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Liao L, Muszynski P, Zhu F, Harsan O, Lopes De Medeiros L, Bracard S, Anxionnat R. Endovascular management of saccular aneurysms of the proximal A1 segment: technical particularities and long term outcomes. J Neurointerv Surg 2024:jnis-2024-021799. [PMID: 38876784 DOI: 10.1136/jnis-2024-021799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Saccular aneurysms of the proximal A1 segment (SAPA1) are rare, but their treatment is challenging and scarcely described in the literature. We report the immediate and long term outcomes of their endovascular management. METHODS We retrospectively analyzed all consecutive SAPA1 cases treated endovascularly at our center between 2003 and 2023. Per procedural complications and radioclinical outcomes were prospectively recorded. RESULTS Among 2468 patients followed up for aneurysms, 12 (0.49%) had an SAPA1 (average age 53.8±9.6 years, 9 women). The SAPA1 averaged 3.3 mm, all posteriorly oriented. Ten were ruptured (83.3%). Initial treatments included conventional coiling or balloon assisted coiling (CC/BAC) for nine aneurysms, and proximal A1 segment focal occlusion (PA1FO) for three. Initial occlusion was deemed satisfactory in all instances: total occlusion in eight cases (67%) and subtotal occlusion in four cases (33%). Four aneurysmal perforations occurred (33%), all during CC/BAC on ruptured aneurysms. Over a 10.2 year average follow-up, six recanalizations (50%) were noted, all after initial CC/BAC: three were early (≤14 days), with one causing fatal rebleeding. No recanalizations after PA1FO was observed (five in total, two as a complement after CC/BAC). Favorable clinical outcomes (modified Rankin Scale score of 0-2) were seen in 91% of cases (11/12) at the last follow-up. CONCLUSIONS Selective coiling of the aneurysmal sac is technically difficult due to their small size and the complex microcatheterization pathway. This method presents a significant risk of aneurysmal perforation, especially in ruptured cases, and a high rate of recanalization. PA1FO, when collateralization permits, appears to be a reliable therapeutic alternative offering favorable long term outcomes.
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Affiliation(s)
- Liang Liao
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
- INRIA, LORIA, Vandoeuvre-les-Nancy, France
| | - Patricio Muszynski
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
- Department of Neuroradiology, Instituto Oulton, Córdoba, Argentina
| | - François Zhu
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
- University of Lorraine, Nancy, France
| | - Oana Harsan
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
| | | | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
- University of Lorraine, Nancy, France
| | - René Anxionnat
- Department of Diagnostic and Interventional Neuroradiology, CHRU de Nancy, Nancy, France
- University of Lorraine, Nancy, France
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Gao B, Ding H, Ren Y, Bai D, Wu Z. Study of Typical Ruptured and Unruptured Intracranial Aneurysms Based on Fluid-Structure Interaction. World Neurosurg 2023; 175:e115-e128. [PMID: 36914031 DOI: 10.1016/j.wneu.2023.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Most intracranial aneurysms (IAs) will be abnormal bulges on the walls of intracranial arteries that result from the dynamic interaction of geometric morphology, hemodynamics, and pathophysiology. Hemodynamics plays a key role in the origin, development, and rupture of IAs. In the past, hemodynamic studies of IAs were mostly based on the rigid wall hypothesis of computational fluid dynamics, and the influence of arterial wall deformation was ignored. We used fluid-structure interaction (FSI) to study the features of ruptured aneurysms, because it can solve this problem very well and the simulation will be more realistic. METHODS A total of 12 IAs, 8 ruptured and 4 unruptured, at the middle cerebral artery bifurcation were studied using FSI to better identify the characteristics of ruptured IAs. We studied the differences in the hemodynamic parameters, including the flow pattern, wall shear stress (WSS), oscillatory shear index (OSI), and displacement and deformation of the arterial wall. RESULTS Ruptured IAs had a larger low WSS area and more complex, concentrated, and unstable flow. Also, the OSI was higher. In addition, the displacement deformation area at the ruptured IA was more concentrated and larger. CONCLUSIONS A large aspect ratio; a large height/width ratio; complex, unstable, and concentrated flow patterns with small impact areas; a large low WSS region; large WSS fluctuation, high OSI; and large displacement of the aneurysm dome could be risk factors associated with aneurysm rupture. If similar cases are encountered when simulation is used in the clinic, priority should be given to diagnosis and treatment.
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Affiliation(s)
- Bei Gao
- College of Mechanical and Electronic Engineering, Shandong University of Science and Technology, Qingdao, People's Republic of China
| | - Hongchang Ding
- College of Mechanical and Electronic Engineering, Shandong University of Science and Technology, Qingdao, People's Republic of China.
| | - Yande Ren
- The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Di Bai
- The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Zeyu Wu
- The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
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Campero A, Baldoncini M, Martinez J, Villalonga JF, Lucifero AG, Luzzi S. Microneurosurgical management of aneurysms of the A1 segment of the anterior cerebral artery: Anatomy and surgical technique. Surg Neurol Int 2022; 13:310. [PMID: 35928319 PMCID: PMC9345093 DOI: 10.25259/sni_68_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and have characteristics differentiating them from other intracranial aneurysms. Their microsurgical management is challenging and requires different strategies. In this article, we review the surgical anatomy of the A1 segment of the ACA with cadaveric dissections and describe the microsurgical management of complex A1 aneurysms with illustrative cases. Methods: A right pterional craniotomy and Sylvian dissection were performed on a formalin-fixed and silicone-injected cadaver head to depict the key anatomic structures and surgical corridors for microsurgical clipping of A1 segment aneurysms. The microneurosurgical management of ruptured and unruptured aneurysms of the A1 segment of the ACA is described with case illustrations. Results: The A1 segment of the ACA can be subdivided into proximal, middle, and distal subsegments, the former having abundant perforating branches. Both patients treated with microsurgical clipping had excellent and durable outcomes and postoperative cerebral angiograms showed complete aneurysm occlusion. Conclusion: Small A1 aneurysms may require early treatment as their rupture risk appears to be higher. A1 aneurysms are usually embedded in perforators, especially those arising from the proximal A1 subsegment, and require careful distal to proximal microdissection and strategic placement of the aneurysm clip blades. The approach, arachnoid dissection, and angles of attack are carefully planned after accounting for the aneurysm dome projection, precise location of the aneurysm neck and perforators, and the presence or absence of subarachnoid hemorrhage.
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Affiliation(s)
- Alvaro Campero
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Argentina
- Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina,
| | - Jaime Martinez
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA,
| | - Juan F. Villalonga
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Fan Z, Dong L, Zhang Y, Ye X, Deng X. Hemodynamic impact of proximal anterior cerebral artery aneurysm: Mind the posteriorly projecting ones! Proc Inst Mech Eng H 2022; 236:656-664. [DOI: 10.1177/09544119221082420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracranial aneurysm projected posteriorly is associated with high risk of aneurysm rupture. In order to investigate the biomechanical mechanisms for the adverse event, three-dimension intracranial cerebral aneurysms were constructed based on clinical data, and we numerically compared effect of location, position, size, and shape of aneurysm on hemodynamic conditions including velocity, pressure, and wall shear stress (WSS). The numerical results showed that the aneurysm projected posteriorly even at small sizes led to abnormal hemodynamic environment, which was featured by a local high pressure and stress concentration near aneurysm neck area. Moreover, the one located at the proximal A1 segment and ellipsoidal aneurysm would further worse local hemodynamic environment, causing high local stresses. These findings indicated the potential mechanical mechanism for high rupture rate of the aneurysms projected posteriorly, underscoring importance of early and accurate diagnosis and promptly treatment for improved the clinical outcome, even if these aneurysms are of small sizes.
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Affiliation(s)
- Zhenmin Fan
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
| | - Lijun Dong
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
| | - Yingying Zhang
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing, China
| | - Xia Ye
- School of Mechanical Engineering, Jiangsu University of Technology, Changzhou, Jiangsu, China
| | - Xiaoyan Deng
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
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Xu M, Lv N, Sun K, Hong R, Wang H, Wang X, Xu L, Chen L, Xu M. Morphological and Hemodynamic Risk Factors for the Rupture of Proximal Anterior Cerebral Artery Aneurysms (A1 Segment). Front Aging Neurosci 2022; 14:835373. [PMID: 35250548 PMCID: PMC8895198 DOI: 10.3389/fnagi.2022.835373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The treatment of unruptured small intracranial aneurysms remains controversial. A distinguishing characteristic of A1 segment aneurysms is that they tend to rupture when they are small, which may be related to their distinctive morphology and hemodynamics. Our study sought to investigate the rupture risk factors of A1 segment aneurysms by analyzing the clinical risk factors, morphology, and hemodynamic characteristics of A1 segment aneurysms. Methods We retrospectively enrolled 49 (23 ruptured, 26 unruptured) consecutive patients presenting to our institute with A1 segment aneurysms between January 2010 and March 2020. Independent risk factors associated with the rupture of A1 segment aneurysms were analyzed by multivariate regression analysis in the ruptured group and unruptured group. Results Clinical risk factors, including age, sex, hypertension, smoking history, and SAH family history revealed no difference between the ruptured and unruptured groups. The ruptured group presented a significantly larger size (Size, P = 0.007), aspect ratio (AR, P = 0.002), size ratio (SR, P = 0.001), bottleneck index (BN, P = 0.016), dome-to-neck ratio (DN, P = 0.001), and oscillatory shear index (OSI) (P = 0.001) than the unruptured group. The normalized wall shear stress (NWSS) of the ruptured aneurysms was lower than the unruptured group (P = 0.001). In the multivariate regression analysis, only SR (OR = 3.672, P = 0.003) and NWSS (OR = 0.474, P = 0.01) were independent risk factors in the A1 segment aneurysm rupture. Conclusion A higher SR and lower NWSS revealed a close connection with the rupture of A1 segment aneurysms in our study, thus providing a reference for clinical decision-making in treating A1 segment unruptured aneurysms.
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Affiliation(s)
- Mingwei Xu
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Nan Lv
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Kai Sun
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Rujun Hong
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Hao Wang
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Xuhui Wang
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Lunshan Xu
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Lizhao Chen
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
- *Correspondence: Lizhao Chen,
| | - Minhui Xu
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
- Minhui Xu,
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Endovascular treatment for aneurysms at the A1 segment of the anterior cerebral artery: current difficulties and solutions. Acta Neurol Belg 2021; 121:55-69. [PMID: 33108602 DOI: 10.1007/s13760-020-01526-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/08/2020] [Indexed: 01/03/2023]
Abstract
Aneurysms located at the A1 segment of the anterior cerebral artery are considered rare and unique entities. Endovascular treatment (EVT) is effective in preventing aneurysmal bleeding. However, EVT for A1 aneurysms is difficult due to their distinctive configurations. A current review of EVT for A1 aneurysms is lacking. Therefore, we focused on the available literature on this specific issue. To more clearly expound this entity, we also provided some illustrative cases. The A1 segment can be equally divided into the proximal, middle, and distal segments. Proximal aneurysms are most common and difficult to treat via EVT. The A1 segment has a complex anatomy and many important branches. Due to the small size, predominant posterior direction, and sharp upturn of the microcatheter from the parent artery, microcatheter positioning and support is difficult for A1 aneurysms. EVT for A1 aneurysms mainly includes reconstructive and deconstructive strategies. The complications of EVT for A1 aneurysms include aneurysmal perforation, thromboembolic events, and coil protrusion related to stent-assisted embolization. A1 aneurysms represent rare and difficult vascular lesions. EVT is quite challenging for A1 aneurysms due to their distinctive configurations. The outcomes are acceptable.
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Management of Proximal Segment of the Anterior Cerebral Artery Aneurysms. J Craniofac Surg 2020; 32:e52-e54. [PMID: 32833828 DOI: 10.1097/scs.0000000000006918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT The authors reported 2 cases with proximal anterior cerebral artery (A1) aneurysms, and one was treated with aneurysm clipping, whereas another was treated with coil embolization. The authors suggest both endovascular surgery and aneurysm clipping are good options for A1 aneurysms.
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Safety and efficacy of different therapeutic strategies in the endovascular treatment of anterior cerebral artery aneurysms with different features: A single centre experience. Clin Neurol Neurosurg 2020; 193:105786. [PMID: 32200221 DOI: 10.1016/j.clineuro.2020.105786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/25/2020] [Accepted: 03/13/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Outcomes of endovascular treatment of anterior cerebral artery (ACA) aneurysms are still not well-characterized. OBJECTIVE The study aimed to review the clinical effect, procedure-related complications and follow-up outcomes and to evaluate the safety and efficacy of endovascular treatment of ACA aneurysms in our center experience. METHODS From August 2014 to August 2018, a total of 75 consecutive patients with 77 ACA aneurysms were treated via the endovascular approach after providing informed consent. A retrospective review of the clinical, radiological, and endovascular details of these patients was conducted. RESULTS The mortality and the morbidity in this study were 4% and 9.3%, respectively. Compared with A1 and A2 aneurysms, intraoperative rupture was more common in A3 aneurysms (P = 0.029). Difference between the ruptured and unruptured aneurysms in the distribution of therapeutic strategy (P = 0.003) and immediate embolization degree (P = 0.004) was also significant. Statistical analysis demonstrated that the larger aneurysm (P = 0.031) was, the greater the ratio of aneurysm size to parent artery diameter (P = 0.029) was, the more likely the unruptured aneurysms were to occur ischemic events. Higher Hunt-Hess grade (P = 0.0066) was an independent risk factor for poor clinical outcome. CONCLUSION Endovascular treatment is feasible and effective for ACA aneurysms.
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Li CY, Chen CC, Chen CT, Hsieh PC, Yi-Chou Wang A, Wu YM, Wong HF, Yeap MC, Chang CH. Endovascular Treatment of Ruptured Proximal Segment of the Anterior Cerebral Artery Aneurysms: Single-Center Experience and Literature Review. World Neurosurg 2019; 135:e237-e245. [PMID: 31790836 DOI: 10.1016/j.wneu.2019.11.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Proximal anterior cerebral artery (A1) aneurysms are rare among all intracranial aneurysms and are regarded as difficult to treat endovascularly. Treatment is even more challenging in patients with ruptured aneurysms and acute subarachnoid hemorrhage owing to the small size and proximity to perforators. Though challenging, endovascular treatment can provide favorable outcomes in such patients. We report our case series of endovascular treatment in ruptured proximal A1 aneurysms. METHODS Between January 2010 and December 2017, 1200 aneurysms were treated endovascularly at our center. There were 15 patients with 15 ruptured proximal A1 aneurysms who presented with subarachnoid hemorrhage. Five patients underwent simple coiling, 9 underwent balloon-assisted coiling, and 1 underwent catheter protective coiling. Medical records and angiographic results were obtained retrospectively. RESULTS All aneurysms were successfully treated with endovascular techniques. Multiplicity rate was 53.3% (n = 8). Initial complete obliteration rate was 93.3% (n = 14), with a 13.3% recurrence rate (n = 2). One patient experienced intraoperative bleeding; this was the only procedure-related complication. Eleven patients (73.3%) had a good clinical outcome. When excluding Hunt and Hess grade 4 patients, the good outcome rate was 81.8%. CONCLUSIONS Ruptured proximal A1 aneurysm is a rare condition and is highly associated with multiple aneurysms. Despite being a more difficult and complicated technique, endovascular coiling performed in high-volume, experienced medical centers is an effective modality with excellent clinical outcomes.
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Affiliation(s)
- Cheng-Yu Li
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yi-Ming Wu
- Division of Neuroradiology, Department of Radiology, Linkou Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Ho-Fai Wong
- Division of Neuroradiology, Department of Radiology, Linkou Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Chien-Hung Chang
- Department of Neurology, Linkou Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
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Pandey P. Management of A1 Aneurysm: A Critical Appraisal. Neurol India 2019; 67:1264-1265. [DOI: 10.4103/0028-3886.271285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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