 Hello everyone, this is Dr. Antika Maiti, finally a resident of Grand Coffin Medical College and Sir J.J. Group of Hospitals Mumbai, presenting a paper on the role of MRI in diagnosis and early detection of complications of COVID-associated neopermyosis, a case study of 107 patients, under the guidance of Dr. Shilpa Dombkornur, Ma'am, Professor N.H.O.D. and Dr. Shivraj N.Bulesar, Associate Professor of Grand Coffin Medical College and Sir J.J. Group of Hospitals Mumbai. The name of the study was where to evaluate the role of MRI in diagnosis and early detection of complications of COVID-19-associated neopermyosis in 107 patients in a tertiary care hospital in Mumbai and comparison of MRI over CT. Introduction, the emerge of the black fungus. The second wave of COVID-19 pandemic witnessed an increase in the number of opportunistic fungal and bacterial infections, the most threatening of them being invasive neopermyosis and aspergillosis. Now, neopermyosis are the very presentations depending on the organ and the most common being the rhino-orbitocellular form of neopermyosis. First by fungi of the order neoporals, including rhizopress and aspergillus, et cetera, these fungi spread most commonly by airborne route through the inhalation of fungus for angiophores or by contact directly through open wounds of neopoza. These fungi never cause disease in the immune-competent individuals. However, they can cause life-threatening disease in the immune-compromised patients. Factors favoring the disease progression in COVID-19 patients include the already weakened immune system of the COVID-19 patients attributed to the unregulated use of system asteroids, antiviral system and immunomodulators coupled with uncontrolled blood sugar levels over-enthusiastic use of oxygen and elevated blood peritone levels as a part of the inflammatory process. Typically, the primary disease is initiated in the upper of the airways, progressing quickly from sinusitis to rhino-orbitocellular neopermyosis and then pulmonary infection by spreading rapidly via angio-invasion. Now, the role of MRI in detection and early management as we have seen before, my course spreads rapidly to the contigo sites by angio-invasion and causes rapid tissue destruction. If not treated aggressively, it can potentially be fatal. So, MRI is an important role as it delineates the soft tissue structures well. The fluid-sensitive sequences of MRI are such as star and ferritic inflammation, such as myositis, periostitis, and associated edema and osteomyelitis of sinuses and the adjacent bones. Orbit-dedicated sequence of MRI is used for detection of optic neuritis, peri-neuritis, and MRI also helps in detection of the extension of the disease process beyond the nose and paralysal sinuses. MRI helps in early pickup of the intracranial spread and complications such as imparts, abscesses, dural sinus thrombosis and aneurysms, et cetera. Since an SPC sequence of MRI is extremely helpful for evaluation of the cranial nerves, MRI angiography and denography provides additional information regarding the vessel involvement. Now, advantages of the MRI over CT as we discussed, there's artificial characterization of MRIs unparalleled. It helps in early detection of extrinsic spread, bone edema, and infarcts. MRI is more informative regarding decision-making about patient management, and MRI can also be done in patients with relative contraindications to CT like drug allergy and asthma. Now, what are the advantages of CT over MRI? Although few, but it is extremely crucial. A CT is better for evaluation of the bone destruction. CT is faster, easily available, cheaper, and hence it is utilized for the follow-up imaging in these patients. Methodology, a single-center observational study was conducted between March, 2021 to July, 2021. Patients were conveniently selected, such as those with symptoms and signs or who were confirmed cases of rhinoabitocerebral near-core mycoses with past history of COVID-19 infections within the last three months or having concurrent active COVID-19 infection that is either via rapid antigen or RTPCA positive, and such patients were included in the study with objectives to characterize clinical epidemiological profile of these patients, the role of radiological evaluation, plan of management, and finally to see the outcome. Data was collected by history-taking, customized facts, and evaluation of laboratory reports, analysis of the collected data was tabulated in Microsoft Excel sheet. Results were grouped under clinical epidemiological profile, role of radiological investigations, other investigations, the management, and finally the outcome. Under clinical epidemiological profile, the age for post-common age to being 37 to 60 years means for the most commonly affected, compromising around 76% of the study population symptoms, the most common symptoms with which patients presented were nasal discharge, pain over face, eye, orbital swelling, and decreased vision. Duration of symptoms varied between two days to three months on an average, it was between 70s to 15 days. The time duration between COVID-19 development of symptoms, average time duration was 15 days, though it could vary from four days to a few months. Associated comorbidities, the most common comorbidities being diabetes malitis. About 92% of the patients had diabetes malitis with 18% of them being in diabetic ketoacidosis. Hypertension was seen in 23% of the patients. Treatment history related to COVID-19 infection. Stroids were received by 70% of the patients. Remdesivir was received in 67% and oxygen was received by 82% patients. Clinical examination findings, nose and the PNS findings. In the most specific examination under nose and PNS examination was the presence of blackish discoloration and nose and eyes and blackish crusts and nose and pyrolysis. Other common findings included nasal secretions, bus, mucus condition, polygoidal mucus, cobblestone mucus, et cetera. Opulofinase included proptosis of thalmoplegia and periorbital edema. Neurological findings included duty revision of the GCS, low motor neuron type of perion of pulses, hemiparices, et cetera. In oral cavity examination findings revealed in some patients, palatal perforation swelling in the palate, periorontal abscesses, oirental fistula, palatal erosion, blackish estuarine palate and the pustules on the gums. Role of radiological industry evaluation. Radiological evaluation was done by CT scan of a brain orbit and PNS and MRI of brain orbit and PNS. CT scan was done with 128 slice even CT scanner with dedicated soft tissue and bone window for PNS and orbit and seven drum window for brain with concussed if there was no puncture indication. MRI of brain PNS and orbit, sequences used for brain screening was done with diffusion and susceptibility weighted and plaid imaging with dedicated orbit and PNS sequences with four star D1 and D2 action, post-concuss D1, fat set and all the planes for orbit with or without post-concussed brain sequences as necessary. MRI angiography, veno-grapiensis were added if needed. Parameters on which the other which the CT and MRI findings were reported were bone erosions. Bone erosions were seen in SNH1 cases accounted for 94% of the static population and absent in seven cases which was merely a 6% of the static population. Most common bones were ordered were the medial and postrolateral walls of the maxillary sinuses. Now in the papillatia bobe septae of death, murder, aerosols and curb reform plate. This common involvement was seen of the ansonite crosses, mesolderbinates, floor of the orbit, walls of frontal and spinoid sinuses. Sinusite is most common presentation being sinusitis. Pilar to van sinusitis was seen in 87 patients which accounted for 81%. Most common sinus involved was the maxillary sinus. Least common sinus involved was the frontal sinus. Extra sinus spread has been categorized as the according to the area of involvement which is orbital extension seen in 54%. Terecomaxillary and terecopalytic cossa involvement seen in 34%, 37%. Intracranial extension seen in 47%. Spinopalatin, pormin and pormin were termed the involvement was seen. Less common. Now this is a CT scan and MRI of a patient who represented very early during the milk or mycosis disease spread. The CT scan showing bone window and actual postfrontal soft tissue window. Bone window is showing multiple sort of bone defects and erosions seen in the bilateral curb reform plate, bilateral medial walls of the orbit, the laminar papillatia, bobe septae of the ethmoids and the erosions in bilateral, medial and postrolateral walls of bilateral mycelary sinuses. Soft tissue window is showing soft tissue obfuscification of the bilateral mycelary and ethmoid sinuses. Now the patient underwent a test and postoperative MRI of this patient shows there is residual persistent disease in the bilateral mycelary sinuses and right ethmoid sinuses and also there is extension of the disease process into the intracranial space involving the left basic frontal lobe and with extensive peridational edema in the left basic frontal lobe. Now this patient who actively managed the surgical and medical management and he has been under continuous follow-up with us, the recent follow-up scan of this patient of June 2022 reveals this, that there has been a near complete respiratory disease process in bilateral mycelary sinuses and the total resolution of the disease process in the left basic frontal lobe. Hence the role of the active and prompt management including the imaging modality and the surgical and medical management which plays a key role in the survival of these patients. Bone erosions and sinusitis, some more images showing the bone, extensive bone erosions and some patients who are in this patient, there is extensive erosion of the flow of the bilateral mycelary sinuses extending up to the alveolar process of the mycelar and the palate. Here is also one patient showing bone erosions and the peripheral form plate, ethmoidal bone septae and the medial wall of the right orbit and the medium wall of the right mycelar and the right laser turbulence. The soft tissue went up the same patient showing extensive soft tissue opacification of the bilateral mycelary in ethmoid and frontal sinuses with hyperdense content within the disturbable conglolate energy. This patient had pan sinusitis with extension into the left terribum mycelar fissure. Now, am I evaluation of this patient by starboard and post-concast even fat set images is showing there is extension of the inflammation into the right orbit leading to right orbital cellulitis, right optic neuritis and hyperindulged signal in all these extracular muscles of the right side of the stem of myositis. Post-concast even fat set images confirms the same showing right orbital right optic neuritis, perineuritis and myositis. Now, the post-concast their images of the same patient is showing the post-concast enhancement of the packing and inches of the left temporal lobe suggested to the packing and inches within our NGO additional information will update of the internal cerebral arteries. That is, there is annulment dilution of the cavernous segments of the right cavernous in ICA. Now, one day later, the GCS of this patient dropped and follow-up CT scan reveal hyperdense attenuation in the particle of the bilateral cerebral hemispheres with the end syruvial fissures for extension of the hyperdense blood attenuation into the bilateral ventricles and third ventricle. The patient also had developed some amount of hydrocephalus with very ventricles around the lateral ventricles. The patient was immediately taken up for DSA and NGO where it was revealed that the patient had an aneurysm of the cavernous segment of the right ICA. The patient was actively managed with the foiling of the aneurysm in DSA, but the patient could not be right and succumb to death. Some more images of CT scan of a patient showing extensive soft tissue involvement of the sinuses of the ethyl moiden right spinoid sinuses with bone erosion some of the medial walls of the ethyl moide sinuses. The post contrast MRI images with D1 post contrast action showing extension of the disease process into the right orbit leading to right optic baryneuritis, myositis extending up to the right orbital epics. D1 post contrast implant images also showing the right orbital involvement with the orbital cellulitis surf or images showing the abnormal hyperventil signal in the right optic nerve and the right extracular muscles such as to work myositis and right optic neuritis post contrast flare images is showing the focal vacuum and engine enhancement along the right busy frontal lobe and the right temporal lobe such as to vacuum and engines. Now we come to the complications and the role of MRI detection of these complications applications has been divided into intraorbital complications, intracranial complications and other complications predominantly picked up by MRI. Infra-orbital complications is graph is showing the intra-orbital complications and its frequency. The most common intra-orbital complication being the orbital cellulitis followed by optic nerve involvement, optic neuritis baryneuritis, extracular muscle involvement, orbital epics involvement followed by others such as inferior orbital and superior orbital fissure involvement intra-orbital axis superior permigraine involvement, orbital period of stentas, et cetera. Among the intracranial complications we see the most common being ischemic infarcts and meningitis followed by cavernous sinus thrombosis IC and thrombosis IC aneurysm followed by SH and IV due to the rupture of aneurysms in intracranial nodes involvement, the element echopulmonary of the cranial nodes. The other intracranial complications are meningitis and capillitis, abscess formation, lower extension of the inflammatory process. Also images of the intra-orbital complications are, this is an image of post-fascist status of the patient. T2 core and T1 fax at images are showing post-fantast hyper-intensities of this right optic nerve and the right extroplar muscles suggestive of right orbital cellulitis, optic neuritis and myositis. And also there is a focal leptomanageal enhanced strength in the right basic frontal lobe suggestive of vacuum and intratas. Another patient showing similar features in the MRI with T1 fax at post-fantast imaging. So showing right orbital cellulitis, optic neuritis and perineuritis with right orbital periostitis. This is the right orbital post-fantast enhancement on T1 post-fantast imaging suggestive of orbital periostitis. Another patient CT scan and MRI findings of another patient who had gross left-sided proktosis on CT scan it was evident the patient had preceptile edema, the extension of the inflammatory process into the left orbit suggestive of left orbital cellulitis, preceptive cellulitis with grossly deformed left glow. On MRI these findings were confirmed and even better delineated showing left-sided or preceptile cellulitis and orbital cellulitis with preceptile edema with deformation of the left glow with left-side orbital cellulitis, right? Left optic neuritis and myositis. Star core images showing this conforming the same with abnormal hyperintensive signal in the left optic nerve and the left extraculae muscles conforming the diagnosis. Another image showing the intracranial complications as on flare post-frontal imaging this patient had a focal packy menaceal enhancement along the right temporal lobes and right cavernous sinus thrombosis. Another CT and the diffusion weighted imaging of another patient showing there is diffusion restriction along the posterior aspect of right parietal lobe and the right occipital lobe and the suggestive of vasculatic impact on CT scan this appears to be hypodensity regular in defined areas in the right post-reparation of an occipital lobe which will be confirmed to be in fact on MRI. Hence this in fact were early and easily picked up on MRI as compared to CT scan. Imaging findings of CT and MRI of another patient on whom ill-defined hypodense areas were seen in the left temporal lobes and which were non-enhancing on MRI it was confirmed to be left temporal lobe collection and extinction of the disease process this clearly depicts non-enhancing areas with very poor enhancing enhancement on T1 post-contrast imaging on flare imaging it shows perillational edema on post-contrast flare imaging there was focal vacuum and angel enhancement along the left frontal and left temporal lobe suggestive of vacuum and enginitis. Other complications which were predominantly picked up on MRI the most common of them being the teregoid masseter muscle and temporonase muscle involvement and manositis temperamentable joint collection osteomyelitis of the disinvores wall of mancillary sinus periostratus orbital periostratus cortical laminar necrosis masticator space involvement CVST etc. Other investigations including microbiological and histopathological investigations for microbiological and histopathological examinations can only confirm necromycosis and the species involved in the disease microbiological investigations were beneficial to find out the drug sensitivity so as to comment on sensitive resistance of organisms which were isolated from a given specimen Gramstain, curexmer, culture, HPR with periodic acid ship and rubbery methanomics case change for performance. Treatment, surgical management and medical management surgical management and medical management were mostly used combined form. Surgical management include FIS with debridement plus or minus orbital excentration with the drainage of the brain access as and when required the decision was made on case to case basis medical management included injection amputalism with or without post-opinion. Now images for some of these complications are right temper this image showing right temporalis masseter and the terepore muscle myositis and right zygomatic this osteomyelitis this post contrast T1 fat set image is showing post contrast enhancement of the lesser wing of the bilateral lesser wing of the spinal and also disturb or bilateral lesser wing of the spinal and osteomyelitis another patient in whom MRE is showing left paraffin gel collection the disease process is extending to involve the left mastigator space the temporalis the teregoid and the masseter muscles and on this image the extension of the collections is also seen to be involved in extending up to the left temporal mandibular trial leading left temporal mandibular trial osteomyelitis CT scan of the patient here it is depicting the left cavernous sinus thrombosis and the left ICF thrombosis another patient in whom the CT scan was showing bilateral ACA in parts with bilateral in parts of the ganglion capsular regions another patient in whom the flare post contrast image is showing pachymenin gel and left to menin gel enhancement along the bilateral vasifrontal lobes with peripheral enhancement of the region and the right vasifrontal lobe on diffusion weighted imaging there was diffusion restriction of the right vasifrontal lobes the distable absis formation and right vasifrontal lobe now we come to the outcome the outcome of this patients was the most crucial of this of this study since now from the overall death rate of the patient was found to be 17% and overall survival of these patients was found to be 82.2% now outcome was also correlated with the patients who had under one surgery it was found that the percentage of deaths in patients who had under one surgery was extremely low around 11 to 12% and the percentage of patients who did not undergo surgery the percentage of deaths in patients who did not undergo surgery was around 82 percent hence we can clearly state that the active management of this patients starting from the imaging to surgery surgical and medical management data cushion tool in the reducing the percentage of deaths and improving the overall survival of these patients hence we can include in this study 107 patients were evaluated in which 76% were mails most common presentation was by paranesial sinuses involvement most common radiological finding was pan sinusitis where my excellent sinus involvement was most common where most commonly eroded born being the medial and postural lateral walls of the mycillary sinus laminopaculation etc spread of the family into the contiguous structures led to most of the complications the most common intracranial complication being ischemic impact meningitis followed by carotidin sinus convulsus whereas most common intro by to the complication being orbital cellulite is followed by optic nerve involvement there was a definite role of MRI as we've seen it helped in early detection of the disease as well as well as the spread of the disease present beyond the parallelism sinuses into the adjacent important structures MRI also helped in early detection of complications as well as the life threatening one such as in part cerebritis brain abscess etc which was picked up on CD at a on later date the MRI also helped in rapid rapid and aggressive management by early pickup of these complications now this rapid pick early pickup the early diagnosis of the complications combined with surgical and medical options later crucial role to improve the survival of the patients thus the early detection of competition was beneficial for improving the survival of the patients CT definitely was a first-time modality because of its wide availability and being faster and CT also helped in evaluating the bone destruction better CT had a crucial role in operative and pre-operative management for evaluation of bony landmarks and vital structures then CT was also helpful for the call of imaging in these patients these are my references thank you