 Good evening, everyone. Today I will be discussing my paper on MRI features of COVID-associated rhino-orbito-cerebral mucormycosis. It is a case study of 20 patients and I am junior resident in Department of Fatal Diagnosis and Imaging, MSBHU Varanasi. So as we all know that India is currently seeing a massive rise in cases of COVID-associated mucormycosis, Hino nasal disease being the most common. Mucor is an opportunistic fungal infection that causes acute fungal disease that warrants early diagnosis and treatment and MRI plays an important role in mapping the disease extent. There are only some case reports and only few case series in the literature that explain the MRI features of ROCM. So the objective of our disease was to describe the spectrum of MRI features in 20 patients with post-COVID ROCM. What were the materials and methods? So this study was concluded in SSL Hospital, IMSBHU from May 2021 to June 2021 in Department of Radio Diagnosis and Imaging. It was a cross-sectional observational study and a total of 20 patients were enrolled in the study and their MRIs were evaluated. Inclusion criteria for our study was all the post-COVID patients who had Sino nasal disease and which were microbiologically proven to be the cases of rhinoorbital cerebral mucormycosis. Exclusion criteria were all the patient who had symptoms but microbiologically they were negative who had undergone intervention for the disease and contraindications to MRI like claustrophobia and metallic implants. Imaging protocol MRI was performed on a 1.5 Tesla scanner. Agile scans were obtained from T2 vertex whereas coronal scans from tip of nose to the cerebellum and the sequences that we took were T1 weighted, T2 weighted, axial flare, coronal stir, DWI, ADC, SWI and post-contrast even weighted images. Now for the scan evaluation which was a very important part of our study we followed a compartmental approach. We evaluated Sino nasal, extra sinus, orbital intracineal disease separately. For the Sino nasal disease we mainly looked for the mucosal thickening, T2 hypo intense content within the sinuses, what was the pattern of sinus mucosal enhancement and whether there was any bractaminate sign present or not. For extra sinus we looked for disease extension into the premaxillary facial tissues, whether there was any retroental fat stranding, hyperintensity in the premaxillary tissue, whether there was replacement of fat in the pterigopalata in FOSA by any soft tissue and altered signal intensity was looked for in the intratemporal FOSA muscles. For orbit preceptile extraconal intraconal compartments were evaluated separately we looked for fat stranding on T1 weighted and T2 weighted imagings and hyperintensity on axial flare images and coronal stir images. For extracular muscles we looked whether the muscles were bulky, had any altered signal intensity and fuzzy margins. For optic nerve involvement restriction for optic nerve on DWI images and bulky optic nerve with fuzzy margins was taken as optic nerve involvement. Soft tissue at the orbital apex was looked for in patients to confirm any presence of orbital apex syndrome and in patient with soft tissue we looked for whether there was any dilatation and non enhancement of SOV which can lead to the extension of disease into the cavernous sinus and finally we looked for globed deformity which is indicative of extensive retroorbital disease. Now intracranial extension of the disease was looked for in the form of meninger enhancement and thickening involvement of cavernous sinus. I see a direct spread along the nerves and a direct panel canal infiltration in the form of abscesses or cerebritis. Now a few images the first three images show the pattern of sinus mucosa involvement. In the first image we can see in the first image we can see that there is nodular mucosal thickening on the right side whereas on the left side we can see T2 internal T2 hypo intense content which can be due to the presence of paramagnetic substances which are prescenium fungal hyphae. On second is the T1 weighted post contrast image in this we can see that there is a thin peripheral rim of mucosal enhancement with a central non enhancement and on the left side we can see that there is mucosal enhancement on the periphery of the mucosa whereas it has central non enhancing hypo intense content which also is indicative of fungal disease and on the last image we can see a classic black turbinate sign with non enhancement of premaxillary facial tissue, a non enhancement of turbinates and the muscles in the intratemporal fossa with this all is indicative of necrotic tissue which warrants extensive debridement. Now for orbital involvement there is a preseptile hyper intensity on the right side on coronal stir images in the middle image we can see that there is non enhancing soft tissue adjacent to the orbital floor which has caused the displacement of orbital muscles inferior rectus as well as the medial rectus. In under third image we can see flare hyper intensity in the extracunnel as well as in the intracunnel compartment which is indicative of extensive retro orbital disease associated with deformity in the globe this is called as posterior tenting of the globe which is the classical guitar pick sign. Now for optic nerve involvement on the left side we can see that there is restriction in the optic nerve which is indicative of optic neuritis similarly in the same patient we can see that there is extensive retro orbital disease compared the fat with the right side with the guitar pick sign and on the last image we can see on the right side that the optic nerve is bulky with fuzzy margins negative of direct infiltration of the nerve. Now for brain involvement on the right side we can see there is non enhancement non enhancement of the maxillary artery compared it with the normal left side as well as the internal as well as the extracunnel part of the internal carotid artery in the middle image we can see the left cavernous anus thrombosis there is non enhancement of left cavernous anus thrombosis with adjacent abscess in the left inferior temporal loam and this was the NCA territory in fact in in a patient with ROCM. Now this is first image is in with an ADC image which shows the extension of disease along the trigeminal nerve up to its exit point in the pond so we can see that left trigeminal nerve is thickened compared with the normal right side this is the second image shows cavernous anus thrombosis with non enhancement of the cavernous anus left cavernous anus and its convex margins and the third image shows the cerebellar abscess. Now what were the results discussing the results 65% were male and the average duration of disease onset post COVID was 20 days diabetes and steroid were the most important risk factor and among all the diabetics 95% were 95% were diabetic with 57% of them having uncontrolled diabetes mellitus we can see that diabetes and steroid were most important risk factors MRI features 20 patient all the 20 patient has Sano nasal disease that is the stage 1 and stage 2 disease 14% patients had stage 3 disease that is Sano nasal orbital disease and 8 patients have Sano orbital cerebral that is the stage 4 disease and among the sinus maxillis anus was most commonly involved with frontal sinus being the least common sinus involvement 55% patient had heterogeneous sinus mucosine involvement whereas 40% patient had black turbinate sign in the orbit involvement extraconal compartment was most commonly involved and the globe deformity was seen in least number of patients most common extra sinus site involved was premaxillary facial tissue which was seen in 60% of the patient and pterigopilatine fossa involvement was seen in 30% assessing the pterigopilatine fossa involvement is very important because it can serve as crossroads for the disease extension bilateral Sano nasal disease was noted in 85% of the patient whereas bilateral orbital disease was seen only in 35% of the patient and equal to 8 that is 40% of patient had intracranial extension with meningel enhancement followed by cavernous anus involvement being the second most common so meningel enhancement was seen in most common form of intracranial extension followed by cavernous sinus and then followed by the intracranial abscesses so moving on to the discussion we all know that India has witnessed a huge surge in COVID-19 associated ROCM cases in epidemic proportions we have described the MR MR findings through our study the observed imaging findings in our study indicate the aggressiveness and infiltrative nature of the disease with the involvement of paranasal sinus orbital soft tissue and spread along the vascular and neural structure while mucosal enhancement is a non-specific finding more than half of the study patient had black turbinate sign which indicate necrotic tissue necessitating debridement involvement of pterigopilatine foci should be diligently looked for because it can act as a cross-road for disease spread into the infrared temporal foci as well as intracranially and finally the role of radiologist in cases of ROCM should be focused more towards mapping of the disease rather than diagnosing an early identification of extension beyond their beyond the anatomic boundaries as helping the clinician in deciding the treatment protocol thank you