The next item of business is portfolio questions, and today's portfolio is environment, climate change and land reform. I remind members that questions 1 and 3 will be grouped together. Question 1 is Neil Findlay. To ask the Scottish Government what action it is taking to improve air quality. Roseanna Cunningham. A cleaner air for Scotland strategy set out a series of actions to further reduce air pollution across Scotland. An independent review of the strategy is currently under and will identify priorities for additional action. We are also working closely with local authorities to deliver low-emission zones across Scotland's four biggest cities by 2020, with Scotland's first LEZ already introduced in Glasgow in December 2018. We provide £2.5 million of funding annually for local authorities and have set objectives for particular matter, which are more than twice as stringent as those set by the EU. Neil Findlay. Vehicle missions have a major role to play in improving air quality. At the moment, electric vehicles are very, very expensive. The cheapest one is around £21,000, and most of the smaller ones are between £25,000 and over. Currently, there is great success with the cycle-to-work scheme. Does the Government have any plans to expand subsidy to individuals who want to buy electric bikes? Roseanna Cunningham. I think that, in all honesty, that is a question that might be better applied to my colleague, who is the transport minister. I hear where the member is coming from and I certainly would be sympathetic to the direction of travel, and I do not mean that as a deliberate pun. I think that we are all of us going to be having to look at ideas like this in the future. I will direct my colleague, Michael Matheson, to the question, and I hope that he will be in direct contact with Mr Findlay. Question 3, Johann Lamont. To ask the Scottish Government what action it is taking to improve air quality and reduce pollution in the Glasgow area. Roseanna Cunningham. Glasgow City Council has produced an action plan containing a number of measures to improve air quality. The Scottish Government is working closely with the council as it implements the measures contained in the plan and is providing practical and financial assistance to monitor air quality and support delivery of measures to improve air quality. Glasgow was the first city in Scotland to put in place a low emission zone following the announcement in the 2017-18 programme for government. That will contribute to improving air quality in the city alongside the measures outlined in the action plan. Johann Lamont. Given the report from the World Health Organization that Glasgow is one of the most polluted cities in the UK, I am sure that the cabinet secretary agrees that working to improve air quality in Glasgow must be a priority and a shared responsibility at all levels. I wonder if the cabinet secretary agrees that that responsibility should include transport providers such as First Bus Glasgow, which should not put forward any successful bids for Scottish Government funding to improve pollution levels from their fleet of over 900 buses. Does the cabinet secretary agree that this is not good enough? Will the cabinet secretary discuss with her colleague the transport secretary the urgent need to work together to discuss with First Bus Glasgow how it can play a full role in improving air quality in Glasgow? The latest air quality monitoring data confirms that air pollution levels are continuing to decline across Glasgow, a trend that is also seen at most locations throughout Scotland. However, I am aware of the situation with bus operators in respect of Glasgow. The member may be reassured to know that I have not just discussed this already with my colleague the transport secretary, but also with the convener and Glasgow council, because it is a matter of some concern as they try to move forward into the low emission zone. It has been unfortunate that some operators may have created a challenge for themselves to be able to meet the yearly target set for buses by Glasgow City Council by failing to bid for the money that was available for that. It is an on-going matter of discussion, however, and I will make sure that the member is kept updated. Can I remind members that supplementary questions should really just be one question and not a whole series of questions? That has taken up quite a long time and stops other supplementaries. To ask the Scottish Government what its position is in the work of society zero, which is a Glasgow-based social enterprise that provides zero waste and plastic-free food produce and products, and how it supports the establishment of such startups. The Scottish Government welcomes the continued innovative approach that is taken by SMEs and charities to develop a variety of zero waste initiatives across Scotland. We provide funding to Zero Waste Scotland, which can distribute grants to zero waste shops and other organisations through the Zero Waste Town Development Fund and the Waste Prevention Implementation Fund. Zero Waste Scotland is also running workshops for zero waste shops and advising them on the support that they can receive both from them and other agencies. Scotland is right at the forefront of exciting circular economy developments, but we all need to work harder to lower our waste output. Can the cabinet secretary outline what steps are being taken to drive behaviour change and encourage the public to choose sustainable packaging over plastic packaging and convenience? We are a signatory to the UK plastics pact, led by the charity RAP, and set up in partnership with the Ellen MacArthur Foundation. That is a coalition whose members cover the entire plastics value change. It has ambitious targets running to 2025 for plastic packaging that includes working towards 100 per cent of packing to be reusable, recyclable or compostable, 70 per cent of plastic packaging to be effectively recycled and 30 per cent average recycled content across all plastic packaging. Of course, we work closely with RAP through Zero Waste Scotland to support consumer messaging and behaviour change initiatives to help citizens to make sustainable consumer choices. To ask the Scottish Government how it is responding to the latest unplanned flaring at the ExxonMobil plant at Mossmorran. The recent flaring event at Mossmorran has created significant disruption for local residents and it is essential that the operators take steps to minimise the frequency and impact of flaring. The plant is subject to regulation by SEPA, which has announced a formal investigation into the latest incident. As part of a regulatory requirement imposed by SEPA, ExxonMobil has now submitted an evaluation of the best available techniques available to reduce and, where practicable, prevent the impacts associated with flaring. SEPA is now considering that and we will continue to monitor developments closely. Alexander Stewart I thank the cabinet secretary for that response, with hundreds of angry residents submitting complaints on the social and health impacts that are being faced by the recent flaring. Can I ask what the cabinet secretary is planning to do to address the long-term environment social impacts for the operation at Mossmorran? Roseanna Cunningham I have been advised that, at the moment, because of the on-going investigation by SEPA, I need to be very careful about making further commitments. I am very conscious, however, of the issues that have arisen. I suspect that Mr Stewart may not be the only one who wants to raise the issue this afternoon. I do not want to prejudice the formal investigation that is currently taking place. I believe that the immediate priority should be to progress that. However, I am also concerned to make sure that SEPA and ExxonMobil communicate to keep the community itself updated. I know that there is a meeting, I think, that I am right in saying in the near future that has been organised in that regard. If I can have quick supplementaries and responses where possible, I will get all the supplementaries in here. Annabelle Ewing Thank you, Presiding Officer. I know what the cabinet secretary has said, and I would argue that a comprehensive inquiry should indeed not be ruled out and must rather remain on the table, which is what my long-suffering constituents want. If it is the case that the already-lawn SEPA investigation into this recent unplanned flaring incident should take its course in the first instance, surely that investigation must be expedited and proceed as a matter of urgency and must include an examination of the impacts on public health, as I have already called on SEPA to do. Roseanna Cunning As I have already said, SEPA's on-going investigation does need to be allowed to make progress before any further independent inquiries are considered. As with all investigations of this nature, I would encourage swift progress, of course, while recognising that that must also be done thoroughly and is likely to involve a degree of technical complexity. In the meantime, SEPA is sharing their latest information with the independent air quality review group, Fife Council, NHS Fife and Health Protection Scotland. Roseanna Cunning As quickly as possible, please. Matt Ruskell and then Willie Rennie. Matt Ruskell There are no clear signs that the plant operators are prepared to make a level of investment needed to secure long-term environmental compliance or indeed to meet Scotland's climate targets. Will the cabinet secretary agree with me that we need to learn the lessons from Longannet and start planning now for the long-term closure of Mossmorran? Does she believe that there is a role here potentially for the Just Transition Commission to ensure that no worker is left behind in that transition? Roseanna Cunning I would hope that the Government would always seek to learn long-term lessons, and if the Just Transition Commission feels that there is a role to play, they are, of course, able to play it. I do not want to add further to what I have already said, some of what I would respond to Matt Ruskell would be simply repeating what has already been said. Willie Rennie I know myself that local tolerance of Mossmorran has plummeted. The life of the plant has already been extended, so if it breaks down this often, how much longer can it last? Roseanna Cunningham That is a technical question that I am going to admit that I am absolutely not qualified to answer. It is something that SIPA will have, I expect, an eye to when it is undertaking all of its investigations, but there are huge issues that are raised by the notion of the closure of something like Mossmorran, as I am sure that the member understands, and they go far beyond the immediate issue that we are facing at the moment. Question 5, Oliver Mundell To ask the Scottish Government what its response is to reports that levels of wild salmon in Scotland are at their lowest levels since records began. Roseanna Cunningham The decline in reported catches of wild salmon is of great concern. We are determined to safeguard the future of this important species, but we recognise that the problem is a result of a range of complex factors. We have identified 12 high-level groups of pressures on salmon, and in this international year of the salmon we will continue to work within Scotland and beyond with our key partners such as Fisheries Management Scotland, district salmon fishery boards and fishery trusts to better understand and tackle all of those, taking into account affordability and practicality. Oliver Mundell I thank the cabinet secretary for that answer. Fisheries Management Scotland has called on the Scottish Government to make salmon conservation a national priority. In that context, what specific measures will the Government introduce to ensure that existing man-made pressures on our iconic salmon populations are reduced and new pressures are avoided? Roseanna Cunningham We are continually assessing and taking action. We are already working across a range of projects to address the various pressures on salmon and with a number of key partners that I have already listed, such as SNH and SEPA. In March last year, we committed £500 million to help fund research and projects to better quantify and mitigate the pressures on Scotland's salmon stocks. In addition, SEPA is leading on work to remove or ease redundant barriers and rivers, utilising around £5 million of annual funding from the Scottish Government into the Water Environment Fund. There is no quick fix on that. I need to say this now. Action on any single one of the pressures that we have identified is not a panacea that will resolve all of the challenges. Claudia Beamish As a follow-on to the serious concerns about the decline of the iconic species, will the cabinet secretary consider committing to taking action to ensure that the conservation status of salmon is fully taken into account in all regulatory decisions of relevance, including not just planning but SEPA on controlled activity regulations and licensing decisions by Marine Scotland licensing operation teams and SNH? As I have indicated, there are a huge range of pressures on wild salmon, not just here in Scotland but right across the North Atlantic and in other countries. Any one or two things that we might be able to think about here in Scotland will not address the problem overall. We have really got to look at it in a much bigger way. In actual fact, the Government has been doing so over the past number of years, as we have done with the recategorisation of a number of rivers, which is not always welcome, of course, by anglers, but the figures that we have seen published recently are perhaps a clearer exposition of why that has been necessary. Question 6, Stuart McMillan. Thank you, Presiding Officer, to ask the Scottish Government what it is doing to eliminate using single-use plastic packaging. Roseanna Cunningham. Yesterday, I announced ambitious plans for a deposit return scheme for single-use drinks containers. That scheme is going to play an important role in our efforts to increase the amount of packaging, including plastic packaging, which is recycled. I look forward to working with partners on its implementation. There is an on-going UK-wide consultation on packaging producer responsibility and that is another important development. That consultation includes proposals to incentivise the use of easier to recycle packaging by businesses across the UK. We also have an expert panel on environmental charging, which has an important role to play in shaping future plans, and we look forward to receiving its recommendations in the summer. Stuart McMillan. I thank the current secretary for that reply. Does she agree with me that, following the First Minister declaring a climate emergency that supermarkets need to do more, an act immediately to stop selling fruit and vegetables in plastic packaging, as well as using packaging that should be recycled on its own brand products? As I indicated, we are already consulting on this UK-wide basis. I should say that all of the UK Governments are involved in that consultation. That is on reform of packaging producer responsibility arrangements. Under the principle of extended producer responsibility, those businesses who place packaging on the market should be required to meet the costs associated with management of that packaging at the end of its life. The consultation commenced on 18 February and runs until 13 May. We would encourage anyone with an interest to submit a response. Supermarkets are a key part of any future solution, and we are engaging directly with them on packaging reform, whilst also ensuring that the food waste agenda is considered as part of the equation. Short supplementaries, please, from Mordisgold and then Eileen Smith. Data on single-use plastics in Scotland has been in short supply. For example, last year, the cabinet secretary confirmed that it was not known how many plastic straws were being used when the announcement was made. What steps has been taken since then to ensure reliable data is available to inform policy? I will ask the expert panel to look at that and get back to the member. That is a kind of short and snappy answer, Eileen Smith. Thank you for reading, officer. We know that communities across Scotland have been working to reduce single-use plastics, but can the cabinet secretary tell me how many communities have applied for funds to the action on plastic zero waste towns initiative, which she announced nearly a year ago and how much of the £500,000 fund has been allocated to debt? Checking quickly through my briefing, I cannot see it straight away. I undertake to get back to the member with those figures. To ask the Scottish Government how it ensures that environmental safety standards are met in landfill sites. The Scottish Environment Protection Agency is responsible for regulating the environmental impacts of landfill sites within the framework that is set by legislation. Can I thank the cabinet secretary for that answer? However, I have raised the issue of the Tarbolten landfill site going into her administration before the Scottish Government, and given that both site pumps and flaring ceased at this point when the subsequent contamination is leachet and gas emissions, I am yet to establish which organisation is responsible for the clear-up of the contamination and making the site safe, as despite meeting with SEPA local councils. Could you get your question, please? Could the cabinet secretary please clear the matter up of accountability and how can she bring pressure to the bayer to have this site cleared? Roseanna Cunningham. As I have indicated, SEPA is the regulatory authority, and they are actively involved in the situation at Tarbolten, which is extremely unfortunate. There is a complicated legal scenario at the moment, which is not easy to resolve, but SEPA is looking at that. As soon as there is a way forward, we will communicate that. There is a role to play, however. I think that councils, local councils, should be thinking about the role that they can play, too. I know that there is a bit of uncertainty around the readiness of some councils to help in regard to that kind of issue, so I hope that that can also be looked at. There is an official receiver appointed, and at the moment, legally, the environmental obligations of the site really fall to the official receiver, but that is a changing scenario. Short supplementary, please. Thank you, Presiding Officer. The cabinet secretary mentioned their local authorities. How long have local authorities had to prepare for the implementation of the ban, and where can those local authorities feel that they may not be meeting their obligations to access appropriate advice and support? Roseanna Cunningham. The member is probably referring to the ban on landfill, which is scheduled to come in 2012. Sorry, the set of legislation in 2012. I feel as if I am on a time warp. There has been significant time to repair, so it is disappointing at the moment that there are not solutions in place in all councils. 14 local authorities do have long-term solutions. Some other authorities have interim solutions in place. We are focused at the moment on working with authorities who do not have a solution in place so that we can try to move them forward into a place where they can comply with the ban as soon as possible. There is extensive engagement going on in that regard. Very quickly, please. Lewis Macdonald. The Scottish Government on what grounds a local authority can refuse to provide a grant for the replacement or improvement of a private water supply where there is no access to mains water? A local authority can refuse an application for grant under the private water supply's grants regulations, where the applicant is not an eligible person, is a public body or office holder, if the premises are in new building or if the proposed work has already begun or has finished before the application was submitted. An application can also be refused if the premises are subject to certain orders or notices under housing and building legislation or do not meet the tolerable standard. Lewis Macdonald. I am grateful to the cabinet secretary. I noticed that there was no mention of requiring a shared supply in circumstances where one property is still occupied and the other is not. Private water supplies are often in areas of rural depopulation. Does she agree that councils should act in such a way as to stem rural depopulation in making such grant decisions? Roseanna Cunningham. The member is probably dealing with a very particular case that is in this particular circumstance. Local authorities consider each case on its own merits. Given the costs of upgrading private water supplies, ideally you would be looking at a joint approach by householders where possible, rather than the idea that each residence would have to have its own single water supply. That would become extremely expensive, and I think that councils have got to manage that when they are looking at grants for private water supplies. That concludes portfolio questions, and we will move on to the next item of business. If people could move quickly, please.


Yeah, and what was the occasion? And the occasion was that when Ja'far al-Tayyar, God be pleased with him, came to Medina from Ethiopia. He made his hijra now to Medina. You know he made the hijra to Ethiopia during the Lankan period. And he doesn't come along. He brings with him a whole contingent of Ethiopian converts among the first Africans to come into Islam. Bilal, of course, was also an Abyssinian. And do you think they love the Prophet? They can't control themselves. They love him so much. And they fast the whole month of Ramadan. And they're in heaven. And so would you be. Right? And then on the day of Eid, they just do an Ethiopian thing. They get out their swords. They get out their spears. They get out their drums. They begin to beat their drums and dance, sword dances and spear dances in the mosque. Now outside, in the mosque. And Amr al-Fawoob, he was a big, tough person. You don't mess with him. Very big, very tall, very strong. He didn't like that. He said, what are you doing? And so he said, stop it. And in the Prophet Dinovoo, he said, take it easy, Amr. Take it easy. Don't frighten them. And he said, play your games. Benu al-Fidah. Play your games, Benu al-Fidah. So that the Jews and Christians know that we have Apple-ness in our religion. That our religion is not rigid. And also so that they know that Ethiopians can be Ethiopians. You don't have to become Arabs. You'll be Ethiopian. And you dance. And you have drums. And you have swords and so forth. Okay, so this is an incredible hadith. And then they continued to dance. They were still a little bit frightened by Allah. But the Prophet didn't just take it easy. And then he lifted Aisha up over his shoulders. And she put her cheek next to his. And she watched and watched and watched until she got tired. And they said, okay, I want to get down. And they just went on and on and on. They were delighted. And a lot of people are like that, aren't they? A lot of Africans dance. That's what they do, drums and dance. Go to a wedding and maybe you won't like it, but they dance. Okay, and this is part of their culture. And of course, you want the dance to be good. You now want it to be sexually beyond the limits. Okay, and they don't do that. In fact, the women dance with the women. That's what it is. And then the men dance with the men, but they dance. Leave the Ethiopians alone. That can be Ethiopians. Let the Chinese be Chinese. They don't have to become Arabs. We don't even want that. Although if you go there today, you'll see groups that like, get rid of these Chinese masks. We're going to have a mask like we have in our country. Change those clothes.  That's culturally predatory. And you're destroying their whole culture. And that also puts them in danger in the eyes of the Chinese because they become alien. You don't tell African American Muslims that you've got to become Arabs. No, you be African Americans. You be proud of your past. And you build on that past.


With that, I'm gonna check the questions and answers again. What is the cause of subdural effusion and hypotension? That's a good question. So presumably there's actually negative pressure in the subarachnoid space so that it's actually exerting sort of like a vacuum on the hacky meninges to the point where it's actually pulling basically the dura and causing the subdural effusions to occur. So that's what we believe is happening basically. And that's what we believe is causing the enhancement as well. It's causing inflammation. Do you stent vocal venous sinus stenosis in patients only have tinnitus? Ooh, that's a really good one. So I will often do their full workup. I'll do their LPC, see what their pressure is. And if their pressure is very high to the point where I'm worried about them, then I will often offer them the venous sinus pressure measurements. And I do all this away. So I'll basically do an LP. I'll tell them, hey, your pressure's 30. You're lucky that you don't have papillodema. Let's go ahead and do venous sinus pressure measurements if you're okay with it. And I'll just flip them over and do the venous access and just quickly. I use a very small micro catheter. So I don't even give them that much heparin. So it's safe to do on the same day. I give them like 1500 a heparin.   And then I'll measure the pressures all the way across. It's like 10 minutes of added time. And then in most cases, like if the pressure gradient is there, I'll just tell them it's there and then we'll have a big conversation in clinic. But I can tell you, I've never personally stented anyone who just had tinnitus. I've stented someone who had tinnitus and bad headaches, but never just tinnitus. Okay. Next question. What is the specific sign of imaging studies for NPH and not any kind of hydrocephalus? Ooh, I don't think there really is the specific sign for NPH and imaging. That colossal angle that we were talking about really just predicts atrophy versus hydro. I don't think there is an imaging specific finding. It's just a general gestalt that there is enlargement of ventricles. It's out of proportion of the degree of overall volume loss. And that colossal angle is narrow to the point where we suspect hydrocephalus. It really is a clinical diagnosis. And that's what I fall back on. Anytime someone tries to push me on NPH, that's generally what I do. So someone's asking what the stroke volume cutoff. Is there any role? Oh, sorry. This thing is, man, I'm getting a lot of questions real quick. So the cutoff that I use is 100 because we have GE machines. And then in which side are CSF venous fissures more frequently and in what level? Ooh, that's a good question. I find them to be more common, actually on the right side of the patient and more common at the thoracolumbar junction. And I think the reason that that happens is because of the pressure. Actually, yeah, I think it's just because the pressure is a little bit lower. I mean, there's less interference with the fistula forming because you're closer to the IVC, closer to the, also closer to the azagus, hemi-azagus system, et cetera. Let's see, what about A genesis of the transverse sinus? Oh, that's a good question. So A genesis of the transverse sinus, I've never seen bilateral. I've seen it unilateral in the setting of a contralateral stenosis. And in those cases, a lot of those patients doing that benefiting from a stent. But yeah, A genesis is a good thing to think about when you're talking about stenosis. So that's where the gradients come in when you're actually measuring the pressure gradients. You need to make sure it's significant. Let's see here. Regarding fallout hydrocephalus, is there any objective score that can be used? I assume they mean for NPH. No, there's not really an objective score that I've used. I'm not aware of one. That being said, somebody's saying crocrum k-rad scale. I've not used that. I just, I look at the close angle and it's, oh, Kiari 1.5, yes. How can we determine normal pressure hydrocephalus in the background of generalized atrophy? Oh, that actually gets back to the close angle. So that's a good question too. I mean, that close angle tells us basically that it's probably more likely hydro and not just generalized atrophy because the normal close angle is actually usually greater than 100. If it's less than 80, it's more likely to be NPH. But I don't use any other scoring system because I don't think anything's reliable. I just, as a gestalt, I look at it that the ventricles are bigger than I would expect for the degree of volume loss. And I just measure the close angle if it's positive. Then I just say this is suggestive to NPH in the appropriate clinical setting. And then the neurologist evaluates the patient and they say, yes, it looks like NPH. Then they send them back to me and I end up doing the LP or a three day lumbar drain trial. And if it's positive, then they go to shunt. Occasionally, like I said, I'll do a flow study and just see if it jives with my flow diversion, or sorry, my temporary flow diversion. Particularly if they're immobilized and they can't walk. Let's see, do you use CT and MR Mylo in the same setting? How much MR Max contrast can be used? Okay, so I personally never use more than 0.5 intrathecal gadolinium, I usually stick to 0.3. As far as I'm aware, there's no FDA approval for that. I normally just tell them it's off-label and actually put it in a consent that this is off-label. And that's usually what I will do. Do you use the NPH scale from Scandinavia? No, I don't use that NPH scale. Let's see, about intracranial hypertension. What do you think is the most reliable MRX? Honestly, optic disc cupping and optic nerve sheath dilation, I think is probably most reliable in intracranial hypertension. I see empty cellas all the time and it means nothing. The other thing that's pretty reliable is diffuse sinus narrowing in the appropriate clinical setting along with those findings within the optic nerve sheath. So if you have diffuse sinus narrowing, particularly along the spear sagittal sinus as it transitions into the transverse sinuses, if you have narrowing right there, a lot of those patients have NPH. Patient 50 female CSF leak, history of direct head trauma last 20 years. What suitable imaging needed? So from nose, oh, okay. So I normally do a super thin section max face to see if I can see it to hissins. And then I actually go to nuclear medicine pretty quickly. And when I do the nuclear medicine scan for those patients that I'm looking for CSF rhinorrhea, I actually raise their pressure substantially. I take them to 35 centimeters of water with Elliott B solution right before, sorry, right after I inject the nuclear medicine tracer. So for Zandia, it'll be my LP. I confirm I mentioned intrathecal with a little bit of iodinated contrast. Then I inject the radio tracer. Then I inject a lot of Elliott Bs or you can inject saline and get them up to 35, just intermittently monitoring. Also, you kind of tolerate to their, you kind of titrate to their tolerance. Some people won't get to 35. If you can get them to 30, even 25, that makes a difference. But if you leave them with a CSF hypotension or even a normal pressure, you might not elicit the leak. So I typically try to get them around 30 if I can, even for that. And then I normally have my ENTs packed the nose with Pledgeits right before and we actually count the Pledgeits. You can also do thin section T2s through the anterior skull base and try and see if you can see the CSF leak. There are some cases where you can see that his it's a little bit better on thin section, T2 cube or Fiesta imaging, compared to just a plain maxillofacial CT, but that being said, seeing the dehiscence you're relying upon, seeing a tiny, usually assigned a tiny encephalocel, basically that's what you're looking for. How to differentiate small perineural cysts from CSF leaks on planes and you can't, it's impossible. If the patient doesn't have, if the patient has a prior MRI of the brain and they do not have a positive burn scale score and they don't have symptoms of CSF leak, then it clearly is just a normal perineural cyst. But if they have signs of CSF leak on MRI and or clinical, then you just have to report that there are perineural cysts in all these locations. And in general, if you've already done that, you could ask your tech to go ahead and try and do a Fatsat T2, but that's gonna add a lot of time to your scan. The Fatsat T2 is really useful. If you go back or if you remember back earlier when I was showing a Fatsat T2 of that young lady who had the lumbar puncture, you could see stranding in the epidural space.  And that can help you kind of focus on one perineural cyst. I think that probably is what you're asking, basically a Fatsat T2, but on a standard scan, you can't tell if a perineural cyst is gonna be a leak or not. You need the Fatsat T2 at minimum to be able to tell if it's really suspicious. Threshold for stroke volume to be CSF low study. Again, I go back to the 100 microliters for G or 42 microliters for Siemens. But I still rely ultimately on a temporary flow diversion, meaning like a lumbar puncture or a lumbar drain. Is there any significance using needle gauge ties when doing, yes, there is significance. So when you're looking for a high flow leak, somebody asked a question about what size gauge needle to use. So if you're doing a high flow leak, you need to be able to inject the contrast really quickly if you're doing a DSM. So I use a 20 gauge needle to be able to inject it quickly. That being said, if you're doing a high flow leak in CT, presumably you got the head up for a while and you're actually injecting slowly. The sort of the distinction is that in a DSM, the patient can't be moved. So in a DSM, you already have the head down. So you have to inject quickly and wait for it to flow up. Whereas in CT, you can inject the entire volume and drop the head. You can't drop the head and do a DSM as easily. It's theoretically possible if your table moves really, really quickly for you to drop the head and quickly subtract and then before the contrast runs in. But I tend to use the smallest gauge needle I can for the low flow leaks because I don't want my puncture to obscure the leak, basically. So I try to use the smallest thing I can. The good compromise though is the GERDY set. So there's a GERDY set out there that I think it has a 20 gauge coaxial. It's about an inch and a half long and then a 22 gauge pin cam that goes through it. I've had a lot of luck with those. So for those sort of leaks where I'm not sure if it's high flow or not, if I think it may be a type two lateral leak and it may be kind of high flow, then I'll use that GERDY set. It's a good compromise. But when I think it's a low flow leak, I tend to use a 25, basically a discogram set more or less. What needle should we use for diagnostic LPs? Like I said, I tend to use that GERDY set for diagnostic LP if I'm worried about CSF leaks. If I'm not worried about CSF leaks, I'm trying to do a very quick assessment of whether or not someone has NPH. I tend to use a bigger needle because I don't want to sit there all day. So I tend to use a 20 gauge needle and I have this 33 inch one meter tubing that I hooked to the 20 gauge needle and I actually raised the head of the bed up and I actually dropped the tubing down lower. And generally I can finish a high volume LP in about 15 minutes. So our epidural CSF leak surgical emergencies like hemorrhage, they can be if they're really fast. So if an epidural leak is extremely fast to the point where the patient's comatose, it can be an emergency. I've run into those situations where I don't even have time to localize them and I take exactly what I do. Usually the epidural space is so engorged because of the leak and it's so soupy for lack of a better way of saying it. You can put almost anything into the epidural space. So I'll take a vascular forefront sheath and actually just use like a twoy needle and get my twoy needle in the epidural space. I take a really steep angle into it. And then once I get in there, I'll put like either an 035 or a nitrex wire into the epidural space and I'll put either a four French radial or just a small four French vascular sheath into the epidural space. And then I'll put like a vert, a four French vert or a four French baronstein catheter over an 035 wire. And I will run a catheter all the way up the dorsal epidural space to the cervical thoracic junction. I will patch them with 125 CCs of blood, generally injecting about two to four CCs per level titrated into the patient's ability to tolerate it. But that's how I deal with emergent leaks like where I don't really have time to localize it like the patient's comatose, I need to do something fast. So I'll put in a catheter and just inject a lot of blood. What is the anticoagulation policy for venous stent and follow-up? So I normally will give them aspirin and plavix for three months, I do check levels for those. So I checked P2Y12 level and aspirin verify now and I send out whole blood platelet aggregation for ADP and for the AA levels because they're more reliable but they're 24 hours in that lab for us. So if the P2Y12 level is less than 194 and the aspirin's less than 550 I normally feel comfortable proceeding. And then I'll wait for the final numbers but generally I like them to be below 50% when I'm putting in a venous stent on the ADP activation. And then for AA I like them to be about the same below 50%. What is flow compensated fiesta for this point? Essentially, we put on EKG leads and we're actually timing the patient's heart and we're compensating for flow based on when their heart beats because when their heart beats their brain pulsates essentially. I mean, we're actually compensating for essentially when their heart beats and when the CSF is moving. So it's almost like gating. I mean, and you can do it that way. Another way, there are a couple of other ways to do it but I'm not a physicist full disclosure. There are other ways to do flow compensated fiesta but you can gate based on the heartbeat. And then there are a couple of other ways to do it but in general, flow compensated fiesta is helpful because it removes a lot of different artifacts. Fiesta itself removes truncation and then the flow compensation removes the flow artifact so that you can see those epidural collections much more easily but you can either gate to the cardiac cycle or there's a couple other tricks. And again, I'm not a physicist. I don't know all of the tricks to that but I have a very good physicist here and they do really nice flow compensated fiesta as far as and that's how I see a lot of my CSF leaks. Okay, I think we have all of our questions and answers done. I really appreciate everyone sticking around to the very end and I hope this was helpful. I know it's a lot of information to throw at you all at once and it's as comprehensive as I can get about the specific topics that I'm talking about in this amount of time.


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