• The right answer to your question is Brain Stem Hernia although it’s probably not the answer you were looking for.

    The picture above is a very sad one. This is why.

    1. There was an event that required an MRI of the brain. Seldom a happy occasion.
    2. This scan has what doctors call a “positive radiologist’s sign.” The sign is that arrow pointing to an area of the brain called the brain stem. This means that the radiologist thinks that this is super important and doesn’t want anyone to miss it.
    3. At the tip of the arrow you will notice a little patch of whiteness in an otherwise grey zone. This is a patch of tissue that doesn’t work any more.

    The brain stem is an area that has control over a bunch of automatic and absolutely necessary functions.

    • Alertness
    • Breathing drive
    • Blood pressure control
    • Heart rate
    • Relays information between the peripheral nerves and spinal cord to the upper parts of the brain. (Crucial for video gaming)

    Radiologists have a super power. They are able to remember what a normal MRI scan looks like and compare your scan to the ideal normal one kept in their noggin.

    This is a normal MRI for you non-radiologists. See how uniformly grey the brain stem is? See the nice black space around it that represents the cerebrospinal fluid (CSF) flowing freely around it? This is a happy MRI scan.

    Hernia is a term that doctors use when an organ (any organ, brain, guts, etc.) gets pushed through a hole. In the case of brain stem hernia that organ is the brain and the hole is the foramen magnum. In plain English foramen magnum is Latin for “big opening.” If your doctor actually called it the “big hole” though, he would have to charge less.

    Obligatory medical anecdote to contextualize brain stem herniation.

    (The following vignette is intended to be humorous because if I think about it in terms of human tragedy I would depress the crap out of myself and my readers. Don’t judge.)

    I’m minding my own business curing cancer or just texting my wife dog memes, I don’t recall which, when I get a call to the ER for a RTTWBBB. Those who work ER will recognize this as an official medical abbreviation for “Rat-a-tat-tat with a Base Ball Bat” (not kidding.)

    I arrive to find a cop standing outside the room. Inside a young man who smells of stale beer and stress sweat is laid out on a gurney. He is motionless and unresponsive to shaking or yelling. His arms are rigidly held against his sides, fists clenched. Legs are stiffly extended with his toes pointed like a dancer. He is taking irregular, snoring breaths. There is a pile of bloody gauze taped to the top of his head. On examination his pupils are nonreactive to light and too large for the well-lit room (fixed and blown). Blood pressure is 220/110 with a heart rate in the 40′ls. The neurosurgeon on call is looking at the first scan above. “Crap!” he says resignedly. Why did he say that?

    1. His Mercedes convertible is illegally parked.
    2. There is almost nothing he can do to save this young man.
    3. He has to endure working with Dr. Williams.
    4. All of the above answers are correct.

    The correct answer is of course #4. The cold hard fact is that this poor young dude is probably already brain dead. We won’t stop treating him though. He will be intubated, have an art line and central line placed, and be sent to the ICU on a ventilator. Everything will be done if that is the wish of his family. A battery of tests will be done to see if he truly is brain dead.

    Depending on the wishes of the family, we will either turn off the vent and let him die or activate the organ retrieval system for a new organ donor. Often this is the best solution. His organs can go on to save eight people and help many more. Scant consolation for his grieving family.

    TLDR: The worst hernia you can have is a brain stem hernia—it is also the last hernia you can have.

    Thanks for reading to the bottom.

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