

33:43

the correct answer of genetic causes aortic surgery

33:46

unfortunately is the most common of the iatrogenic.

33:50

Etiologies for court stroke. It doesn't happen very often.

33:53

Thank goodness. But remember that we do have that supply

33:56

of the

33:59

Artery of adding caveats, which is the most common.

34:03

Source of the stroke this one up

34:06

top in the cervic was buying very uncommon you can

34:09

see that with vertebral water. We dissections occasionally and

34:12

sometimes surgery but the vast

34:15

majority of these are really in the thoric lumbar

34:18

Junction and their secondary to either aortic surgery

34:21

or aortic dissection or aorticoact or

34:24

aortic aneurysms that they're operating

34:27

on and unfortunately, they pick off one of

34:30

these supplies of the artery events

34:33

through the intercostal arteries,

34:37

for example

34:39

Jeanette causes I'm not really sure where I came up with that.

34:42

I'm you know, theoretically Marfan syndrome

34:45

I guess but that's the least common vasculitis is

34:48

a common cause and in fact this patient that

34:51

had that cervical spine actually had lupus and

34:54

a mixed connective tissue disorder

34:57

and had the lupus antibody the

35:00

Lupus anticoagulant factors and

35:03

that was presumed to be the source of the patient cervical

35:06

spine stroke. And as you would imagine

35:09

it's very devastating. This is a 26 year old. I believe

35:12

trauma occasionally Will Will Curry if

35:15

you have aortic transaction, for example

35:19

But genetic causes was the correct answer. Let's move on to case

35:22

109.

35:24

sharing here

35:27

Stop sharing.

35:29

Okay. Okay. So we are

35:32

on case 109 this patient had left-sided back

35:35

pain, you're seeing a set of coronary reconstruction of

35:38

the axial scan. He was a one of the axial scans. You're seeing

35:41

A sagittal reconstruction through the sacrum

35:44

and this is a axial scan with

35:47

soft tissue window as opposed to the Bone window.

35:50

case 109

35:54

best diagnosis for this lesion is its spondylolysis?

35:58

Is its bundle with thesis?

36:00

Is it Bastrop's disease? Is it

36:03

bertolotti syndrome or none

36:06

of the above?

36:09

best diagnosis here

36:11

It's bundle Isis bundle with thesis.

36:14

Bastrop's disease

36:16

bertolotti syndrome or none in the above?

36:24

All right guys are hitting home runs these days. Okay, so

36:27

the correct answer was indeed number

36:30

four. Bertolotti syndrome. Bertolotti's syndrome

36:33

is a syndrome in which

36:36

One or both of the transverse processes

36:39

of L5 articulates

36:42

with the sacrum and Via

36:45

this unusual articulation. You

36:48

have abnormal spinal mobility and

36:51

that can lead to either unilateral bilateral

36:54

or midline low back pain and

37:00

This Believe It or Not There is a gene that

37:03

predisposes you to Burton syndrome.

37:06

It's called the Hawks 10 Gene strange

37:09

thing. But we we

37:13

walk by this quite a few quite a bit.

37:16

And you know, this is the best diagnosis in a outpatient setting

37:19

of a patient who has a low back pain you get the CT

37:22

scan or MRI of the of the lumbar spine

37:25

first off on the MRI. It's gonna be very hard to pick this up.

37:29

On the CT. This is what you're looking at

37:32

this communication between the transverse process

37:36

of L5 with the sacrum.

37:39

And you know, I suspect that we walk by this

37:42

quite a bit in our

37:44

In our practice on in

37:47

the emergency room for those residents taking ER call

37:50

you want to make sure you don't call this

37:53

a fracture. You can see that the edges are

37:56

actually quite bright and this is

37:59

a congenital deformity rather than an acute traumatic deformity.

38:06

Okay, we're moving on to case 110 stop.

38:11

Oh.

38:13

All right case 110 We Have A sagittal T2 weighted image

38:16

doesn't look like it's stir because the fat is still preserved.

38:19

Here's an axial T2 weighted scan.

38:29

Which does not fit with this case?

38:33

B12

38:36

copper

38:37

folate

38:39

nitrous oxide

38:41

or none of the above. They all fit which

38:44

does not let me

38:47

go back just to show the axial scan one more time.

38:50

So here's case 110 sagittal and axial.

38:53

Which of these does not fit?

38:57

Is it B12 is it copper is

39:00

it full weight is it nitrous oxide

39:03

or nothing the above the preceding

39:06

for?

39:08

options all fit together

39:12

so

39:15

All right, almost evenly split I

39:18

stumped quite a few of you on this one.

39:22

So this is let's just

39:25

go back to the previous image. This is a pretty classic for Subacute

39:28

combined degeneration in which

39:31

you have the high signal intensity in the posterior aspect of

39:34

the spinal cord. You notice the two posterior columns here

39:37

and there's often a little spared portion

39:40

right in the midline of the raphe there. But these are

39:43

indeed in the posterior comms bilaterally.

39:47

Of the spinal cord. So we have the diagnosis is

39:50

Subacute combined degeneration. Now we

39:53

have to ask what are the various causes of

39:56

Subacute combined degeneration and

39:59

the answer is that B12 deficiency?

40:04

copper deficiency

40:06

and folate deficiency all can cause Subacute

40:09

combined degeneration in a pattern just like

40:12

that often. The folate is in conjunction with

40:15

the B12. But before this morning I

40:18

checked and said Can folate in and

40:21

of itself without B12 cause Subacute combined

40:24

degeneration. I looked online and said, yes that

40:27

is that does occur.

40:30

The other thing that can lead to

40:33

the pattern of Subacute combined degeneration Is nitrous

40:36

oxide overdose. This

40:39

is laughing gas. And when I

40:42

when I was young many years

40:45

ago, we used to have these things called a little

40:48

whippets and it was like a little canister sized laughing gas

40:51

that you could get, you know, elicitly and

40:54

have a good time in at the party.

40:57

So nitrous oxide overdose or

41:00

use whippets as we called them. These are

41:03

the things that can cause Subacute combined degeneration.

41:06

This pattern of posterior involvement of

41:09

the spinal cord can also be seen in

41:12

demyonating disorders such as

41:15

your mmosd. It's a little bit too long for us

41:18

to be thinking in terms of multiple sclerosis because

41:21

of this, you know, longitudinal extensive transverse,

41:24

my latest appearance. The other thing

41:27

is vacuole or my apath

41:30

Which has in recent years

41:33

been most commonly associated with HIV infection. So

41:36

there is a differential diagnosis. But when

41:39

you see this, you know too little bright stuff

41:42

right in the posterior Columns of the spinal cord.

41:45

That's you know, we're going certainly raise

41:48

these issues in the report so that

41:51

way the clinicians check check those values and

41:54

supplement. This is some in particular

41:57

because the number of vegetarian and

42:01

vegan Americans has been rising.

42:04

not rapidly enough occurring to my wife who's a strict

42:07

vegan, but it has been rising and therefore B12 deficiency

42:10

is something that can be a complicated or

42:14

not complication, but something that vegans and vegetarians have

42:17

to be careful about

42:19

Okay, stop sharing.

42:24

This is case 111 you're looking at A sagittal.

42:29

team T2 US CIS

42:32

image

42:34

high resolution CIS image

42:39

Which does the patient have?

42:43

Chiari 1

42:45

syringohydromyelia

42:47

a chondroplasia

42:50

hydrocephalus or all of the above, which

42:53

does the patient have

42:56

Chiari 1

42:58

seringo hydromyelia

43:00

a chondroplasia

43:02

hydrocephalus

43:04

Or all of Libya all of the

43:07

above.

43:09

Okay, so I mean most of you would recognize the

43:13

the searings here the the syringohydraminealia

43:16

we use the term seringo

43:19

hydromyelia, because purest will say that Hydro. Myelia

43:22

is just Central Canal dilation. Whereas a

43:25

searing says not in the central Canal but

43:28

peripheral to it. A lot of times we can't tell the difference. You might

43:31

also look at the ballooning out of the

43:35

Third ventricle and we've lost our infundibular

43:38

recesses of the third ventricle.

43:41

We got a big lateral ventricle.

43:44

So we have hydrocephalus and we have something to hydromyalia. So

43:47

you got to go with all the above if we look at the

43:50

size of the frame and Magnum here it is small.

43:54

And so that will go along with a chondroplasia, you

43:57

might but I'd shown the head size. You might

44:00

have figured that out as well and on the

44:05

on the Chiari one

44:07

It's a little soft. So I might want to

44:10

change this question. This patient actually had in addition

44:13

aqueductal stenosis.

44:17

So the correct answer here and I'll share the result.

44:20

Was indeed Choice number five all

44:23

the above. Although soft on the carry

44:26

one. We want to you know, when we draw that line from

44:29

the episton on to the

44:32

base on we want to see tonsil herniation

44:36

more than five millimeters. I'm not sure what would have got there. Let's move

44:39

on to case 112

44:46

Okay case 112 is a

44:49

trauma case.

44:51

And it's a cranial cervical Junction.

44:54

trauma case

45:00

Which ligament me?

45:04

Already got answers coming in feet. I mean

45:07

repo because I didn't even show the question yet. Okay,

45:10

which ligament?

45:13

is injured in this

45:15

patient who had cranial cervical Junction trauma. Is

45:18

it the tectorial ligament?

45:21

Is it the anterior longitudinal ligament? Is it the

45:24

posterior longitudinal ligament? Is that delanoccipital ligament

45:27

or membrane? Or is it the apical

45:30

ligament? This is a T2 Wade scan

45:33

and a patient with cranial cervical Junction trauma, which

45:36

ligament is demonstrated to be injured. Is that

45:39

the tutorial membrane or ligament? Is

45:42

it the inter longitudinal ligament? Is it

45:45

posterior longitudinal ligament is that they

45:48

know occipital ligament remembering or is it the apical

45:51

ligament?

45:54

All right. So people are having a little bit difficulty

45:57

on this one. All right. Well, um,

46:00

I would recommend that for those of you who are

46:03

about to take call in the

46:06

emergency room that you might want to relook over the anatomy here.

46:09

So the most common answer was

46:12

Choice number four, which is the correct answer but only got

46:15

29% correct response rate

46:18

the amino occipital

46:21

membrane or ligament is that extension of

46:24

the anterior longitudinal ligament where it comes

46:27

to the skull base and the C1 C2

46:30

level? So that's the area where we

46:33

have our injury. I I put up a diagram

46:36

here. So remember that the tutorial

46:39

membrane is this guy right here and that's the

46:42

extension of the posterior longitudinal ligament.

46:45

But up here this bright area

46:48

here represents the anterior manual

46:51

occipital membrane and that is

46:54

again the extension of the inter longitudinal ligament,

46:57

which usually say ends up to see 1c2 kind

47:00

of Junction there. You have the transverse ligament

47:03

behind the c1c2. So

47:06

back here would be our transverse ligament.

47:11

So what is the let me

47:15

stop sharing and the invest the next question name the

47:18

extension of the posterior longitudinal ligament to

47:21

the clivus. Is that the tech mental ligament is that detectoral membrane

47:24

is at the apical ligament is that the cruciate ligament

47:27

or is that the posterior longitudinal membrane? What

47:30

is the term for the extension of the posterior longitudinal

47:33

ligament as it connects to the clivus, is that the

47:36

tegmental ligament?

47:38

Tectorial membrane the apical ligament to cruciate ligament or

47:41

the posterior longitudinal membrane. So this

47:44

is what I call for the residents. You're five minute

47:47

recall question since I

47:51

just mentioned that to you. Okay. So

47:54

here again the

47:57

tech tutorial man this Arrow should be right here. This tutorial

48:00

membrane is the extension of

48:03

the posterior longitudinal C is post your longitudinal

48:06

ligament. And then this is the tutorial membrane

48:09

going to the this is our clivus. We're a

48:12

little bit flipped in our usual orientation. The

48:15

apical ligament is this guy right here, which goes

48:18

from the top or the apex of the odontoid

48:21

process to the

48:23

Clovis that's the apical ligament and then remember that

48:26

the anterior lanto occipital membrane is

48:29

the extension of the anterior longitudinal ligament up to the

48:32

clitis.

48:34

so case 117 we're going to stick with this theme

48:37

just

48:39

to push you on it. We launch the pole here.

48:42

So here's another trauma case another.

48:45

injury case

48:47

cranial cervical injury

48:49

Which is the non-injured ligament, is

48:52

it the tectorial membrane? Is it the anterior

48:55

longitudinal ligament? Is it

48:58

the apical ligament? Is it the delanoccipital membrane or

49:01

none of the above? All of them

49:04

are injured so which of these is not injured. Would

49:07

that be the pictorial membrane?

49:10

Would be the inter longitudinal ligament would be the apical

49:13

ligament.

49:14

The lanoccipital membrane or none of

49:17

the above? They're all injured.

49:22

All right. So if you look here the there's this

49:25

displacement and the ligament that should be

49:28

going from the top of the odontoid process

49:31

to the clivus, which is the apical ligament is involved. Right

49:34

the inter longitudinal ligament is

49:37

all this stuff here with the bright stuff and then

49:40

It this there should be a ligament connecting.

49:44

From here to here at the c1c2 junction.

49:47

This is all bright. So this nanoccipital membrane

49:50

and I would argue that this goes down

49:53

further. You can see this darker signal here

49:56

of the Interior longitudinal ligament where it was intact. So

49:59

this is involved. This is involved in this is above the next

50:02

question is is the tectorial membrane about so here's the tectorial

50:05

membrane going.

50:08

As I said the extension the posterior longitudinal ligament

50:11

to the clivus and I would

50:14

say this is intact. So the correct answer should be number one.

50:18

We'd want to see it on multiple views, you

50:21

know you want you know, some people

50:24

might say well, what about right at the attachment of the clivus questionable,

50:27

but usually if it's

50:30

going to tear it's like long this portion not and its

50:33

Junction with the climate so correct answer was pictorial

50:36

membrane.

50:39

All right case 114 we're still rocking and rolling here. Oh, I

50:42

forgot to show result.

50:45

I mean relaunch.

50:48

Okay, so we have case 114 and

50:55

This is gradient. Echo

50:58

scan.

51:00

and T2 Wade scan

51:03

T1 not much seen there T2. The

51:06

region is here.

51:10

on the sagittal

51:14

given everything

51:17

one two three. Yeah and

51:20

this

51:22

What's the best diagnosis would this be an ependymoma?

51:25

multiple sclerosis

51:28

post-traumatic myelomaisha

51:30

A cavernoma or none in

51:34

the above?

51:35

Given everything. What do you think? This most likely represents? Is this going to be an

51:38

append a moment Ms. Plaque post traumatic myelomalacia a

51:41

cavernoma or none of the above?

51:46

you

51:47

knocked it. Now the Park good job.

51:50

So this little dot of Darkness here

51:53

in the spinal cord is indeed a little

51:56

focus of Hema Citron in the spinal cord.

51:59

You notice that the court is not expanded. So this that

52:02

could be an append a Moma. It's negative on

52:05

T1 here. It actually has a rim of dark

52:08

signal around it on the

52:11

T2 Wade sagittal scan which is

52:14

typical of cavernoma with the bright

52:17

signal intensity and the dark single

52:20

intensity of the hemocidin around the periphery of it. So this

52:23

is not an acute injury. You don't see any of demon the

52:26

spinal cord. This is an old injury with hemocidro and deposition in a

52:29

cavernoma.

52:34

Okay.

52:37

All right, next Case Case one 15

52:41

T2

52:42

T1

52:44

postgand

52:46

T1

52:48

all these sagittal plane

52:50

case 115

52:53

best category of disease is most likely neoplastic degenerative

52:56

metabolic.

52:59

Infectious or atrogenic something that

53:02

we did as Physicians. What is the

53:05

best category of disease you think this is neoplastic degenerative metabolic

53:08

infectious or

53:11

something one of the doctors did

53:17

All right. So Choice number

53:20

four overwhelmingly, this is indeed this guy

53:23

this and osteomyelitis and you also see this.

53:27

extra Duro enhancing tissue

53:32

You know, I wouldn't necessarily call this

53:35

an epidural abscess. I still like to see some Central necrosis

53:38

to cause something absence. I'm more likely to use the

53:41

term phlegmod for this enhancing tissue

53:44

that is associated with the infection. So you

53:47

got enhancement in the disc, you've got

53:50

abdominal signal and then disc the end plates are all eroded T1, dark

53:53

and Signal intensity. So infectious this

53:56

guy is asking my eyes complex. So it

53:59

is 12:55 with me.

54:02

So I'm going to

54:05

stop the share.

54:06

And start in there's

54:09

some chat.

54:11

Questions. I'll try to get to the chat questions and I'll

54:14

go to Q&A. So with the size of the sequestration point

54:17

to an acute or chronic process, I don't think

54:20

the size helps at all with making that differentiation for

54:24

a sequestration. It can be small they can be large.

54:27

But what you do see is a tend to be a peripheral rim

54:30

of enhancement.

54:31

One Chad. Can you mention injuries

54:34

expected with other mechanisms, please? I think

54:37

this is this what we were when we

54:40

was talking about the occipital condo fracture.

54:43

So the roadational injuries you

54:46

can have rotatory subluxation and to see 1C to

54:49

Junction and specifically talking about that. Obviously. We

54:52

know the mechanism for The Hangman's fracture with

54:55

the pedicle fracture of C2 and you

54:58

have the Jefferson fracture of C1 where

55:01

it's kind of a burst fracture. So there are different mechanisms specifically

55:04

for what we usually talk about cranial cervical

55:07

Junction injuries. Candy jerem

55:10

came changes mimic a type one occipital

55:14

fracture

55:16

Um type one is is commonuted.

55:19

I don't I don't think that that's

55:23

not where you usually have degenerative change that you would have

55:26

little ossicles. For example.

55:28

Question 106 not sure what that's about hyperacute Ms.

55:31

Plex can show a restricted diffusion.

55:36

I would agree in the brain. We

55:39

don't have I think enough

55:42

experience in the spinal cord to be

55:45

able to say that they're restricted. You're usually so small

55:48

and DWI is so

55:52

Is is so low resolution that I

55:55

don't I haven't seen literature about spinal Ms.

55:59

Blacks showing restricted diffusion. I would still be

56:02

very worried about according part 51254. Thank

56:05

you for that. I don't know what that means. Thank you for attending very

56:08

good. Thank you for your time. Okay.

56:10

Looks like that's um again, let me

56:13

go to the Q&A.

56:14

Can you address ectopic gas

56:17

in the spinal canal? So ectopic gas

56:20

and spinal canal usually means obviously vacuum phenomena, it

56:23

can occur in the intervertebral disc,

56:26

but it can also occur in the facet joints and therefore

56:29

you might see it laterally you may see it.

56:33

Centrally um, it is

56:36

an indicator of a degenerative

56:39

change. Not only that but what

56:42

there's a statement that people making that as

56:45

you should not see vacuum cleft phenomenon in fused

56:48

spines because it shouldn't

56:51

be moving and it and trapping nitrogen. So

56:54

if you see a topic

56:57

gas in a spinal fusion case, it usually means

57:00

that the spinal fusion has not taken and it's not truly fused.

57:03

Can you please tell me in detail about gradient coils used

57:06

in MRI skin? That's a little bit removed.

57:09

From what?

57:12

from

57:14

what I want to talk about but you know

57:17

the there are a lot of we we tend to use small coils

57:20

in tandem in order to

57:23

maximize signal to noise and yet have

57:26

enough coverage to be able to cover the cervical thoracic

57:29

region. For example in an MS case.

57:32

Usually we're doing it with like 30 centimeters 24

57:35

to 30 centimeters field of view and you

57:38

have to have a lot of parallel coils used for

57:41

for the spine if it's right in with usmo. Yeah.

57:44

Thank you very much. I hope so how how many you

57:48

make a difference between apical ligament injury and a manual occipital

57:51

one behind the one behind the other. So the land of

57:54

occipital membrane is anterior to the apical

57:57

ligament the apical ligaming you would see it the top of the odonto

58:00

process going to the clivus as

58:04

you saw in the diagram the Atlanta occipital

58:07

one follow the inter longitudinal ligament.

58:10

It's it's interior to apical agreement. Thanks

58:13

so much greater.

58:14

Do you put in your report the potential for spontaneous regression

58:17

of the disk Extrusion?

58:20

So with respect to the sequestrated disc

58:24

over the course of time they do.

58:28

A resolve and in fact

58:31

the presence of that enhancement around that sequest rated

58:34

fragment is a good sign because it means granulation tissue is

58:37

growing in and it can result. Basically. It doesn't

58:40

matter what we're showing on the Imaging. What's the patient's symptoms.

58:43

Is it referable to that disc herniation. I've seen

58:46

horrible disc herniations and patients who are symptomatic at

58:49

a different level in a different side. Can you get degenerative gas

58:52

in a vertical body when you get degenerative gas and the vertebra by you

58:55

worry about Customs syndrome, which is

58:59

Potentially from a vascular necrosis of

59:02

the vertebral body. However, the most common source of

59:05

gas in a vertebral body is from the disc going up. But if

59:08

you don't have degenerative change and you have the disc the

59:11

gas in the center of the virtue by consider caissons

59:14

disease sickle cell disease a vascular

59:17

necrosis of Liberty. What do you think about resorption of

59:20

herniated discs? What is the criteria for full resorption?

59:23

Mmm, I'll pass on that one. I don't know what you

59:26

mean by full resorption. But obviously if you

59:29

don't see it, I guess that means these option.

59:32

Can you explain in the last case why it is

59:35

not a metastasis. So the last case is centered on the disc. It

59:38

has high signal intensity in the disc.

59:41

It has enhancement in the disc. That's not a

59:44

site where we usually see metastases and it had the epidural phlegman,

59:47

which is unlikely to

59:50

be with a metastasis most metastases

59:53

are to the bones. They're not

59:56

to the spinal cord and they're not to the epidural space.

60:00

All right, I think well, they're like to

60:03

pretty well with answering all this questions. Let me see. Can you please describe the traumatic injuries

60:06

in rheumatoid arthritis regarding cranial cervical Junction? So not so

60:09

much the trauma but clearly the transverse ligament becomes

60:12

lacks, you have that possibility of linox Reno

60:15

axial subluxation greater than

60:18

three to five millimeters at the c1c2 junction and

60:21

it's more of an inflammatory process

60:24

rather than a traumatic injury. Does it

60:27

predispose you to having some laxity at c1c2 it

60:30

does but that combination of

60:33

trauma and ra is not as much thinking what

60:36

is the instance of solitary spinal without intracranial

60:40

reasons, so it wouldn't be the HL if it's only

60:43

a solitary spinal without a family

60:46

members. That's what makes the BHL is the family

60:49

history with a single command your

60:52

blessedoma as it were I would say it's probably

60:56

less than 5% will present as just Smiley

60:59

major blastoma and family member

61:02

with financial window. That's pretty uncommon.

61:06

All right. I think that doctor you

61:09

said I I commend you

61:12

15 cases 15 questions. That was that was

61:15

fantastic. Thank you so much for leading us through

61:18

this case review and thanks for everybody for participating

61:21

in this new conference.

61:23

You can access the recording of today's conference and all our

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61:34

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61:37

Neurography of the cranial spinal nerves below

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Don't forget the quiz Bank.