Podcasts about sih

Idiopathic intracranial hypertension (IIH) is characterized by symptoms and signs of unexplained elevated intracranial pressure (ICP) in an alert and awake patient. The condition has potentially devastating effects on vision, headache burden, increased cardiovascular disease risk, sleep disturbance, and depression.  In this episode, Teshamae Monteith, MD, FAAN speaks with Aileen A. Antonio, MD, FAAN, author of the article “Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Antonio is an associate program director of the Hauenstein Neurosciences Residency Program at Trinity Health Grand Rapids and an assistant clinical professor at the Michigan State University College of Osteopathic Medicine in Lansang, Michigan. Additional Resources Read the article: Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Guest: @aiee_antonio Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Monteith: Hi, this is Dr Teshamae Monteith. Today I'm interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics.  Hi, how are you? Dr Antonio: Hi, good afternoon. Dr Monteith: Thank you for being on the podcast. Dr Antonio: Thank you for inviting me, and it's such an honor to write for the Continuum. Dr Monteith: So why don't you start off with introducing yourself? Dr Antonio: So as mentioned, I'm Aileen Antonio. I am a neuro-ophthalmologist, dually trained in both ophthalmology and neurology. I'm practicing in Grand Rapids, Michigan Trinity Health, and I'm also the associate program director for our neurology residency program. Dr Monteith: So, it sounds like the residents get a lot of neuro-ophthalmology by chance in your curriculum. Dr Antonio: For sure. They do get fed that a lot. Dr Monteith: So why don't you tell me what the objective of your article was? Dr Antonio: Yes. So idiopathic intracranial hypertension, or IIH, is a condition where there's increased intracranial pressure, but without an obvious cause. And with this article, we want our readers---and our listeners right now---to recognize that the typical symptoms and learning about the IIH diagnostic criteria are key to avoiding errors, overdiagnosis, or sometimes even misdiagnosis or underdiagnosis. Thus, we help make the most of our healthcare resources. Early diagnosis and management are crucial to prevent disability from intractable headaches or even vision loss, and it's also important to know when to refer the patients to the appropriate specialists early on. Dr Monteith: So, it sounds like your central points are really getting that diagnosis early and managing the patients and knowing how to triage patients to reduce morbidity and complications. Is that correct? Dr Antonio: That is correct and very succinct, yes. Dr Monteith: And so, are there any more recent advances in the diagnosis of IIH? Dr Antonio: Yes. And one of the tools that we've been using is what we call the optical coherence tomography. A lot of people, neurologists, physicians, PCP, ER doctors; how many among those physicians are well-versed in doing an eye exam, looking at the optic disc? And this is a great tool because it is noninvasive, it is high resolution imaging technique that allows us to look at the optic nerve without even dilating the eye. And we can measure that retinal nerve fiber layer, or RNFL; and that helps us quantify the swelling that is visible or inherent in that optic nerve. And we can even follow that and monitor that over time. So, this gives us another way of looking at their vision and getting that insight as to how healthy is their vision still, along with the other formal visual tests that we do, including perimetry or visual field testing. And then all of these help in catching potentially early changes, early worsening, that may happen; and then we can intervene more easily. Dr Monteith: Great. So, it sounds like there's a lot of benefits to this newer technology for our patients. Dr Antonio: That is correct. Dr Monteith: So, I read in the article about the increased incidence of IIH, and I have to say that I completely agree with you because I'm seeing so much of it in my clinic, even as a headache specialist. And I had a talk with a colleague who said that the incidence of SIH and IIH are similar. And I was like, there's no way. Because I see, I can see several people with IIH just in one day. That's not uncommon. So, tell me what your thoughts are on the incidence, the rising incidence of IIH; and we understand that it's the condition associated with obesity, but it sounds like you have some other underlying drivers of this problem. Dr Antonio: Yes, that is correct. So, as you mentioned, IIH tends to affect women of childbearing age with obesity. And it's interesting because as you've seen that trend, we see more of these IIH cases recently, which seem to correlate with that rising rate of obesity. And the other thing, too, is that this trend can readily add to the burden of managing IIH, because not only are we dealing with the headaches or the potential loss of vision, but also it adds to the burden of healthcare costs because of the other potential comorbidities that may come with it, like cardiovascular risk factors, PCOS, and sleep apnea. Dr Monteith: So why don't we just talk about the diagnosis of IIH? Dr Antonio: IIH, idiopathic intracranial hypertension, is also called pseudotumor cerebri.  It's essentially a condition where a person experiences increased intracranial pressure, but without any obvious cause. And the tricky part is that the patients, they're usually fully awake and alert. So, there's no obvious tumor, brain tumor or injury that causes the increased ICP. It's really, really important to rule out other conditions that might cause these similar symptoms; again, like brain tumors or even the cerebral venous sinus thrombosis. Many patients will have headaches or visual disturbances like transient visual obscurations---we call them TVOs---or double vision or diplopia. The diplopia is usually related to a sixth nerve palsy or an abducens palsy. Some may also experience some back pain or what we call pulsatile tinnitus, which is that pulse synchronous ringing in their ears. The biggest sign that we see in the clinic would be that papilledema; and papilledema is a term that we only use, specifically use, for those optic nerve edema changes that is only associated with increased intracranial pressure. So, performing of endoscopy and good eye exam is crucial in these patients. We usually use the modified Dandy criteria to diagnose IIH. And again, I cannot emphasize too much that it's really important to rule out other secondary causes to that increased intracranial pressure. So, after that thorough neurologic and eye evaluation with neuroimaging, we do a lumbar puncture to measure the opening pressure and to analyze the cerebrospinal fluid. Dr Monteith: One thing I learned from your article, really just kind of seeing all of the symptoms that you mentioned, the radicular pain, but also- and I think I've seen some papers on this, the cognitive dysfunction associated with IIH. So, it's a broader symptom complex I think than people realize. Dr Antonio: That is correct. Dr Monteith: So, you mentioned TVOs. Tell me, you know, if I was a patient, how would you try and elicit that from me? Dr Antonio: So, I would usually just ask the patient, while you're sitting down just watching TV---some of my patients are even driving as this happens---they would suddenly have these episodes of blacking out of vision, graying out of vision, vision loss, or blurred vision that would just happen, from seconds to less than a minute, usually. And they can happen in one eye or the other eye or both eyes, and even multiple times a day. I had a patient, it was happening 50 times a day for her. It's important to note that there is no pain associated with it most of the time. The other thing too is that it's different from the aura that patients with migraines would have, because those auras are usually scintillating and would have what we call the positive phenomena: the flashing lights, the iridescence, and even the fortification that they see in their vision. So definitely TVOs are not the migraine auras. Sometimes the TVOs can also be triggered by sudden changes in head positions or even a change in posture, like standing up quickly. The difference, though, between that and, like, the graying out of vision or the tunneling vision associated with orthostatic hypotension, is that the orthostatic hypotension would also have that feeling of lightheadedness and dizziness that would come with it. Dr Monteith: Great. So, if someone feels lightheaded, less likely to be a TVO if they're bending down and they have that grain of vision. Dr Antonio: That is correct. Dr Monteith: Definitely see patients like that in clinic. And if they have fluoride IIH, I'm like, I'll call it a TVO; if they don't, I'm like, it's probably more likely to be dizziness-related. And then we also have patient migraines that have blurriness that's nonspecific, not necessarily associated with aura. But I think in those patients, it's usually not seconds long, it's usually probably longer episodes of blurriness. Would you agree there, or…? Dr Antonio: I would agree there, and usually the visual aura would precede the headache that is very characteristic of their migraine, very stereotypical for their migraines. And then it would dissipate slowly over time as well. With TVOs, they're brisk and would not last, usually, more than a minute. Dr Monteith: So, why don't we talk about routine imaging? Obviously, ordering an MRI, and I read also getting an MRV is important. Dr Antonio: It is very important because, one: I would say IIH is also a diagnosis of exclusion. We need to make sure that the increased ICP is not because of a brain tumor or not because of cerebral venous sinus thrombosis. So, it's important to get the MRI of the brain as well as the MRV of the head. Dr Monteith: Do you do that for all patients' MRV, and how often do you add on an orbital study? Dr Antonio: I usually do not add on an orbital study because it's not really going to change my management at that point. I really get that MRI of the brain. Now the MRV, for most of my patients, I would order it already just because the population that I see, I don't want to lose them. And sometimes it's that follow-up, and that is the difficult part; and it's an easy add on to the study that I'm going to order. Again, it depends with the patient population that you have as well, and of course the other symptoms that may come with it. Dr Monteith: So, why don't we talk a little bit about CSF reading and how these set values, because we get people that have readings of 250 millimeters of water quite frequently and very nonspecific, questionable IIH. And so, talk to me about the set value. Dr Antonio: Right. So, the modified Dandy criteria has shown that, again, we consider intracranial pressure to be elevated for adults if it's above 250 millimeters water; and then for kids if it's above 280 millimeters of water. Knowing that these are taken in the left lateral decubitus position, and assuming also that the patients were awake and not sedated during the measurement of the CSF pressure. The important thing to know about that is, sometimes when we get LPs under fluoroscopy or under sedation, then these can cause false elevation because of the hypercapnia that elevated carbon dioxide, and then the hypoventilation that happens when a patient is under sedation. Dr Monteith: You know, sometimes you see people with opening pressures a little bit higher than 25 and they're asymptomatic. Well, the problem with these opening pressure values is that they can vary somewhat even across the day. People around 25, you can be normal, have no symptoms, and have opening pressure around 25- or 250; and so, I'm just asking about your approach to the CSF values. Dr Antonio: So again, at the end of the day, what's important is putting everything together. It's the gestalt of how we look at the patient. I actually had an attending tell me that there is no patient that read the medical textbook. So, the, the important thing, again, is putting everything together. And what I've also seen is that some patients would tell me, oh, I had an opening pressure of 50. Does that mean I'm in a dire situation? And they're so worried and they just attach to numbers. And for me, what's important would be, what are your symptoms? Is your headache, right, really bad, intractable? Number two: are you losing vision, or are you at that cusp where your optic nerve swelling or papilledema is so severe that it may soon lead to vision loss? So, putting all of these together and then getting the neuroimaging, getting the LP. I tell my residents it's like icing on the cake. We know already what we're dealing with, but then when we get that confirmation of that number… and sometimes it's borderline, but this is the art of neurology. This is the art of medicine and putting everything together and making sure that we care and manage it accordingly. Dr Monteith: Let's talk a little bit about IIH without papilledema. Dr Antonio: So, let's backtrack. So, when a patient will fit most of the modified Dandy criteria for IIH, but they don't have the papilledema or they don't have abducens palsy, the diagnosis then becomes tricky. And in these kinds of cases, Dr Friedman and her colleagues, when they did research on this, suggested that we might consider the diagnosis of IIH. And she calls this idiopathic intracranial hypertension without papilledema, IIHWOP. They say that if they meet the other criteria for modified Dandy but show at least three typical findings on MRI---so that flattening of the posterior globe, the tortuosity of the optic nerves, the empty sella or the partially empty sella, and even the narrowing of the transverse venous sinuses---so if you have three of these, then potentially you can call these cases as idiopathic intracranial hypertension without papilledema. Dr Monteith: Plus, the opening pressure elevation. I think that's key, right? Getting that as well. Dr Antonio: Yes. Sometimes IIHWOP may still be a gray area. It's a debate even among neuro-ophthalmologists, and I bet even among the headache specialists. Dr Monteith: Well, I know that I've had some of these conversations, and it's clear that people think this is very much overdiagnosed. So, that's why I wanted to plug in the LP with that as well. Dr Antonio: Right. And again, we have not seen yet whether is, this a spectrum, right? Of that same disease just manifesting differently, or are they just sharing a same pathway and then diverging? But what I want to emphasize also is that the treatment trials that we've had for IIH do not include IIHWOP patients. Dr Monteith: That is an important one. So why don't you wrap this up and tell our listeners what you want them to know? Now's the time. Dr Antonio: So, the- again, with IIH, with idiopathic intracranial hypertension, what is important is that we diagnose these patients early. And I think that some of the issues that come into play in dealing with these patients with IIH is that, one: we may have anchoring bias. Just because we see a female with obesity, of reproductive age, with intractable headaches, it does not always mean that what we're dealing with is IIH. The other thing, too, is that your tools are already available to you in your clinic in diagnosing IIH, short of the opening pressure when you get the lumbar puncture. And I need to emphasize the importance of doing your own fundoscopy and looking for that papilledema in these patients who present to you with intractable headaches or abducens palsy. What I want people to remember is that idiopathic intracranial hypertension is not optic nerve sheath distension. So, these are the stuff that you see on neuroimaging incidentally, not because you sent them, because they have papilledema, or because they have new headaches and other symptoms like that. And the important thing is doing your exam and looking at your patients. Dr Monteith: Today, I've been interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Thank you again. Dr Antonio: Thank you. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Recently, sophisticated myelographic techniques to precisely subtype and localize CSF leaks have been developed and refined. These techniques improve the detection of various types of CSF leaks thereby enabling targeted therapies. In this episode, Katie Grouse, MD, FAAN, speaks with Ajay A. Madhavan, MD, author of the article “Radiographic Evaluation of Spontaneous Intracranial Hypotension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California San Francisco in San Francisco, California. Dr. Madhavan is assistant professor of radiology at the Mayo Clinic in Rochester, Minnesota. Additional Resources Read the article: Radiographic Evaluation of Spontaneous Intracranial Hypotension Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Full episode transcript available here Dr Jones:  This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Grouse:  This is Dr Katie Grouse. Today I'm interviewing Dr Ajay Madhavan about his article on Radiographic Evaluation of Spontaneous Intracranial Hypotension, which he wrote with Dr Levi Chazen. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr Madhavan:  Hi, thanks a lot, Katie. Yeah, so I'm Ajay Madhaven. I'm a neuroradiologist at the Mayo Clinic in Rochester, Minnesota. I did all my training here, so, I've been here for a long time. And I have a lot of interest in spinal CSF leaks, and I do a lot of that work. And so I'm really excited to be talking about this article with you. Dr Grouse:  I'm really excited too. And in fact, it's such a pleasure to have you here talking today on this topic. I know a lot's changed in this field, and I'm sure many of our listeners are really interested in learning about the developments and imaging techniques to improve detection and treatment of CSF leaks, especially since maybe we've learned about this in training. I want to start by asking you what you think is the most important takeaway from your article. Dr Madhavan:  Yeah, that's a great question. I think---and you kind of already alluded to it---I think the main thing is, I hope people recognize that this field has really changed a lot in the last five to ten years, through a lot of multi-institutional collaboration and also collaboration between different specialties. We've learned a lot about different types of spinal CSF leaks, how we can recognize the disease, particularly the types of myelography that we need to be using to accurately localize and treat these leaks. Those are the things that have really evolved in the last five to ten years, and they've really helped us improve these patients' lives. Dr Grouse:  Can you remind us of the different common types of spinal leaks that can cause spontaneous intracranial hypotension? Dr Madhavan:  Yeah, so there are a number of different spinal CSF leaks, types, and I would say the three most common ones that really most people should try to be aware of and cognizant of are: first, ventral dural tears. So those are, like, just physical holes in the dura. And they're usually caused by little bone spurs that come from the vertebral columns. So, they're often patients who have some degenerative changes in their spine. And those are really very common. Another type of spinal CSF leak that we commonly see is a lateral dural tear. So that's like the same thing in a slightly different location. So instead of being in the front, it's off to the side of the dura laterally. And so, it's also just a hole in the dura. And then the third and most recently discovered type of spinal CSF leak is a CSF-venous fistula. So those are direct connections between the subarachnoid space and little paraspinal vein. And it took us a long time to even realize that this was a real pathology. But now that it's been recognized, we've found that this is actually quite common. So those three types of leaks are probably the three most common that we see. And there's certainly others out there, but I would say over 90% of them fall into one of those three categories. Dr Grouse:  That's a great review, thank you. Just as another quick review, as we talk more about this topic, can you remind us of some of the most common or typical brain imaging findings that you'll see in cases of spontaneous intracranial hypotension? Dr Madhavan:  Yeah, absolutely. So, when you do a brain MRI in a patient who has spontaneous intracranial hypotension, you will usually, though not always, see typical brain MRI abnormalities. And I kind of think of those as falling into three different categories. So, the first one I think of is dural enhancement or thickening. So that's enlargement or engorgement of the dura, the pachymeninges, and enhancement on postgadolinium imaging. So, that's kind of the first category. The second is that, when you lose spinal fluid volume, other things often expand to take up the space. So, for example, you can get distension or enlargement of the dural venous sinuses, and sometimes you can also get subdural food collections or hematomas. They can arise spontaneously. And I kind of think of those as, you know, you, you've lost the cerebrospinal fluid volume and something else is kind of filling up the space. And then the third category is called brain sagging. And that's a constellation of findings where the posterior fossa structures and the pituitary gland in the cell have become abnormal because you've lost the fluid that normally cushions those structures and causes them to float up. For example, the brain stem will sag down, the distance between the mammillary body and the ponds may become reduced. The suprasellar cistern space may be reduced such that the optic chiasm becomes very close to the pituitary gland, and the prepontine cistern may also become reduced in size. And there are various measurements that can be used to determine whether something is subtly abnormal. But just generally speaking, those are really the three categories of brain MRI abnormalities you'll see. Dr Grouse:  That was a great review. And of course, I think in many times when we are thinking about or suspecting this diagnosis, we may be lucky to find those imaging findings to reinforce a diagnosis. Because as it turns out, after reading your article, I was really surprised to find out that in as many as 19% of cases we actually see normal brain imaging, which really was a surprise to me, I have to say. And I think that this really encompasses why spontaneous intercranial hypotension is such a difficult diagnosis to make. I think a lot of us struggle with how far to take the workup when, you know, spontaneous intercranial hypotension is clinically suspected, but multiple imaging studies are normal. Do you have any guidance on how to approach these more difficult cases? Dr Madhavan:  So, that's a really good question. And you know, it's- as you can imagine, that's a topic that comes up in most meetings where people discuss this, and it's been a continued challenge. And so, like you said, about 19 or 20% of patients who have this disease can have a, a normal brain MRI. And we've tried to do some work to figure out why that is and how we can identify patients who still have the disease. And I can just provide, I guess, some tips that have helped me in my clinical practice. One thing is, if I ever see a patient with a normal brain MRI where this disease is clinically suspected---for example, maybe they have orthostatic headaches or other very typical symptoms and we don't know why, but their brain MRI is normal---the first thing I do is I try to look back at their old imaging. So many times, these patients who present to us at Mayo, who, when we do their MRI scan here, their brain MRI looks normal… if you really look back at imaging that they've had done elsewhere---maybe even two to three years prior---at the time their symptoms started, they actually had some abnormalities. So, I might see that a patient, two years ago, had dural enhancement that spontaneously resolved; but now they still have symptoms of SIH and they may still have a CSF leak that we can find and treat, but their brain MRI has, for whatever reason, normalized. So, I always start by looking back at old imaging, and I found that to be very helpful. The other thing is, if you see a patient with a normal brain MRI, it's also important to look at their spine MRI because that can provide clues that might suggest that they could still have a spinal CSF leak. And the two things I look for on the spine MRI: one, if there's any extradural CSF. So, spinal fluid outside of where it's supposed to be within the confines of the subarachnoid space. And you know, really, if you see extradural CSF, you know they probably have a spinal fluid leak somewhere. Even if their brain MRI is normal, that just gives you the information that there is a dural tear probably somewhere. And so, in those patients we'll definitely still proceed to myelography or other testing, even if they have a normal brain MRI. And then the last thing I look for is whether or not they have prominent meningeal diverticula. Patients with CSF venous fistulas almost always have one or more prominent diverticula on their spine along the nerve root sleeves. And that's probably because most of these fistulas come from nerve root sleeve diverticula. We don't completely understand the pathogenesis of CSF venous fistulas, but they're clearly associated with meningeal diverticula. So, if I see a patient who has a normal brain MRI, but I see on their spine MRI that they have many meningeal diverticula that are relatively prominent, that makes me more inclined to be a little bit more aggressive in doing myelography to find a CSF leak. And then I look at other demographic features, too. So, for example, elevated BMI and older age are associated with CSF venous fistulas. So, that can help you determine whether or not it's warranted to go on to more advanced imaging, too. So those are all just a variety of different things that we've used to help us. Dr Grouse:  Thank you for sharing that. I wanted to go on to say that, you know, reading your article, of course, as you mentioned, you alluded to the fact there's lots of new imaging modalities out there. It was very illuminating and just an excellent resource for the options that exist and when they're useful. You did a great job summarizing it. And I encourage our readers to check out your article, to refresh themselves, update themselves on what's happened in this space. And of course, we can't summarize them all today, but I was wondering if you could possibly walk us through a hypothetical case of a patient who comes in with a history very suspicious for SIH? How would you approach this patient? Say you have gotten imaging that suggested that there is a spinal fluid leak and now you have to figure out where it is. Dr Madhavan:  Yeah. So, you know, I think the most typical scenario it'll be a patient who has been seen by one of my excellent neurology colleagues and they've done a brain MRI and they've made the diagnosis through a combination of clinical information and brain MRI finding. And then the next thing we'll do always is, we'll obtain a spine MRI. So, I think of the purpose of the spine MRI as to determine what type of spinal fluid leak they have. On the spine MRI, if you see extradural CSF, those patients essentially always will have a dural tear. And it may be a ventral dural tear or a lateral dural tear. But if you see extradural CSF, that is pretty much what they have. And conversely, if you don't see extradural CSF---if you just see, for example, many meningeal diverticula, but you don't see anything else particularly abnormal---most of those patients have a CSF venous fistula, just common things being common. So I use the spine MRI to determine what type of leak they have. And then the next thing I think about is, okay, I'm going to do a myelogram on this patient. How do I want to position them? Because it turns out that positioning is probably the most important factor for finding these spinal fluid leaks. You have to have the patient positioned correctly to find the leak that you're trying to localize. And so, if I suspect they have a ventral dural tear, I will always position those patients prone for their myelogram. And I might do one of many different types of myelograms. And, you know, the article talks about things like digital subtraction myelography and dynamic CT myelography. And you can find any of these leaks with any of those techniques, but you just have to have the patient positioned correctly. So, if I think I have a ventral dural tear, I'll put them prone for the myelogram. If I think they have a lateral dural tear, I'll put them in the cubitus position for the myelogram. And also, if they- if I think they have a CSF-venous fistula, I'll also put them in the decubitus position. Obviously if you're putting them in the decubitus position, you have to decide whether it's going to be left or right side down. So that may require a two-day exam. Sometimes you don't have to; in many cases, we're able to just do everything in one day. But those are all the different factors I think about when I'm trying to determine how I'm going to work those patients up further. So, I really use the spine MRI chiefly to think about what type of leak they're going to have and how I'm going to plan the myelogram. Dr Grouse:  That's really great. And it's, I think, really nice to emphasize how much the positioning matters in all this, which I think is not something we've been classically taught as far as the diagnosis of spinal leaks. Another thing I'm really interested in your opinion on is, you talked a lot about how to optimize and what can make you successful at diagnosis. I'm curious what you think one of the easiest mistakes to make or, you know, that we should hopefully avoid when treating patients with this disease. Dr Madhavan:  Yeah. And I think, you know, one other thing that's been discussed a lot in this topic… you know, we've talked about the patients with a normal brain MRI. Another barrier or challenge particularly with CSF-venous fistulas is, sometimes they can be very subtle on imaging. So, it's not always you see it very definitive CSF-venous fistula where you can say, like, there's no question, that's a fistula. There are many times where we do a good-quality myelogram and we see something that looks, like, possible for a CSF venous fistula, or probable. If I had to put a number on it, maybe there's a 50 to 70% chance of real. So, in those cases, we end up wondering, like, should we treat this suspected leak? And I think one common mistake  or one thing that needs to be looked at further is, how do we handle these patients where we don't know whether the fistula is real or not? That's usually something where I will have a discussion with the patient, and I'm usually just very upfront with him about my interpretation of the imaging. I'll just tell them, we did a good-quality myelogram. You did a great job. We got good images. I don't see anything definitive, but I see this thing that I think has maybe a 60% chance of being real. And then I'll confer with one of my neurology colleagues and we'll decide whether it's worth treating that or not. And we'll just be very upfront with a patient about whether- about the likelihood of its success and what their long-term prognosis is. And oftentimes we let them make the decision. But I think that remains to be one of the big challenges is, how do we treat these patients who have suspected leaks that are not definitive on imaging. Dr Grouse:  That sounds absolutely like an important area where there can be problems, so I appreciate that insight. I'm interested what you think in your article would come as the biggest surprise to our listeners who may not have kept up as much with all of the changes that have happened in recent years? Dr Madhavan:  One of the things that was certainly, at least, a surprise to me as I was going through my training and learning about this topic is how diverse myelography has really become. You know, when I was a radiology resident, I learned about myelography as this thing that we've been doing for 30 to 40 years. And historically we've used myelograms just to look for degenerative changes: disc bulges, you know, disc herniations and things like that. Now that MRI is more prevalent, we don't use it as much, but it has turned out that it has a very big role in patients with spinal fluid leaks. Furthermore, something that I've learned is just how diverse these different types of myelograms have become. It used to kind of be just that a myelogram is a myelogram is a myelogram, but now we have different types of positioning, different types of equipment that we use. We vary the timing between contrast injection and imaging to optimize success for finding spinal fluid leaks. So, I think many times I talk to people who may not be as familiar with this field and they're surprised at just how diverse that has become and how sophisticated some of the various myelographic techniques have become and how much that really makes a difference in being able to accurately diagnose these patients. Dr Grouse:  Well, I can say it was a surprise to me. Even as someone who does treat quite a few patients with this condition, I was surprised to see the breadth of different options that have become available. And then kind of a follow-up to that, what do you think the current area of controversy is in this area of diagnosis and treatment? Dr Madhavan:  The biggest ones are ones you've sort of already alluded to. So, one big one is, how far do we go in patients who have a normal brain MRI who still have a clinical suspicion of the disease? And sometimes it's really hard, because sometimes you will find patients who clinically have a very strong case for having spontaneous intracranial hypotension. You look at them, they have very acute-onset orthostatic headaches. There's no better explanation for their symptoms that we know of. And it's hard to know what to do with those patients, because some of them want to continue to undergo diagnostic workup, but you can only do so many myelograms and you can only do so much with this diagnostic workup that requires some radiation dose before it becomes very challenging. That's a major point of just, I guess, ongoing research as to what can we do better for that subset of patients. Fortunately, it's not all of them, it's a subset of them, but I think we could help those patients better in the future as we learn more about the disease. So that's one. And the other one is treating these equivocal findings, like I discussed.  And where should our threshold be to treat a patient, and what type of treatment should we do in patients where we don't know whether a leak is real? Should we just do a very noninvasive- relatively noninvasive blood patch? Do we do an embolization where we're leaving a foreign body there? Is it worth sending those patients to surgery? Those are all unanswered questions and things that continue to spark ongoing debate. Dr Grouse:  Do you think that there's going to be any new big breakthroughs, or even, do you know of any big developments on the horizon that we should be keeping our eyes out for? Dr Madhavan:  You know, I think for me the biggest thing is, imaging is dramatically improving. We talked a little bit about photon counting detector CT in our article, and that's one of the newest and best techniques for imaging these patients because it has very, very high resolution, it has a lower radiation dose, it has allowed us to find leaks that we were not able to find before. And there are other high-resolution modalities that are emerging and becoming more accessible to things like cone beam CT which we do in addition to digital subtraction myelography. And on top of that, we've started to use AI-based tools to make images look a lot better. So, there are various AI algorithms that have come out that allow us to remove artifacts from imaging. They help us image patients with a bigger body habitus better without running into a lot of imaging artifacts. They help us reduce noise in imaging. They can just give us better-quality images and aid us in the diagnosis. For me as a radiologist, those are some of the most exciting things. We're finding less invasive ways with less radiation to better diagnose these patients with just better-quality imaging. Dr Grouse:  Well, that is definitely something to be excited about. So, I just want to thank you so much for talking with us today. It's been such an interesting, informative discussion and a real privilege to talk with you about this important topic. Dr Madhavan:  Yeah, thanks so much. I really appreciate the time to talk with you, and I look forward to seeing the article out there and hopefully getting some interesting questions. Dr Grouse:  Again, today I've been interviewing Dr Ajay Madhavan about his article on Radiographic Evaluation of Spontaneous Intracranial Hypotension, which he wrote with Dr Levi Chasen. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Spontaneous intracranial hypotension reflects a disruption of the normal continuous production, circulation, and reabsorption of CSF. Diagnosis requires the recognition of common and uncommon presentations, careful selection and scrutiny of brain and spine imaging, and, frequently, referral to specialist centers.  In this episode, Gordon Smith, MD, FAAN speaks with Jill C. Rau, MD, PhD, author of the article “Clinical Features and Diagnosis of Spontaneous Intracranial Hypotension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Smith is a Continuum® Audio interviewer and a professor and chair of neurology at Kenneth and Dianne Wright Distinguished Chair in Clinical and Translational Research at Virginia Commonwealth University in Richmond, Virginia. Dr. Rau is an assistant professor of clinical neurology at the University of Arizona, School of Medicine-Phoenix in Phoenix, Arizona. Additional Resources Read the article: continuumjournal.com Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @gordonsmithMD Full episode transcript available here Interview with Jill Rau, MD Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Smith: This is Dr Gordon Smith. Today I'm interviewing Dr Jill Rau about her article on clinical features and diagnosis of spontaneous intracranial hypotension, which she wrote with Dr Jeremy Cutsworth-Gregory from the Mayo Clinic. This article appears in the 2025 Continuum issue on disorders of CSF dynamics. I'm really excited to welcome you to the Continuum podcast. Maybe you can start by just telling our listeners a little bit about yourself? Dr Rau: Hi, thanks for having me. I'm really honored to be here, and I really enjoyed writing the paper with Dr Cutsforth-Gregory. I hope you guys enjoy it. I am the director of headache medicine at the Baba Bay Neuroscience Institute at Honor Health in Scottsdale, Arizona. I'm also currently the chair of the special interest group in CSF Dynamics at the American Headache Society, and I've had a special interest in this field since I first watched Dr Linda Gray speak at a conference where she talked about spinal CSF leaks and their different presentations. And they were so different than what I had been taught in residency. They're not just the post-LP headache. They have such a wide variety of presentations and how devastating they can be, and how much impact there is on someone's life when you find it and fix it. And I've been super interested in the field and involved in research since that time. And, yeah. Love it. Dr Smith: Well, thanks for sharing your story. And as I reflected on our conversation ahead of time and have been thinking about this issue… this is a cool topic, and every time I read one of these manuscripts and have the opportunity to speak with one of the authors, I learn a ton, because this was something that wasn't even on the radar when I trained back in the 1800's. So, really looking forward to the conversation. I wonder if you could really briefly just summarize or remind for everyone the normal physiology about CSF dynamics, you know, production, absorption, and so forth? Dr Rau: So, the CSF is the fluid that surrounds the brain and the spinal cord, and it's contained by the dura, which is like a canvas or a sac that covers that whole brain and spinal cord. And within the ventricles of the brain, the choroid plexus produce CSF. It's constantly producing and then being reabsorbed by the arachnoid granulations and pushed into the venous space, the cerebral sinuses, venous sinuses. And also some absorption and push into the lymphatics that we've just learned about in the past year. This is kind of new data coming out, so always learning more and more about CSF, but we know that it bathes the brain and the spinal cord, helps keep some buoyancy of the brain as well as pushing nutrients in and pulling out metabolic waste. And it sort of keeps the brain in the state of homeostasis that's happy. And so, when there's a disruption of that flow and the amount of fluid there, that disrupts that, that can cause lots of different symptoms and problems for people. Dr Smith: One of the many new things I learned is that even the name of this---spontaneous intracranial hypotension---is misleading. And I think this is clinically relevant, as we'll probably get to in a moment, but can you talk a little bit about this? Is this really like a pressure disorder or a volume disorder? Dr Rau: Yeah. It's almost certainly a volume disorder. We do see in some people that they have low pressure, and it's still part of the diagnostic criteria. But it's there because if you have a low pressure, if you measure an opening pressure and it's below six, if you're measuring it in the spine in the right place, then you have indication that there's low volume. But there's over 50% of people's opening pressure who have a spinal CSF leak, have all the symptoms and can be fixed. So, they have normal pressure in 50% of the people. So, it is an inaccurate term, hypotension, but it was originally discovered because of the thought that it was a low-pressure situation. Some of the findings would suggest low pressure, but ultimately, we are pretty sure it's a low-volume condition. Dr Smith: Another new thing that I learned that really blew me away is how bad this can be. I did a podcast with Mark Burish about cluster, and I was reminded many cluster patients are pushed to the point of suicidal ideation or committing suicide by the severity of pain. And this sounds like for many patients it's equally severe. Can you maybe paint a picture for our listeners why this is so clinically important? Dr Rau: A large number of people, even people who are known to have leaks because they've had them before or they've releaked, they have a lot of brain fog and cognitive impairment. They often have severe headaches when they're upright. So, orthostatic headache is probably the number one most common symptom, and those headaches are one of the worst headaches out there. When people stand up, their fluid is not supporting the brain and there's an intense amount of pain. And so, they spend a large portion of their lives horizontal. And there's associated symptoms with that, it's not just headache pain and brain fog. There's neck pain. There's often subsequent disorders that accompany this, like partial orthostatic tachycardia syndrome. We don't know if that's because of deconditioning or an actual sequela of the disease, but it's a frequent comorbidity. We have patients that have extreme dizziness with their symptoms, but many patients are limited to hours, if that, upright per day, combined, total. And so they live their lives, often, just in the dark, lots of photophobia, sensitive to the light, really unable to function. It's also very hard to find and so underrecognized that a lot of patients, especially if they don't have that really clinical symptom of orthostatic headache. So, it's often missed. So, they're just debilitated. You know, treatments don't work because it's not a migraine and it's not a typical headache. It's a mechanical issue as well as a metabolic issue and not found, not a lot helps it. Dr Smith: So, you know, I have always thought about this as really primarily an orthostatic symptom. I wonder if you can talk about the complexity of this; in particular, kind of how this evolves over time, because it's not quite that simple. And maybe in doing so, you can give our listeners some pearls on when they should be thinking about this disorder? Dr Rau: A large portion of people do have headache with spinal CSF leak, in particular, spontaneous intracranial hypertension- hypotension, excuse me. And that's something to be thought about, is that there are spontaneous conditions where people have either rupture of the dural sac, or an erosion of the dural sac, or a development of a connection between the dura and the venous system. And that is taking away or allowing CSF to escape. In these instances that patients have spontaneous, there may be a different presentation than if they have, like, a postdural puncture or a chronic traumatic or iatrogenic leak. And we're not sure of that yet, but we're looking into that. Still, the largest presentation is headache, and orthostatic headache is very dominant in the headache realm. But over time, patients' brains can compensate for that lack of CSF and start overproducing---or at least we think that's probably what's happening. And you may see a reduction in the orthostatic symptoms over time, and you may see an improvement in the radiographic findings. So, there are some interesting papers that have been published that look at these changes over time, and we do see that sometimes within that first three to four months; this is the most common time to see that change. Other patients may worsen. You may actually see someone going from looking sort of normal radiographically to developing more of a SIH-type of picture on the brain. And so it's not predictable which patients have gone from orthostatic to improvement or the other way around, both radiographically and clinically. So, it can be quite difficult to tell. So, for me, if I have a patient that comes to me and they're struggling with headache… if it's orthostatic, very clearly orthostatic: I lay down, I get considerably better or my headache completely goes away. And then when I stand up, it comes on relatively quickly, within an hour. And sometimes it's a worsening-throughout-the-day type of thing, it's lowest in the morning and it worsens throughout the day. These are the times that it's most obvious to think about CSF leak. Especially if that headache onset relatively suddenly, if it onset after a small trauma. Like I've had patients that say, you know, I was doing yoga and I did some twists and I felt kind of a pop. And then I've had this headache that is horrible when I'm upright but is better when I lay down ever since, you know, since that time. That's kind of a very classic presentation of spinal CSF leak or spontaneous intracranial hypotension. Maybe a less common presentation would be someone who comes to you, they've had a persistent headache for a couple years, they kind of remember it started in March of a couple years ago, but they don't know. Maybe it's, you know, it's a little better when they lay down. It may be a little worse when they're up moving around, but so is migraine, and it's a migrainous headache. But they've tried every migraine drug you can think of. Nothing is responding, nothing helps. I'm always looking at patients who are new daily, persistent headaches and patients who aren't responding to meds even if it's not new daily, but they have just barely any response. I will always go back and examine their brain imaging and get full spine to make sure I'm not missing. And you can never be 100% sure, but it's always good to consider those patients to the best of your ability, if that- have that in the back of your mind. Dr Smith: So obviously, goes without saying, this is something people need to have on their radar and think about. And then we'll talk more about diagnostic tools here in a second. But how common is this? If you're a headache doc, you see a lot of patients who have intractable headaches. And how often do you see this in your headache practice? Now you're- this is your thing, so probably a little more than others, but, you know, how common will someone who sees a lot of headache encounter these patients? Dr Rau: If you see a lot of headache, I mean, currently the thought is it's about 5 in 100,000. That was from a study before we were finding CSF venous fistulas. I think a lot of us think it's more common than that, but it's not super common. We don't have good estimates, but I would guess between 5 and 10 for 100,000 persons, not “persons who come to a tertiary headache clinic with intractable headaches”. So, it's hard to gauge how frequent it is, but I would say it's considerably more frequent than we currently think it is. There's still a group of people with orthostatic headaches that we can't find leaks on; that, once you treat other things that can cause or look for other things that can cause orthostatic headaches. So, there may be even still a pathophysiology out there that is still a leak type. Before 2014, we didn't even know about CSF venous fistulas. And now here we are; like, 50% of them are CSF venous fistulas. So, you know, we're still in a huge learning curve right now. Dr Smith: So, I definitely want to talk about the fistulas in a second. But before moving on, one of the things that I found really interesting is the wide spectrum of clinical phenotype. And we obviously don't have a lot of time to get into all of these different ones, but the one that I was hoping you might talk about---and there's a really great case, and you're on bunch of great case, a great case of this---is brain sagging dementia, not a term I've used before. Can you really briefly just tell our listeners about that, because that's a really interesting story and a great case in your article? Dr Rau: Yeah. So, brain sag dementia is a… almost like an extreme version of a spontaneous intracranial hypotension. Where there is clear brain sag in the imaging---so that's helpful---but the patients present kind of like a frontotemporal dementia. And when this was first started to being determined, you could turn the patient into Trendelenburg, and sometimes they would improve. There are some practitioners that have introduced fluid into the thecal sac and had temporary improvement. Patching has improvement, then they leak again, sometimes  not. But the clinical changes with this have been pretty tremendous to be able to identify that that's a real thing. And in some cases, out of Cedars Sinai, you know, who does a lot of the best research in this, they've had lots of cases where they can't find the leak, but there's clear brain sag that fits with our clinical picture of CSF leaks. So, we're on a learning curve. But yeah, this- they really present. They have disinhibition and cognitive impairment that is very similar to frontotemporal dementia. Dr Smith: Well, so let's talk about what causes this. You mentioned CSF venous fistulas. I mean, that was reported now just over a decade ago, it's pretty amazing. That accounts for about half of cases, if I understand correctly. What are the other causes? And then we'll talk more about therapy in a minute, but what causes this? Dr Rau: So, within the realm of spontaneous, you know, we say it's spontaneous. But the spontaneous cases we account for, they can be tears in the dura, which are usually sort of lateral tears in the dura. They can be little places that rubbed a hole, often on an osteophyte from the spine. They can come from these spinal diverticuli. So, I always describe it to my patients like those balls that have mesh and squishy, and you squeeze them in the- through the mesh, there's the extra little bubbling out. If you think of like the dura bubbling, out in some cases, through the framing of the spine, right where the spinal nerve roots come out, they should poke out like wires from the dura. But in many cases they poke out with this extra dura surrounding them, and we call that spinal diverticuli. And if you imagine like the weakening of where you squeeze that, you know, balloon through your fingers, in those locations, that's a very common place to find a CSF leak, and you can imagine that the integrity of the dura there may be less than it would be if it were not being expanded in that direction. And that's often the most common place we see these CSF venous fistulas. So, you can get minor traumas; like I said, it can be spontaneous, like someone just develops a leak one day. It can be rubbed off, and it can be a development of a connection between the dura and the venous system. There are also iatrogenic causes, but we don't consider them spontaneous. But when you're considering your patients for spontaneous cases, you should consider if they've ever had chronic---even long, long time ago---had any spinal implementation, procedures near the spine, spinal injections, LPs in the past, and especially women who've had epidurals in pregnancy. Dr Smith: All right, so we see a patient, positional severe headache, who meets the clinical criteria. Next step, MRI scan? Dr Rau: Yeah. So, the first thing is always to get the brain MRI with and without contrast. Most places will have a SIH or a spinal CSF leak protocol, but you should get contrast because one of the most pathognomonic findings on brain MRI is that smooth diffuse dural enhancement. And that's a really fantastic thing when you find it, because it's kind of a slam dunk. If you find it, then you will see other findings. It almost never exists alone. But if you see that, it's pretty much a spinal CSF leak. But you're also looking for subdural collections, any indication of brain sag. We do have these new algorithms that have come out in the past couple of years that are helpful. They're not exclusionary---you can have negative findings on the brain and still have spinal CSF leak---but the brain MRI is extremely helpful. If it's positive for the findings, it really does help you nudge you in the direction of further investigations and treatments. Dr Smith: And what about those further investigations and treatments, right? So, you see that there's findings consistent with low pressure, and I guess I should say low intracranial CSF volume. Be that as it may, what's the next step after that? Dr Rau: Depends on where you are and what you can do. I almost always will get a full spine MRI: so, C spine, T spine, and L spine separately. Not, you know, we don't want it all in one picture, because we want to get the full view. And you want to get that with at least T2 highly- heavily T2 weighted with fat saturation in at least the sagittal and axial planes. It's really helpful if you can get it in the coronal planes, but we have to have- often have good talks with your radiologist to get the coronal plane. I spoke about the spinal diverticuli earlier, and I want to clarify a little bit of something. The coronal image will show those really nicely. It's interesting, but 44% of people have those. So just having the spinal diverticuli does not indicate that you have a leak. But if you have a lot of those, there may be more likelihood of having leak than if you don't have any of those. So, I will get all of those and I will look at them myself, but I've been looking at them myself for a long time. But a lot of radiologists in community hospitals, especially not- nonneuroradiologists, but even neuroradiologists, this isn't something that's that everybody's been educated about, and we've been learning so much about it so rapidly in the past ten years. It's not easy to do and it's often missed. And if it's not protocoled properly, the fat saturation's not there, it's very hard to see… you can have a leak and not see it. Even the best people, like- it's not always something that's visible. And these CSF venous fistulas that we talked about are never visible on normal MRI imaging. Nonetheless, I will run those because if I can find a leak---and 90% of the ones that are found on MRI imaging are in the thoracic spine. So that's where I spend the most of my time looking. But if you find it, that's another thing to take to your team to say, hey, look, here it is, let's try and do this, or, let's try and do that, or, I've got more evidence. And there are other findings on the spine; not just the leak, but other findings, sometimes, you can see on spine that maybe help you push you towards, yes, this is probably a leak versus not. Dr Smith: So, your article has a lot of great examples and detail about kind of advanced imaging to, like, find the fistula and what not. I guess I'm thinking most of our listeners are probably practicing in a location where they don't have a team that really focuses on that. So, let's say we do the imaging of the spine and you don't find a clear cause. Is the next step to just do a blood patch? Do you send them to someone like you? What's the practical next step? Dr Rau: Yeah, if your- regardless of whether you find a leak or not, if your clinical acumen is such that you think this patient has a leak or I've treated them for everything else and it's not working and I have at least a high enough suspicion that I think the risk of getting a patch is lower than the benefit that if they got a patch and it worked, I do send my patients for non-directed blood patches, because it currently does take a long time to get them to a center that can do CT myelograms or any kind of advanced imaging to look for sort of a CSF venous fistula or to get treated outside of a nondirected patch. You know, sometimes nondirected patches are beneficial for patients, and there's some good papers out there that sort of explain the low risks of doing these if done properly versus the extreme benefit for patients when it works. And, I mean, I can't tell you how many people come in and tell me how their lives are changed because they finally got a blood patch. And sometimes it works. And it's life-changing for those people. You know, they go back to work. They can interact with their kids again. Before, they didn't know what was wrong, just had this headache that started. So it's worth doing if you have a strong clinical suspicion. Dr Smith: Yeah. I mean, that was great. And, you know, to go back to where we began, this is severe. It's something like 60% of patients with this problem have thought about suicide, right? And you take this patient and cure the problem. I feel really empowered having read the article and talked to you today. And so, I'm ready to go out and look for this. Thank you so much for a really engaging conversation. This has been terrific. Dr Rau: Thank you. I appreciate it. I enjoyed being here. Dr Smith: Again, today I've been interviewing Dr Jill Rau about her article on clinical features and diagnosis of spontaneous intracranial hypotension---which I guess I should say hypovolemia after having talked to you---which she wrote with Dr Jeremy Cutsworth-Gregory. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Please be sure to check out Continuum Audio episodes from this really interesting issue and other interesting issues. And thank you, our listeners, again for listening to us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Dr. Jessica Ailani and Dr. Kathleen Digre discuss the evolution of spontaneous intracranial hypotension (SIH) diagnosis and treatment over the past decade.

Dr. Jessica Ailani talks with Dr. Kathleen Digre about the evolution of spontaneous intracranial hypotension (SIH) diagnosis and treatment over the past decade. Disclosures can be found at Neurology.org. 

In this episode of Nursing EDge Unscripted, host Kellie Bryant from the National League for Nursing's Center for Innovation in Education Excellence is joined by Dr. Lou Clark, current president of the Association of SP Educators (ASPE) and the Executive Director of M Simulation at the University of Minnesota. This episode discusses a recent call to action from ASPE on properly honoring simulated participants (SPs) and collaborating with SP educators in healthcare education. Dr. Clark emphasizes the importance of respecting SPs as human beings, rather than referring to them as tools, and highlights the hidden work of SP educators in training, coaching, and safeguarding SPs. The conversation explores best practices for integrating SP methodology, such as using inclusive language, providing fair compensation, and recognizing SP educators' contributions in research and curriculum development. Listeners are encouraged to access ASPE resources for guidance on SP recruitment, training, and evaluation. The episode concludes with insights on the future of SPs in simulation, emphasizing the need for collaboration with emerging technologies while maintaining the human element in patient care training. Learn more about the Association of SP Educators by visiting their website: https://www.aspeducators.orgRead the Call to Action referenced in this episode: Clark, L., Doyle, A., Elcin, M., McNaughton, N., Nicholas, C., Owens, T., Smith, C., Szauter, K., Xing, K., & Nestel, D. (2024). Call to Action: Honoring Simulated Participants and Collaborating With Simulated Participant Educators. Simulation in healthcare : journal of the Society for Simulation in Healthcare, 10.1097/SIH.0000000000000840. Advance online publication. https://doi.org/10.1097/SIH.0000000000000840Dedicated to excellence in nursing, the National League for Nursing is the leading organization for nurse faculty and leaders in nursing education. Find past episodes of the NLN Nursing EDge podcast online. Get instant updates by following the NLN on LinkedIn, Facebook, X, Instagram, and YouTube. For more information, visit NLN.org.

“ Tugas kaum ibu kanggo ngembangake pikiranne lan njaga supaya atine tetep suci” ”Sih katresnané Gusti Yesus Kristus yaiku kangge sekabehaning umat manungsa“

Ascultați un cuvânt care ar trebui să ne trezească puțin în fața marilor păcate care se apropie cu pași repezi de noi. De asemenea, sunt prezentate și amintiri de la Hramul de la Sihăstria.Vizionare plăcută!Pentru Pomelnice și Donații accesați: https://www.chilieathonita.ro/pomelnice-si-donatii/Pentru mai multe articole (texte, traduceri, podcasturi) vedeți https://www.chilieathonita.ro/

Ascultați un frumos cuvânt al părintelui Pimen Vlad în care acesta ne vorbește despre hramul Sfintei Teodora de la Sihla, despre mănăstirea Sihla precum și despre mănăstirea Sihăstria și despre sfinții acesteia.Vizionare plăcută!Pentru Pomelnice și Donații accesați: https://www.chilieathonita.ro/pomelnice-si-donatii/Pentru mai multe articole (texte, traduceri, podcasturi) vedeți https://www.chilieathonita.ro/

Dr. Jessica Ailani and Dr. Ian Carroll discuss intracranial hypotension, the challenges of diagnosing and treating patients with CSF leaks, and the study's findings. Show reference: https://www.neurology.org/doi/10.1212/WNL.0000000000209449  This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information.

Dr. Jessica Ailani talks with Dr. Ian Carroll about intracranial hypotension, the challenges of diagnosing and treating patients with CSF leaks, and the study's findings. Read the related article in Neurology.  This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information. Disclosures can be found at Neurology.org.

“Anak-anak kudu diwulang nggunaake wektune sakbecik-becike” “pangapura iku peparing sih-rahmat saka Gusti Allah kang ngedhapi - edhapi asil saka Sih - kadarmane kang agung”

“Wiwit tahun-tahun sepisanan saka uripe, anak-anak kudu diwulang kanggo nglaksanaake bagiane sakjerone pakaryan bale wisma” “Sih-welase Gusti Allah diparingake ora mung kangge Israel nanging uga kangge marang sekabehaning titah”

Severe orthostatic headaches could indicate a serious condition called spontaneous intracranial hypotension (SIH). Neurologist Will Meador, M.D., and interventional neuroradiologist Jesse Jones, M.D., discuss how they interpret a combination of symptoms and imaging to make diagnoses and the common first-line treatments for cases that do not resolve with conservative lifestyle interventions. Learn details about a complex surgery to address severe cases.

In deze vierde aflevering van “Hersenspinsels” staat het spontane liquorhypotensiesyndroom (SIH) centraal. We spreken hierover met Matthijs Brouwer, neuroloog en hoogleraar neurologische infectieziekten en neuro-immunologische aandoeningen in het AmsterdamUMC. Hij legt ons uit wanneer we aan het SIH moeten denken en wat de klinische kenmerken zijn. We bespreken de pathofysiologie en welke diagnostiek je moet inzetten als je een patiënt van het SIH verdenkt. Uiteraard komen ook de behandeling en prognose aan bod. Welke atypische manifestaties kan het SIH hebben? Wat is een digitale subtractie myelografie? En hoe behandelt een interventieradioloog tegenwoordig het SIH? De antwoorden krijg je allemaal in deze podcastaflevering. Ookvertelt Matthijs of hij een ANIOS die zijn/haar eerste dienst heeft bij hemzelf een lumbaalpunctie zou laten verrichten (uiteraard indien geïndiceerd), wat zijn favoriete South park aflevering is, en of hij liever kiest voor twerken of salsa op de dansvloer. Deze podcast wil je kortom horen!Voor meer informatie zie ook: - Het artikel over SIH in Continuum: https://journals.lww.com/continuum/abstract/2021/06000/spontaneous_intracranial_hypotension.14.aspx-Het Nervus artikel over het SIH: https://www.nervus-online.nl/tijdschrift/editie/artikel/t/het-spontane-liquorhypotensiesyndroom-SIH foundation met tevens informatie over congressen:https://spinalcsfleak.org/

“Tugas kaum ibu kanggo ngembangake pikiranne lan njaga supaya atine tetep suci” - ”Sih katresnané Gusti Yesus Kristus yaiku kangge sakabehing jalma manungsa“

Trusting what you see investors doing on social media can be tempting, but looks can sometimes be deceiving. On this episode of Zen and the Art of Real Estate Investing, Jonathan interviews Denis Shapiro, Managing Partner of SIH Capital Group. Denis began investing in real estate in 2012. Over the years, he has created a diversified portfolio that includes ATM funds, mobile home parks, life insurance policies, tech startups, and industrial property. Denis is also the author of The Alternative Investment Almanac: Expert Insights on Building Personal Wealth in Non-Traditional Ways. Jonathan and Denis begin their discussion by delving into Denis's early exposure to real estate with the book Rich Dad, Poor Dad, and why it didn't stick the first time around. They cover the lessons he's teaching his kids about money using Monopoly, why he loves having a diversified portfolio, and what types of affordable housing he prefers. Denis explains how he finds off-market deals in the affordable housing space, the three asset classes he loves the most, and why private lending is an integral part of the three pillars of his business. You'll hear why creating relationships is crucial to his business model rather than leaning on reputation, why taking actionable steps matters when introducing yourself to other investors, and the value of knowing your skillset and having a basic knowledge of terminology at your disposal. Finally, Denis emphasizes being cautious when choosing syndications to invest with and knowing what uncomfortable questions to ask. Denis's career is centered on relationships and trust, which continues to help his business scale and thrive. In this episode, you will hear: Denis Shapiro's early exposure to real estate investing and his pivot from a career in government to real estate investing What Monopoly is teaching his kids about real estate investing The lessons he's trying to teach his kids about money and why having money doesn't necessarily make you rich Why Denis loves being diversified with his investments His first property and some of the big lessons he learned from it The importance of having a team in place to help manage affordable properties at scale The types of affordable housing Denis prefers, and the barrier of entry red tape creates that you won't find in commercial real estate Finding off-market deals in the affordable housing space The three asset classes Denis loves the most and why he stays focused on those Private lending and what makes it an attractive pillar in his business model Creating relationships with other investors and building trust instead of basing a business deal on reputation Learning to ask the right questions as a new investor Taking actionable steps when you're working on building relationships with people you want to work with Why knowing your skillset and some industry terminology can improve how you relate to those you want to learn from and work with What you can learn from LP investors and being careful when choosing syndications Denis's advice for not becoming too dependent on track records and knowing what uncomfortable questions to ask Follow and Review: We'd love for you to follow us if you haven't yet. Click that purple '+' in the top right corner of your Apple Podcasts app. We'd love it even more if you could drop a review or 5-star rating over on Apple Podcasts. Simply select “Ratings and Reviews” and “Write a Review” then a quick line with your favorite part of the episode. It only takes a second and it helps spread the word about the podcast. If you enjoyed this episode, we've created a PDF that has all of the key information for you from the episode. Just go to the episode page at http://www.trustgreene.com/podcast/zen/135 to download it. Supporting Resources: SIH Capital Group - sihcapitalgroup.com SIH's YouTube channel - www.youtube.com/channel/UCSd5v7aB8DSn9Ef9LyuXlVA SIH Capital on Facebook - www.facebook.com/SIH-Capital-Group-104648791684808 SIH on Instagram - www.instagram.com/sihcapitalgroup Connect with Denis Shapiro on LinkedIn - www.linkedin.com/in/denisshapiro Find SIH Capital on Twitter/X - twitter.com/sihcapital Website - www.streamlined.properties YouTube - www.youtube.com/c/JonathanGreeneRE/videos Instagram - www.instagram.com/trustgreene Instagram - www.instagram.com/streamlinedproperties TikTok - www.tiktok.com/@trustgreene Zillow - https://www.zillow.com/profile/StreamlinedReal Bigger Pockets - www.biggerpockets.com/users/TrustGreene Facebook - www.facebook.com/streamlinedproperties Email - info@streamlined.properties Episode Credits If you like this podcast and are thinking of creating your own, consider talking to my producer, Emerald City Productions. They helped me grow and produce the podcast you are listening to right now. Find out more at https://emeraldcitypro.com Let them know we sent you.

The first multidisciplinary consensus guideline for the diagnosis and treatment of spontaneous intracranial hypotension (SIH) has recently been published by the UK SIH Specialist Interest Group. Group members Prof. Manjit Matharu (1), Dr. Indran Davagnanam (2), and Mr. Parag Sayal (3) join Dr. Amy Ross-Russell to explain their recommendations. They discuss the impact this condition has on patients, the possible presentations, and approaches for diagnosis and treatment.   Read the article: Spontaneous intracranial hypotension   (1) Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK (2) Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK (3) Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK

TurkuOz 23 Nisan Çocuk Festivali'ne bu yıl Aborijin, Vietnam, Nepal, Bosna Hersek, Uygur ve Sih toplumlarından çocuklar da katılıyor. Etkinlik 28 Nisan tarihinde Holroyds Gardens'ta.

To end this season of Speaking in Hues, Taylor is joined by Nia, and SIH editors Jessica and Carson to talk about friendships post graduation.Follow us on Twitter @HUESPodcast or email the hosts at speakinginhues@virginia.edu.

Mabuting Balita l Marso 22, 2024 – Biyernes sa Ikalimang Linggo ng Ebanghelyo: Jn 10:31-42 Dumampot ng mga bato ang mga Judio para batuhin si Hesus. Sinabi sa kanila ni Hesus: “Maraming mabubuting gawa ang itinuro ko sa inyo mula sa Ama. Alin sa mga ito ang dahilan kung baki't n'yo ako binabato?” Sinagot siya ng mga Judio: “Binabato ka namin hindi dahil sa isang mabuting gawa kundi dahil sa paglapastangan sapagkat gayong ikaw ay tao, itinuturing mong Diyos ang iyong sarili.” Sumagot sa kanila si Hesus: “Hindi ba nasusulat sa Batas ninyo: 'Aking sinabi,” mga Diyos kayo” '? Kaya tinawag na mga diyos ang mga tumatanggap ng salitang ito ng Diyos, at hindi mapawawalang-saysay ang Kasulatan. Kung gayon, nang sinabi kong ako ang Anak ng Diyos—ako na pinabanal ng Ama at sinugo sa mundo –bakit n'yo sinasabing paglapastangan ito? Kung hindi ko ginagawa ang mga gawa ng aking ama, huwag n'yo akong paniwalaan. Kung ginagawa ko naman, kahit hindi kayo naniniwala sa akin, maniwala naman kayo sa mga gawa. Kaya alam na alam nga ninyo na nasa akin ang Ama at ako'y nasa Ama.” Kaya muli nilang pinagtangkaang dakpin si Hesus ngunit nakatalilis siya sa kanilang kamay. At muli siyang lumayo pakabilang ibayo ng Jordan sa lugar na pinagbibinyagan ni Juan sa simula. At doon siya nanatili. Marami ang pumunta sa kanya at kanilang sinabi: “Hindi nga gumawa ng anumang tanda si Juan, pero nagkatotoo nga ang lahat ng sinabi ni Juan tungkol sa kanya.” At doo'y marami ang naniwala sa kanya.   Pagninilay: Lagi nating nababasa ang bahaging ito ng Mabuting Balita, na tinangka ng mga taong batuhin si Hesus, dahil para sa kanila ipinapantay niya ‘di umano, ang kanyang sarili sa Diyos. Mauunawaan natin ito nang mas malinaw, kung titignan natin ang kultura ng mga Hudyo. Isang napakalaking pagkakasala para sa kanila ang angkinin ang pagiging Diyos, dahil iisa lamang ang Diyos. Ang pambabato ang isa sa mga paraan ng kaparusahan sa kanilang panahon. Kaya nga kung may mga ganitong pagkakataon, binabato nila ang mga may pagkakasala.  Pero alam nating lahat na hindi nagpapanggap si Hesus. Alam natin na siya at ang Ama ay iisa. Na siya ang Anak ng Diyos. Marahil mayroon ding ganitong pakiramdam ang mga taong muntik nang bumato kay Hesus. Hindi nila maituloy-tuloy dahil nakikilala nila siya, at nakita nila ang mga kagila-gilalas niyang ginawang himala. Naranasan nila ang pagpapagaling sa mga may sakit, ang pagsasalita ng mga pipi, ang pagkakarinig ng bingi at maging pagkakita ng mga bulag. Higit sa lahat, nakita nila mismo ang muling pagkabuhay ng namatay. Alam ng mga Hudyo na mga tanda ito ng Kapangyarihan at Gawa ng Diyos at ng Mesiyas na ipinangako. Handa na silang bumato, pero hindi nila maipukol-pukol dahil natatakot din sila – Hindi nila kayang batuhin ang Diyos. Kaya nga nagpatuloy pa rin siH esus.  Pero kahit batuhin pa nila si Hesus, hindi siya titigil sabihin ang katotohanan at ipahayag ang paghahari ng Diyos sa sanlibutan. Sa ating panahon ngayon, mahilig tayong bumato ng maraming problema at paratang sa Diyos. Minsan grabe tayo pumukol ng kasalanan, na labis na ikinasusugat ng puso ng Diyos. Hindi natin napapansin ang dakila niyang awa at gawa, na nasa paligid natin, mga araw-araw na himala mula sa pagsikat ng bagong araw, hanggang sa paggaling sa mga karamdaman. Hindi natin makita dahil binubulag tayo ng katigasan ng puso, kasalanan at takot. Sa papalapit na mga mahal na araw ipakikita at ipapaalala sa atin ng Diyos na kahit ilang beses natin siyang batuhin, pukulin, lumatay man ang daang latigo sa kanyang katawan, tatanggapin niyang lahat. Dahil kahit kailan, hindi niya iiwan ang kanyang minamaha na sambayanan. Hindi siya titigil, ni hindi mapapagod, lagi niyang ituturo ang daan ng kapatawaran at kapayapaan tungo sa buhay na walang hanggan.

In this podcast, Series 3, Chapter 5, Dr. Barsuk interviews Dr. Jared Kutzin, Associate Professor of Emergency Medicine and Medical Education at the Icahn School of Medicine at Mount Sinai and Senior Director of Simulation at the Mount Sinai Hosipital.  Dr. Kutzin is a doctorally prepared registered nurse with expertise in healthcare quality, patient safety, and simulation operations.  He is the president-elect of the Society for Simulation in Healthcare (SSH) and will serve as president in 2025. Drs. Barsuk and Kutzin discuss simulation operations at Mount Sinai and the future direction of SSH.

“Gusti bakal mulang akeh wong ing saklumahing jagad kanggo nggabungake woh-wohan, wiji-wijian lan jejanganan dadi panganan sing nyokong panguripan sing ora nggawa lelara” - ”Sih katresnané Gusti Yesus Kristus kuwi kanggo sekabehaning manungsa“

“Yaiku sawijining dosa sing nggegirisi menawa kita ngrusak kesehatan sing diparingake Gusti Allah marang kita” - “Pengalamane Yunus nalika ing wetenge iwak minangka satunggaling pagelaran dramatis saka Sih-katresnan lan kamirahaning Gusti Allah“

Dr. Tesha Monteith talks with Dr. Wouter Schievink about what spontaneous intracranial hypotension is and why it's commonly misdiagnosed.  Visit NPUb.org/Podcast for additional podcasts and associated article links.

Dr. Derek Stitt talks with Dr. Andrew Callen about the relationship between bern score, spinal elastance, and opening pressure in patients with spontaneous intracranial hypotension. Read the related article in Neurology. For links to articles and previous podcast episodes, please visit NPUb.org/Podcast. This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information.

Ascultați pe părintele Cosma Giosanu, cunoscut autor de cărți duhovnicești și stareț al primei mănăstiri cu hramul Sf. Neagoe Basarab, care ne povestește întâmplări minunate despre marii duhovnici ai mănăstirii Sihăstria, duhovnici pe care i-a cunoscut în perioada în care s-a nevoit la mănăstirea Sihăstria.Audiție plăcută!Pentru Pomelnice și Donații accesați: https://www.chilieathonita.ro/pomelnice-si-donatii/Pentru mai multe articole (texte, traduceri, podcasturi) vedeți https://www.chilieathonita.ro/

In this two part podcast, Series 2, Chapter 10, Dr. Barsuk interviews Dr. Barry Issenberg, the Michael S. Gordon Endowed Chair and Professor of Medicine and Medical Education, Senior Associate Dean for Research in Medical Education and Director of the Gordon Center for Simulation and Innovation at the University of Miami Miller School of Medicine. They discuss Barry's role at the Gordon Center and the Miller School of Medicine where he helped develop Harvey-the cardiovascular simulator, his scholarly work and his future plans as president elect of the Society for Simulation in Healthcare.

S4E13 Pengalaman Guru Killer Kayak mana Sih ??

Dr. Jessica Ailani talks with Dr. Katharina Wolf, about MRI of CSF-flow and spinal cord motion being a promising diagnostic tool in SIH. Read the full article in Neurology.

Ascultați o mărturie cutremurătoare a doamnei Oana Maria Smoc, medic stomatolog din Iași, cu ocazia lansării cărții „Părintele Proclu - file de Pateric”, sâmbătă, 27 ianuarie 2018, la Mănăstirea Sihăstria Putnei.Doamna stomatolog ne relatează despre vedenia pe care a avut-o părintele Proclu la moartea părintelui Justin Pârvu.Audiție plăcută!Pentru Pomelnice și Donații accesați: https://www.chilieathonita.ro/pomelnice-si-donatii/Pentru mai multe articole (texte, traduceri, podcasturi) vedeți https://www.chilieathonita.ro/

Ascultați un cuvânt cu părintele stareț Arsenie Popa, egumenul cunoscutei mănăstiri Sihăstria în care ne evocă personalitatea sfântului Cleopa și a părintelui Arsenie Papacioc așa cum i-a cunoscut. Dincolo de evocarea acestor mari personalități, părintele stareț Arsenie ne vorbește despre problemele tinerilor și vremurile de astăzi.Vizionare plăcută!Pentru Pomelnice și Donații accesați: https://www.chilieathonita.ro/pomelnice-si-donatii/Pentru mai multe articole (texte, traduceri, podcasturi) vedeți https://www.chilieathonita.ro/

Welcome to #84th episode of The Startup Operator Roundup. Today we have Roshan Cariappa and Gunjan Saha discussing -  1. Smart India Hackathon 2022 comes to an end2. MoHUA has onboarded 76 startups under the ‘India Water Pitch-Pilot-Scale Start-Up Challenge.'3. Zomato unveils intercity food delivery4. Indian central bank is looking to address UPI Duopoly in India5. Samudrayaan Mission launched to explore deep seas...and more! ------------------------------------- Connect with Us: Linkedin: https://www.linkedin.com/company/startup-operator​Twitter: https://twitter.com/OperatorStartup​​ ------------------------------------- If you liked this episode, let us know by hitting the like button and share with your friends and family. Please also remember to subscribe to our channel and switch on the notifications to never miss an episode!

Social innovation refers to the creation of a new product, approach, program etc. that supports social change. Inclusive social innovation is social innovation that has diversity, equity, and inclusion principles at its core.  Inclusive Social Innovation is fundamental to all of the impactful work being done by the Social Innovation Hub (SIH) at the University of Calgary, of which today's guest, Jordana Armstrong, is the Director. During this episode, Jordana shares the meandering journey that led her to her current position, an overview of the programs that the SIH has implemented to support social innovation, and some of the many success stories to come out of the SIH. Jordana's advice to anyone looking to enhance social innovation at their own institution: start with curiosity!    In This Episode: [00:51] Introducing Director of the Social Innovation Hub (SIH) at the University of Calgary (UC), Jordana Armstrong. [02:10] Jordana shares the atypical journey that led her to her current position.   [05:19] The role of the SIH at UC, and the story of its evolution.   [09:15] Defining social innovation, and how it differs from commercialization.  [12:01] The people who make up Jordana's growing team at the SIH.  [15:41] Programs and services that the SIH provides for social enterprises that come out of UC. [19:49] A deep dive into UC's CATALYZE Program. [22:36] Funding opportunities that are available to social enterprises in the SIH.  [28:35] Jordana's advice for people looking to enhance social innovation in their institutions.  [31:44] Some of the SIH's many social enterprise success stories.  [36:18] The biggest challenges that Jordana and her team are facing.   [39:19] The SIH's approach to diversity, equity, and inclusion.  [43:13] Jordana's hopes for the future of social innovation in Alberta, and in the SIH.   Find Jordana: Email LinkedIn Innovate Calgary  

In this episode, Matthew speaks with Jenn Smith (@JennSmithSocBeh), associate professor of biology at Mills College.They talk about Jenn's work directing a long-term study of the social behavior of California ground squirrels, including the opportunities and risks presented by remote data collection technologies. They also discuss Jenn's work connecting animal behavior and sociological questions, such as the female leadership paradox and the inheritance of wealth and privilege.After the break, they talk about Jenn's experience as a professor at a small liberal arts college, what the students and mentorship environment is like, and what steps students and postdocs who are seeking such a job should take.This week's Two-Minute Takeaway comes from Dr. Gabriela Pinho (@Gabriela_MPinho), a researcher at the Instituto de Pesquisas Ecológicas and recent PhD from UCLA . Read Gabriela's open-access paper about aging in marmots here.Media relevant to today's show:1.  Jenn's paper about the social networks of ground squirrels above and below ground: Smith, J. E., Gamboa, D. A., Spencer, J. M., Travenick, S. J., Ortiz, C. A., Hunter, R. D., & Sih, A. (2018). Split between two worlds: automated sensing reveals links between above-and belowground social networks in a free-living mammal. Philosophical Transactions of the Royal Society B: Biological Sciences, 373 (1753), 20170249. 2.  Female leadership in social mammals:Smith, J. E., Fichtel, C., Holmes, R. K., Kappeler, P. M., van Vugt, M., & Jaeggi, A. V. (2022). Sex bias in intergroup conflict and collective movements among social mammals: male warriors and female guides. Philosophical Transactions of the Royal Society B, 377(1851), 20210142. 3.  Jenn's new work on the evolution of privilege:Smith, J. E., Natterson-Horowitz, B., & Alfaro, M. E. (2022). The nature of privilege: intergenerational wealth in animal societies. Behavioral Ecology, 33(1), 1-6.And hear the segment talking about this paper on Wait, Wait...Don't Tell Me!Credits:The Animal Behavior Podcast is created by a team of animal behavior researchers and audio professionals. Come meet us here! We receive production support from the Cornell Broadcast studio, directed by Bert Odom-Reed and financial support from the Animal Behavior Society.

Donate! supportmu.org View the Future Masjid! https://youtu.be/QwO0qwyD5DA Shaykh Hamzah wald Maqbul was born in Whittier, California, and lived in Southern California until the age of ten when he moved to Blaine, Washington. After graduating from Blaine High School, he went on to attend the University of Washington and in 2004 completed a Bachelor of Science in Biochemistry and a Bachelor of Arts in Near Eastern Languages and Civilizations. During his study at the university, he was active on campus, serving as the president of the UW Muslim Students Association. After 9/11 he was also listed by the University of Washington as an expert on Islam and was invited to address various groups from all walks of life from universities to high schools to community groups as well as all forms of media (TV, Radio, Newspaper, Internet). After graduation, Shaykh Hamzah went on to pursue traditional Islāmic studies, which took him to a number of countries, including Syria and Egypt where he studied the Arabic language, Morocco, Mauritania, and UAE, where he studied the madhhab of Imām Mālik, grammar, usul al-hadith, and the two renditions of the qira'ah of Imam Nāfi', Warsh and Qālūn, and finally, Pakistān where he had the opportunity to study tafsīr, Usūl al-Hadīth, Hadīth, ‘Ilm al-Rijāl and Hanafī Fiqh. All of these studies culminated in him receiving an Ijāzat al-Tadrīs, literally meaning “a license to teach” which is the equivalent in Pakistānī Islāmic seminaries to a MA in Arabic and Islāmic studies, as well as an unbroken chain of transmission by which to narrate the Hadīth of such books as the Muwatta' of Imām Mālik, the Sihāh al-Sittah (Bukhārī, Muslim, Abū Dāwūd, Tirmidhī, Nasā'ī, and Ibn Mājah), and the Sharh Ma'ānī al-Athār of Imām al-Tahāwī. After his return to the United States, Shaykh Hamzah spent five years as the resident scholar of the Thawr Institute, a non-profit religious and educational organization based in Seattle, Washington, teaching, giving khutbahs in local Masājid, and traveling through America promoting the knowledge and practice of the sunnah. In parallel with his work at Thawr, he worked closely with Islamic Relief, CAIR Seattle, and a number of other non-profit organizations that serve the Muslim Community. He is currently the resident scholar for Ribāt, a center for learning and remembrance in the Midwest United States. ⏰ New episode every week!

Ascultați o filmare specială în care părintele Pimen dă mărturia sa legată de sfinții Cleopa și Paisie în vederea canonizării acestora. Mitropolia Moldovei și Bucovinei i-a cerut părintelui să vorbească despre ei, ca unul care a viețuit mulți ani la Mănăstirea Sihăstria, unde au fost sfinții, și ca unul care l-a cunoscut foarte bine pe sfântul Cleopa. Părintele povestește minuni, dovezi ale harismelor și întâmplări extraordinare cu sfinții. Ne onorează această cerere a Mitropoliei și facem ascultare în Hristos - chiar dacă suntem nevrednici de această onoare. Să ne ajute sfinții! Audiție plăcută!

Denis began investing in real estate in 2012, when the market was just beginning to recover from the GFC (Global Financial Crisis). He built a cash flowing portfolio including many alternative assets, such as Note and ATM funds, mobile home parks, life insurance policies, tech start-ups, Industrial property, short term rentals, and more. He co-founded an investment club for accredited investors in 2019. Following the success of his investor club he launched SIH Capital Group. SIHCG provides accredited investors with a simplified strategy to invest for passive income. Denis has observed key changes in the alternative asset market in the decade of recovery from the GFC. The JOBS Act of 2012 opened many alternative assets up to everyday investors, but clear expertise and guidance is still hard to find nearly a decade later. This observation compelled Denis to write The Alternative Investment Almanac: Expert Insights on Building Personal Wealth in Non-Traditional Ways in 2021. His book is based on his own experience becoming a successful alternative asset investor and interviews with some of the best alternative asset investors in business today.If you see Denis' work relevant to you, feel free to connect with him through the links below. Let's dive in! [00:01 – 11:30] Opening Segment  Welcome back to another awesome episode! I introduce our guest, Denis Shapiro Connect with Denis through the links below Denis shares how he got into the Real Estate space What Denis really enjoyed about investing Please don't skip becoming an LP! [11:31 – 30:40] Alternative Housing is a Sustainable Key to Investment Denis' Private Investment Club Leaning on each other's investment expertise The reason why SIH loves affordable housing Property Managers are essential Project-Based vouchers are best ways to fill vacancy When is eviction considered? On Tax Abatements Denis and team walks into SIH's Income Fund and other investments   [30:41 – 35:51] Closing Segment “Yesterday Doesn't Exist, Tomorrow Never Comes, Today is Today.” Denis' grandfather's story and his will to live Connect with Denis through the links below Final words   Tweetable Quotes: “I do get excited about Alternative Investments in general, but mainly Commercial Real Estate. I love the fact that each property is its own unique business plan.” - Denis Shapiro   “It will be nice to have exposure in my own personal portfolio, but being able to take advantage of that collective knowledge.” - Denis Shapiro   “You need a Property Manager that can easily see what the vouchers look like, when and what to do with it.” - Denis Shapiro     Shoot Denis a message through email  and follow his LinkedIn at https://www.linkedin.com/in/denisshapiro/ LEAVE A REVIEW + help someone who wants to explode their business growth by sharing this episode. I believe that you only need a small axe to build a lasting empire. Let's start building yours! To know more about me and all the real estate opportunities you can find, you can connect with me on LinkedIn, Instagram, and Facebook or check out my website https://smallaxecommunities.com/ and book a call with me.

Welcome back to the Passive Mobile Home Park Investing Podcast, hosted by Andrew Keel. On this episode of the Passive Mobile Home Park Investing Podcast, Andrew talks with Denis Shapiro of SIH Capital Group. Denis has a unique background that has enabled him to build the skills necessary to be successful throughout his investing career. Today, Denis shares his background and previous experiences with Passive Mobile Home Park Investing Podcast listeners. On this episode Denis Shapiro offers advice to limited partner investors as he discusses his thoughts on the economic future of the mobile home park industry, inflation and interest rates in the United States. Denis began investing in real estate in 2012 when the market was just beginning to recover from the global financial crisis. He built a cash flowing portfolio with alternative assets such as notes, ATMs, mobile home parks, tech startups, and commercial properties. He co-founded an investment club for accredited investors in 2019. Following the success of his investor club, he launched SIH Capital Group. SIH provides accredited investors with a simplified strategy to invest for passive income. Andrew Keel is the owner of Keel Team, LLC, a Top 100 Owner of Manufactured Housing Communities with over 2,000 lots under management. His team currently manages over 30 manufactured housing communities across more than ten states. His expertise is in turning around under-managed manufactured housing communities by utilizing proven systems to maximize the occupancy while reducing operating costs. He specializes in bringing in homes to fill vacant lots, implementing utility bill back programs, and improving overall management and operating efficiencies, all of which significantly boost the asset value and net operating income of the communities. Andrew has been featured on some of the Top Podcasts in the manufactured housing space, click here to listen to his most recent interviews: https://www.keelteam.com/podcast-links. In order to successfully implement his management strategy Andrew's team usually moves on location during the first several months of ownership. Find out more about Andrew's story at AndrewKeel.com. Talking Points: 00:21 - Welcome to the Passive Mobile Home Park Investing Podcast 01:32 - Denis Shapiro's background and journey 05:33 - Investing in a fund of fund with m

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip Fim de ano é a época das confraternizações, festas da firma, amigos secretos/ocultos e na nave Interlúdio não poderia ser diferente. Mantendo a tradição, reunimos nossa tripulação para uma festa e, é claro, não poderia faltar vocês, nossos queridos ouvintes.Ouça e acompanhe nossas indicações feitas através do amigo secreto; aproveite um gostoso - ou não - clima natalino; sinta saudades do karaokê; sinta pena do Basso, altamente citado porém excluído da brincadeira; e boas festas!Acompanhe-nos, estimado explorador de universos! DURAÇÃO: 45 Minutos 25 SegundosCOMENTADOS NO PODCAST:Podcast | Multiverso X.:50 | Festa da Firma (Amigo Secreto de Indicações) #LiteraturaPodcast | Interlúdio.:09 | Então, é Natal! (Amigo Secreto de Indicações) #LiteraturaLivro | As Mentiras de Locke Lamora (Nobres Vigaristas 1), de Scott Lynch - AMAZON - SKOOB - RESENHA Livro | Mares de Sangue (Nobres Vigaristas 2), de Scott Lynch - AMAZON - SKOOB - RESENHA Livro | Procura-se um Namorado, de Alexis Hall - AMAZON - SKOOB Livro | Sempre Vivemos no Castelo, de Shirley Jackson - AMAZON - SKOOBLivro | Quando Presto Atenção, Georgia Barcellos - BANCA TATUÍ - SKOOBLivro | Homens Elegrantes, Samir Machado de Machado - AMAZON - SKOOBENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do DiscordA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Diogo - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  A bordo da Interlúdio, o Capitão Ace Barros e sua Imediata, Hall-e, recebem ajuda a Diogo Fernandes, Camila Loricchio e Samuel Muca para continuar a exploração das páginas da saga A Lenda de Drizzt, agora no primeiro volume da Trilogia do Vale do Vento Gélido em O Fragmento de Cristal.Embarque conosco em dois blocos - um SEM e outro COM spoilers - abordando mais detalhes dessa aventura do elfo negro mais apelão da fantasia. Entenda a relação de publicação e como essa foi a primeira história escrita do personagem; conheça novas facetas de antigos personagens e novos rostos; avalie o progresso do autor ao comparar as duas trilogias; e muito mais.Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 1 hora 3 Minutos 37 SegundosCOMENTADOS NO PODCAST:Livro | O Fragmento de Cristal (Trilogia do Vale do Vento Gélido Vol.1) - Compre na Amazon - Compre na Jambô - SkoobLivro | Pátria (Trilogia do Elfo Negro Vol.1) - Compre na Amazon - Compre na Jambô - SkoobPodcast | Interlúdio.:01 | Pátria (Trilogia do Elfo Negro Vol.1)Livro | Exílio (Trilogia do Elfo Negro Vol.2) - Compre na Amazon - Compre na Jambô - SkoobPodcast | Interlúdio.:12 | Pátria (Trilogia do Elfo Negro Vol.2)Livro | Exílio (Trilogia do Elfo Negro Vol.3) - Compre na Amazon - Compre na Jambô - SkoobPacote Promocional | Trilogia do Elfo NegroArtigo | Ordem de Leitura de A Lenda de DrizztPodcast do Samuel | Boteco dos VersadosLoja/Editora da Camila | Castelo de CartasENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do DiscordA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  Está no ar mais um #ClubedoMultiverso. Aqui, junto com nossos leitores e ouvintes, entregamos o resultado dos debates sobre a leitura conjunta de uma determinada obra, realizada em nossa comunidade no Discord no mês anterior.Em nossa leitura coletiva de Outubro de 2021, entramos nos brejos dos Estados Unidos nos anos 50 e 60 para acompanhar a história de uma garota abandonada pelo mundo e seu desenvolvimento: Um Lugar Bem Longe Daqui, obra de Delia Owens. Nesse episódio, junto do Capitão Ace Barros, estão Airechu e Patrícia Souza.Ouça e descubra o que achamos dessa leitura; conheça a jornada de abandonos e crescimento da garota do brejo; se encante e se apaixone por Kya; torça como um louco em julgamento; e seja surpreendido pelo desfecho do misterioso assassinato circunda a obra.Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 1 Hora 10 Minutos e 38 SegundosCOMENTADOS NO PODCAST:Livro | Um Lugar Bem Longe Daqui, de Delia Owens- Compre - Skoob - GoodreadsENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do Discord e particupe do #ClubedoMultiversoA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  Aproveitando das discussões em live durante a Feira Miolos, o Capitão Ace Barros e sua Imediata, Hall-e, aproveitaram o conteúdo hosteado pela Camila Loricchio para um papo super bacana sobre RPG como ferramenta criativa para escritores, artistas e demais profissionais criativos!Ouça e saiba mais sobre o jogo de interpretação de personagens e como o RPG pode ser uma ferramenta para processos criativos; discuta as possibilidades e as vantagens de trabalhar com desapego; como acrescentar defeitos pode melhorar seus personagens; debata as vantagens de uma construção coletiva e muito mais!Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 1 Hora 3 Minutos 12 SegundosENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do DiscordA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Cum mai putem să mai găsim calea faptelor bune azi? Vizionați pe părintele Pimen Vlad cum ține un cuvânt de folos la mănăstirea Sihăstria, explicând oamenilor cum ne putem mântui în condițiile lumii de azi.Audiție plăcută!Articolul: Calea faptelor bune - p Pimen Vlad - O Chilie Athonită: Bucurii din Sfântul Munte (chilieathonita.ro)

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  Está no ar mais um #ClubedoMultiverso. Aqui, junto com nossos leitores e ouvintes, entregamos o resultado dos debates sobre a leitura conjunta de uma determinada obra, realizada em nossa comunidade no Discord no mês anterior.Em nossa leitura coletiva de Setembro de 2021, invadimos as coxias de um teatro para acompanhar os bastidores de um musical: Bem-Vindos à Rua Maravilha, obra de Gabriel Mar. Nesse episódio, junto do Capitão Ace Barros, estão Camila Loricchio e Patrícia Souza.Ouça e descubra o que achamos dessa leitura; saiba o que tanto nos irrita no protagonista; debata sobre os bastidores do teatro; mergulhe na representatividade bem colocada; e receba um incentivo ao consumo de espetáculos teatrais.Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 54 Minutos e 48 SegundosCOMENTADOS NO PODCAST:Livro | Bem-Vindos à Rua Maravilha, de Gabriel Mar - Compre - Skoob - GoodreadsENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do Discord e particupe do #ClubedoMultiversoA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Ascultați o frumoasă priceasnă compusă și cântată de Mariana Maloș pe versurile părintelui Pimen Vlad. În versuri, părintele își evocă amintirile cu părinții duhovnicești de la mănăstirea Sihăstra Putnei.Audiție plăcută!

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  A bordo de uma Interlúdio vazia, o Capitão Ace Barros e sua Imediata, Hall-e, recebem ajuda de Camila Loricchio para trazer indicações de leitura enquanto deixam a letargia!Ouça e saiba mais sobre uma belíssima HQ que envolve dois talentosos artistas e bastante pesquisa; acompanhe um grupo desajustado liderado por um padre combatente do sobrenatural tentando salvar Chinatown (NY) de um demônio antigo; e aventure-se com o mago Thiago Boanerges em uma jornada  que envolve exorcismos, amores e uma dose blues!Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 37 Minutos 53 SegundosCOMENTADOS NO PODCAST:Apoie | Faça compras na: Amazon - Americanas - Submarino - Magalu - JambôLivro | O Matrimônio de Céu & Inferno, de Enéias Tavares e Fred Rubim - AVEC - Amazon - SkoobLivro | As crias de Hastur (A Irmandade do Olho do Corvo Livro 1), A.Z. Cordenonsi - AVEC - Amazon - SkoobLivro | Exorcismos, amores e uma dose de blues, de Eric Novello - Amazon - SkoobENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do DiscordA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Hi Girlies! Cewek natural atau cewek make up? Cewek sama cowok bisa sahabatan nggak, Sih? Takut engga sama cewek yang pendidikannya tinggi? Cewek cantik atau pinter? Bagaimana pendapat tentang perempuan yang engga mau diajak susah? Pertanyaan itu dan pertanyaan menarik lainnya semua bakal ditanyain oleh Aldella & Laras kepada Team Internal kita alias Enrico as Audio Engineer nya Girls Talk selaku guest episode ini untuk menjawab pertanyaan-pertanyaan terkait perempuan menurut preference dia sebagai representative laki-laki diluar sana tentang perempuan! So, dengerin full episodenya di Anchor & Spotify Podcast Campus untuk mendengarkan keseruan episode ini!

Reproduzir Em Uma Nova Aba - Faça o Download - Arquivo Zip  Está no ar mais um #ClubedoMultiverso. Aqui, junto com nossos leitores e ouvintes, entregamos o resultado dos debates sobre a leitura conjunta de uma determinada obra, realizada em nossa comunidade no Discord no mês anterior.Em nossa leitura coletiva de Agosto de 2021, acompanhamos a história de uma das maiores estrelas de Hollywood e seus sete casamentos: Os Sete Maridos de Evelyn Hugo, obra de Taylor Jenkins Reid. Nesse episódio, junto do Capitão Ace Barros, estão Airechu, Camila Loricchio e Patrícia Souza.Ouça e descubra o que achamos dessa leitura; saiba o que tanto encanta em Evelyn Hugo; debata sobre as falhas das personagens; faça sua escala de marido ruim; e debata se o mistério final foi satisfatório ou não.Acompanhe-nos, estimados exploradores de universos!DURAÇÃO: 1 Hora 21 Minutos e 35 SegundosCOMENTADOS NO PODCAST:Livro | Os Sete Maridos de Evelyn Hugo, de Taylor Jenkins Reid - Compre - Skoob - GoodreadsResenha | Os Sete Maridos de Evelyn Hugo, de Taylor Jenkins ReidENCONTRE O X DO MULTIVERSO:Faça parte do nosso grupo do Discord e particupe do #ClubedoMultiversoA TRIPULAÇÃO NAS REDES:Twitter: @MultiversoX - @CapAceBarros - @_Airechu - @JulioBarcellos - @sih_souz - @camiaetria - @samuelmuca_Instagram: @multiversox - @_airechu - @juliobarcellos - @castelodecartas -  @samuelmuca_ddFacebook: Multiverso XSkoob: - CapAceBarros - Airechu - JulioBarcellos - Sih - Camila Loricchio - Samuel Muca QUER O FEED PARA ADICIONAR NO SEU AGREGADOR FAVORITO?Assine o nosso feed: feeds.feedburner.com/multiversox/podcastSUGESTÕES, CRÍTICAS E DÚVIDAS:Envie e-mails para: contato@multiversox.com.br

Steve Mnuchin pulls the chair out from under the same OECD Pillar One proposals he was advocating for at the last G20 summit, then the bickering begins over Pillar Two, and the IRS asks the Supreme Court to skip hearing SIH's appeal in a $377 million payout for unpaid taxes stemming from a loan guaranteed by its foreign partners. CrossBorder Solutions · The Fiona Show - Facebook Page