 Good morning everyone, I am Dr. Sriraj Hitches, finally a postgraduate from the Department of Radiive Diagnosis and my co-authors are Dr. Yashis Ullasel and Dr. Yuvan Tarbi, I am from Deirajaris Academy of Biological Research and the title of my topic is Midline Shift for Hematoma Thickness as a prognostic factor of mortality in patients with acute subdural hematoma. The need for the study is that acute subdural hematoma is a type of intracranial hematoma which has the highest mortality rate. The mortality rate of acute subdural hematoma ranges from 40 to 70% despite the advancement in management techniques as reported in the previous studies. And literature has shown that the radiological findings on CT like hematoma thickness and midline shift play an important role in assessing the prognosis and determining the surgical management. And midline shift more than the hematoma thickness could mean that the presence of brain edema indicating possible degree of brain injury which may worsen the prognosis. Ames and objectives of the study are to assess the midline shift and subdural hematoma thickness as a prognostic factor of mortality on initial cranial computer tomography scan of the patients with acute subdural hematoma. So coming to the materials and methods, the study was conducted on patients who underwent cranial CT scan due to traumatic SCH in our institution and the study duration was for 3 months. And all of the adult patients ageing more than 15 years were included in the study who have come with traumatic SCH and the people age less than 50 years and with non-traumatic SCH are excluded from the study. It was a prospective study and 61 subjects were considered during the study. And all the data including age, gender and survival status were collected from the database and midline shift and thickness of the SCH in NNM were estimated from the CT scan of the patients during the study duration. So midline shift was measured at the level of the frontal haunts using standard window widths and window levels to evaluate the brain parangama that is 86 and 30. And midline shift was defined as the displacement of the septum pellicidum in relation to the midline in midlines. The subdural hematoma was evaluated with adjusted window width and window length to minimise the underestimation of the hematoma thickness that is of 320. And the thickness of the subdural hematoma and midline shift was compared separately with the survival status. The patient survival was considered as the primary outcome variable. Midline shift and SCH were considered as secondary outcome variables. Descriptive statistics were used to analyse the data in accordance with the objectives of the study. And the data was expressed as mean, minimum, maximum and percentage wherever it is appropriate. And all the quantitative variables were checked for normal distribution. Non-normally distributed quantitative variables were summarised by median and interquartile range. And were compared between study group using the Man-Witney-U test. And the count variables were analysed by the Chi-square test expressing as a number. And the normograms, two of the normograms are used to distinguish these studies. They are evaluated by the area under the curve of the receiver and operating type of stick curve that is ROC. And sensitivity, specificity and predictive values and diagnostic accuracy of the screening test along with the 95% confidence interval were presented. Coming to my results. So as you can see the mean age was 65.3 plus or minus 12.5 years. And among the study population 34 were male and remaining 27 were female. The mean midline shift was 5.45 mm plus or minus 3.68. And the mean subdural hematoma was 3.62 mm plus or minus 1.56 mm. And out of the 61 participants 31 survived. And the mean midline shift and STS difference was 1.83 plus or minus 3.05 mm in the study population. And it rained between 3.10 to 10.70. So this is just a representative image which you know the study with. So here you can see a right counter temporal parietal STS measuring 6 mm. And the midline shift about 8 mm towards the left side. So this is the predictive validity of midline shift and subdural hematoma in predicting survival. This is the ROC analysis. As you can see here the MLS had an accident. That is midline shift has an excellent predictive validity in predicting survival as indicated by the area under the curve 0.936. And the STS thickness had fair predictive validity in predicting survival as indicated by area under the curve of 0.799. So this is a comparison of survival status with midline shift and STS in the study population. There was a significant difference in survival status of patients with a cut off the value of midline shift of 3.94 mm and STS of 3.35 mm. And 90% of the patients died with midline shift of more than 3.95 mm. And it was observed that when the midline shift exceeds that of the STS, the chances of survival is poor. Coming to the predictive validity of midline shift and STS in predicting survival. So the midline shift had a sensitivity of 90.32% and specificity of 90% and diagnostic accuracy of 90.16%. The STS has a sensitivity of 74.19% and specificity of 76.67% and diagnostic accuracy of 75.41%. Coming to the discussion, the study included 61 patients with a mean age of 65.3 and plus or minus 12.5 years and majority were males. And the mean midline shift was 5.45 and STS was 3.62. The mean midline shift and STS difference was 1.83 plus or minus 3.05 mm. So the predictive validity of midline shift was excellent and that of STS was fair in predicting survival as indicated by the area under the curve of 0.936 and 0.799 respectively. And the cutoff value is derived from RFC curve for midline shift was 3.95 mm and that for hematoma thickness was 3.35 mm, above which the chances of survival was poor. So there was statistically significant difference in proportion of survival between those with the midline shift more than the STS and those with midline shift less than the STS. So I'd like to conclude by saying that the sensitivity and specificity of midline shift was found out to be superior in predicting the survival of the patient when compared to the hematoma thickness. And the less chance of survival and the midline shift was more than 3.95 mm than the hematoma thickness. Our uniform definition of grading and standardised method for measurement on clinical CT scan should also be applied to all the future prediction models.