 I'm here with Dr. Schupack, we've got the trifecta up on the far left, the T1 contrast in the middle, the flare or fluid attenuated inversion recovery image, and on the right the T2 spin echo image in a 56-year-old woman with a headache and a droopy eye. I'm going to scroll while you start to elaborate on the finding of importance. Okay. Well, you know, a droopy eye, that's kind of a serious problem, right, meaning if you go to your doctor with a droopy eye that's not working and they tell you that you're tired or depressed, you need another doctor, right? I mean, this is a situation where something's going on and we got to come up with something, okay? So your droopy eye differential, you got to sort of have one in your mind, okay? One thing would be, could it be a third nerve palsy, and that's a serious problem, right? It could be an aneurysm, something of that sort. Sure, and we'd go to the third nerve area here and look around and we don't see much there. That's right. That's something you've got to look for. Now, other question is, which eye, which side, okay? Because sometimes what will happen is one of the people will be small and the other big and that will be mistaken for it. So you've got to really kind of look at your sides here and how it's described. It's a left droopy eye. Yes, because an unsophisticated observer might describe it as a dilated pupil but actually the action's on the other side. Like me. Okay. Like me. So you've got to think about a droopy eye. In this case it's a headache, right? So in this case, so the other thing in your differential is how about Horner's syndrome? Do you guys remember that, ptosis, spiosis, anhydrosis? I remember that. I told you that. But didn't you forget? Now you remember again. I forgot. I'm an old internist. So the place to look right now is we've looked at the third nerve, looking for an aneurysm. So that's a biggie. We did look for the third nerve. We don't see it. We didn't see an aneurysm. We're heading down because the next stop is the carotid canal. All right. Let's check out the carotid canal. And we have action there. We do have action. Right there. So you can see that in the carotid canal there's sort of a meniscal appearance around the carotid, okay? And so carotid dissection as a cause of Horner's syndrome, ptosis, ptosis, anhydrosis, okay? Classic, all right? Kind of easy to miss if you're not thinking about it. But if you see droopy eye on a history, that's one of the two or three things that you're going to have to come up with. And you just cannot miss this if you're on urgent care or you're a call. Absolutely. This is one of the basic basics. I don't care if you're a general rad, if you're a neuro rad, if you're a fellow, if you're a resident. It's terrible if you miss this finding because it is treatable and it can have drastic consequences like a stroke. It does have this kind of arcuate, meniscoid look to it. I've blown it up so our audience can see it a little better and you can see the opposite carotid. And then if I go up and we talked about earlier in our introduction, what's real, what's important, what's not important, well, yes, there are some high signal areas in the ponds, but people with hypertension as they age get those. These are areas of gliosis. They're completely unrelated to the patient's problem. They can throw you totally off the track. And Dr. Shoupek, being a neurosurgeon and being a neuro imager has honed right in on the area of interest, which you can follow longitudinally up and down. It goes right into the pietrus portion of the left carotid artery, and this is a left carotid artery dissection. You better not miss it.