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Niwa R, Ichi S, Nomura R, Sato K. Hypofractionated Stereotactic Radiotherapy with CyberKnife for Large Arteriovenous Malformations and Arteriovenous Malformations Located in Eloquent Areas. Neurol Med Chir (Tokyo) 2022; 62:445-450. [PMID: 36070959 PMCID: PMC9637402 DOI: 10.2176/jns-nmc.2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Literature has yet to establish an appropriate treatment strategy for large arteriovenous malformations (AVMs) and AVMs located in eloquent areas. In this study, the treatment outcomes of hypofractionated stereotactic radiotherapy (HSRT) with CyberKnife (CK) for large AVMs and AVMs in eloquent areas were evaluated. This study retrospectively evaluated 38 consecutive patients with AVMs treated with HSRT in the Japanese Red Cross Medical Center between August 2010 and July 2015. Obliteration rates and hemorrhage rates at 3- and 5-years of follow-up were calculated. Factors for hemorrhage and obliteration were analyzed with logistic regression analysis. Fourteen (36.8%) patients had a history of hemorrhage. Twenty (52.6%) AVMs were larger than 10 mL, and 34 (89.5%) AVMs were located in eloquent areas. The majority of the AVMs (84.2%) were classified into high grades (grades 3, 4, and 5) using the Spetzler-Martin grading scale. The median modified radiosurgery-based AVM score was 2.05, and the median Virginia Radiosurgery AVM Score was 3. The mean marginal dose was 24.5 ± 2.5 Gy. Twenty-three and 15 patients received three- and five-fraction stereotactic radiotherapy, respectively. At 3 and 5 years posttreatment, two (2.0%/year) and six (6.7%/year) patients had hemorrhage with obliteration rates of 15.2% and 16.7%, respectively. AVM localization in eloquent areas was a risk factor for obliteration failure. This study revealed that HSRT with CK for large AVMs and AVMs located in eloquent areas contributed to hemorrhage risk reduction and obliteration, at least in the early stages.
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Affiliation(s)
- Ryoko Niwa
- CyberKnife Center, Japanese Red Cross Medical Center.,Department of Neurosurgery, The University of Tokyo Hospital
| | - Shunsuke Ichi
- CyberKnife Center, Japanese Red Cross Medical Center
| | - Ryutaro Nomura
- CyberKnife Center, Japanese Red Cross Medical Center.,CyberKnife Center, Chigasaki Chuo Hospital
| | - Kengo Sato
- CyberKnife Center, Japanese Red Cross Medical Center
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2
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Zhu S, Brodin NP, Garg MK, LaSala PA, Tomé WA. Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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3
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Tam KY, Lim K, Zhu CXL, Chan KY, Poon WS, Poon D, Kam M, Cheung M, Wong KCG. Long-term outcomes of ruptured cerebral arteriovenous malformations in the paediatric population: A retrospective review in a regional hospital in Hong Kong. J Clin Neurosci 2019; 66:66-70. [DOI: 10.1016/j.jocn.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
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4
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Ishikawa O, Nakatomi H, Saito N. Re-Evaluation of the Size Limitation in Single-Session Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Detailed Analyses on the Outcomes with Focusing on Radiosurgical Doses. Neurosurgery 2019; 86:685-696. [DOI: 10.1093/neuros/nyz280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 04/16/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Single-session stereotactic radiosurgery (SRS) for large arteriovenous malformations (AVMs) ≥10 mL remains controversial, which is considered as the current size limitation.
OBJECTIVE
To reconsider the size limitation of SRS for AVMs by profoundly analyzing dose-volume relationship.
METHODS
Data on 610 consecutive patients with AVM treated with SRS using regular (18-22 Gy) or low (<18 Gy) prescription doses were retrospectively analyzed. AVMs were classified into 4 groups: small (<5 mL), medium (≥5 and <10 mL), medium-large (≥10 and <15 mL), and large (≥15 mL). The maximum volumes were 22.5 mL (regular-dose group) and 23.5 mL (low-dose group).
RESULTS
When treated with regular doses, the cumulative 6-yr obliteration rates for each of the 4 AVM groups were 86%, 80%, 87%, and 79%, respectively; the cumulative 10-yr significant neurological event (SNE) rates were 2.6%, 3.9%, 6.8%, and 5.3%, respectively. Regarding large AVMs, regular-dose SRS resulted in marginally better obliteration rate (6-yr cumulative rate, 79% vs 48%, P = .111) and significantly lower SNE (5-yr cumulative rate, 5% vs 31%, P = .038) and post-SRS hemorrhage rate (8-yr cumulative rate, 0% vs 54%, P = .002) compared to low-dose SRS. Multivariate analyses revealed that regular-dose SRS significantly contributed to increase in the obliteration rate and decrease in SNEs and hemorrhage.
CONCLUSION
The outcomes for large AVMs were generally favorable when treated with ablative doses. Single-session SRS could be acceptable for AVMs up to ≈20 mL if treated with ablative doses.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Shunya Hanakita
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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5
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Hasegawa H, Hanakita S, Shin M, Kawashima M, Takahashi W, Ishikawa O, Koizumi S, Nakatomi H, Saito N. Comparison of the Long-term Efficacy and Safety of Gamma Knife Radiosurgery for Arteriovenous Malformations in Pediatric and Adult Patients. Neurol Med Chir (Tokyo) 2018; 58:231-239. [PMID: 29769453 PMCID: PMC6002683 DOI: 10.2176/nmc.st.2018-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is debated whether the efficacy and long-term safety of gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs) differs between adult and pediatric patients. We aimed to clarify the long-term outcomes of GKRS in pediatric patients and how they compare to those in adult patients. We collected data for 736 consecutive patients with AVMs treated with GKRS between 1990 and 2014 and divided the patients into pediatric (age < 20 years, n = 144) and adult (age ≥ 20 years, n = 592) cohorts. The mean follow-up period in the pediatric cohort was 130 months. Compared to the adult patients, the pediatric patients were significantly more likely to have a history of hemorrhage (P < 0.001). The actuarial rates of post-GKRS nidus obliteration in the pediatric cohort were 36%, 60%, and 87% at 2, 3, and 6 years, respectively. Nidus obliteration occurred earlier in the pediatric cohort than in the adult cohort (P = 0.015). The actuarial rates of post-GKRS hemorrhage in the pediatric cohort were 0.7%, 2.5%, and 2.5% at 1, 5, and 10 years, respectively. Post-GKRS hemorrhage was marginally less common in the pediatric cohort than in the adult cohort (P = 0.056). Cyst formation/encapsulated hematoma were detected in seven pediatric patients (4.9%) at a median post-GKRS timepoint of 111 months, which was not significantly different from the rate in the adult cohort. Compared to adult patients, pediatric patients experience earlier therapeutic effects from GKRS for AVMs, and this improves long-term outcomes.
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Affiliation(s)
| | | | - Masahiro Shin
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Osamu Ishikawa
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Nobuhito Saito
- Department of Neurosurgery, University of Tokyo Hospital
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6
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Pollock BE, Link MJ, Stafford SL, Lanzino G, Garces YI, Foote RL. Volume-Staged Stereotactic Radiosurgery for Intracranial Arteriovenous Malformations: Outcomes Based on an 18-Year Experience. Neurosurgery 2017; 80:543-550. [PMID: 28362923 DOI: 10.1093/neuros/nyw107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/27/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radiation-based treatment options of large intracranial arteriovenous malformations (AVM) must balance the likelihood of obliteration with the risk of adverse radiation effects (ARE). OBJECTIVE To analyze the efficacy and risks of volume-staged stereotactic radiosurgery (VS-SRS) for AVM. METHODS Retrospective study of 34 AVM patients having VS-SRS between 1997 and 2012. A median of 2 stages (range, 2-4) was used to treat a median AVM volume of 22.2 cm 3 (range, 7.4-56.7). The median AVM margin dose was 16 Gy (range, 14-18); the median radiosurgery-based AVM score was 2.81 (range, 1.54-6.45). The median follow-up after VS-SRS was 8.2 years (range, 3-13.3). RESULTS Nidus obliteration was noted in 18 patients (53%) after VS-SRS. The rate of obliteration was 14% at 3 years, 54% at 5 years, and 75% at 7 years. Six patients (18%) had 11 bleeds after VS-SRS. Two patients (6%) remained neurologically stable, 2 (6%) patients had significant deficits, and 2 patients (6%) died. The actuarial risk of a first bleed after VS-SRS was 6% at 1 year, 12% at 3 years, and 19% at 7 years. Six patients (18%) underwent repeat SRS; all achieved nidus obliteration for an overall cure rate of 71%. Two patients (6%) had a permanent ARE after VS-SRS or repeat SRS. CONCLUSION VS-SRS permitted large volume intracranial AVM to be treated with a low rate of ARE. Further study is needed on dose escalation and decreasing the treatment volume per stage to determine if this will increase the rate of obliteration with this technique.
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Affiliation(s)
- Bruce E Pollock
- Department of Neurological Surgery.,Department of Radiation Oncology
| | - Michael J Link
- Department of Neurological Surgery.,Department of Otorhinolaryngology
| | | | - Giuseppe Lanzino
- Department of Neurological Surgery.,Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
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7
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Nagy G, Grainger A, Hodgson TJ, Rowe JG, Coley SC, Kemeny AA, Radatz MW. Staged-Volume Radiosurgery of Large Arteriovenous Malformations Improves Outcome by Reducing the Rate of Adverse Radiation Effects. Neurosurgery 2017; 80:180-192. [DOI: 10.1227/neu.0000000000001212] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/28/2015] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND: The treatment of large arteriovenous malformations (AVMs) remains challenging. Recently, staged-volume radiosurgery (SVRS) has become an option.
OBJECTIVE: To compare the outcome of SVRS on large AVMs with our historical, single-stage radiosurgery (SSRS) series.
METHODS: We have been prospectively collecting data of patients treated by SVRS since 2007. There were 84 patients who had a median age of 37 years (range, 9-62 years) who were treated until July 2013. The outcomes of 76 of those who had follow-ups available were analyzed and compared with the outcomes of 122 patients treated with the best SSRS technique.
RESULTS: There were 21.5% of AVMs that were deep seated, and 44% presented with hemorrhage resulting in 45% fixed neurological deficit. There were 14% of patients who had undergone embolization before radiosurgery. The median nidus treatment volume was 19.7 cm3 (6.65-68.7) and 17.5 Gy (13-22.5) prescription isodose was given. Of the 44 lesions having radiological follow-up at 4 years, 61.4% were completely obliterated. Previous embolization (50% with and 63% without) and higher Spetzler-Martin grades appeared to be the negative factors in successful obliteration, but treatment volume was not. Within 3 years after radiosurgery, the annual bleed rates of unruptured and previously ruptured AVMs were 3.2% and 5.6%, respectively. Three bleeds were fatal and 2 resulted in significant modified Rankin scale 3 morbidity. These rates differ little from SSRS. Temporary adverse radiation effects (AREs) did not change significantly, but permanent AREs dropped from 15% to 6.5% (P = .03) compared with SSRS.
CONCLUSION: Obliteration and hemorrhage rates of large AVMs treated by SVRS are similar to historical SSRS. However, SVRS offers a lower rate of AREs.
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Affiliation(s)
- Gábor Nagy
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Alison Grainger
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Timothy J. Hodgson
- Department of Radiology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Jeremy G. Rowe
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Stuart C. Coley
- Department of Radiology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - Matthias W.R. Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Thornbury Radiosurgery Centre, Sheffield, United Kingdom
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8
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Hanakita S, Shin M, Koga T, Igaki H, Saito N. Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations. Stroke 2016; 47:1247-52. [DOI: 10.1161/strokeaha.116.013132] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/17/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) indicated the superiority of medical management in reducing the risks for strokes and other neurological deficits over observation alone. The aim of our study was to verify the rationale for stereotactic radiosurgery (SRS) for small unruptured arteriovenous malformation.
Methods—
A retrospective review was performed for 292 patients with unruptured arteriovenous malformations referred for SRS. The risks for cerebral hemorrhages were statistically compared before and after SRS.
Results—
Of the 292 patients in whom arteriovenous malformation was found unruptured at initial diagnosis, 17 sustained hemorrhages in the period between the diagnosis and the initial therapeutic intervention (annual bleeding rate, 2.1%; 95% confidence interval [CI], 1.2%–3.4%). Of the remaining 275 patients, 240 were initially treated with SRS, and 16 sustained a hemorrhage after SRS (annual bleeding rate, 1.1%; 95% CI, 0.6%–1.8%), but only 2 sustained a hemorrhage after angiographic obliteration (annual bleeding rate, 0.3%; 95% CI, 0.04%–1.2%). Comparing the risk of hemorrhage between the periods before and after SRS, a 53% risk reduction was achieved after SRS (hazard ratio, 0.47; 95% CI, 0.24–0.94;
P
=0.03), and 85% reduction was achieved after angiographic obliteration (hazard ratio, 0.15; 95% CI, 0.02–0.53;
P
=0.002).
Conclusions—
SRS can significantly reduce the risk of stroke in the patients with small unruptured arteriovenous malformations. To definitively determine the clinical benefits of SRS, a longer follow-up will be necessary. However, based on our results, we can recommend SRS for patients who face a latent risk for stroke from this intractable vascular disease.
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Affiliation(s)
- Shunya Hanakita
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Tomoyuki Koga
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
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9
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Hanakita S, Shin M, Koga T, Igaki H, Saito N. Outcomes of Volume-Staged Radiosurgery for Cerebral Arteriovenous Malformations Larger Than 20 cm3 with More Than 3 Years of Follow-Up. World Neurosurg 2016; 87:242-9. [DOI: 10.1016/j.wneu.2015.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 11/27/2022]
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10
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Hanakita S, Koga T, Shin M, Igaki H, Saito N. The long-term outcomes of radiosurgery for arteriovenous malformations in pediatric and adolescent populations. J Neurosurg Pediatr 2015; 16:222-31. [PMID: 25955806 DOI: 10.3171/2015.1.peds14407] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although stereotactic radiosurgery (SRS) has been accepted as a therapeutic option for arteriovenous malformations (AVMs) in children and adolescents, substantial data are still lacking regarding the outcomes of SRS for AVMs in this age group, especially long-term complications. This study aimed to clarify the long-term outcomes of SRS for the treatment of AVM in pediatric patients aged ≤ 18 years. METHODS Outcomes of 116 patients who were aged 4-18 years when they underwent SRS between 1990 and 2009 at the study institute were analyzed retrospectively. RESULTS The median follow-up period after SRS was 100 months, with 6 patients followed up for more than 20 years. Actuarial obliteration rates at 3 and 5 years after SRS were 68% and 88%, respectively. Five hemorrhages occurred in 851 patient-years of follow-up. The annual bleeding rate after SRS before obliteration was calculated as 1.3%, which decreased to 0.2% after obliteration. Shorter maximum nidus diameter (p = 0.02) and higher margin dose (p = 0.03) were associated with a higher obliteration rate. Ten patients experienced adverse events after SRS. Of them, 4 patients presented with delayed complications years after SRS (range 9-20 years after SRS). CONCLUSIONS SRS can reduce the risk of hemorrhage in pediatric and adolescent AVMs, with an acceptable risk of complications in the long term. However, adverse events such as expanding hematoma and radiation necrosis that can occur after substantial follow-up should be taken into account at the time that treatment decisions are made and informed consent is obtained.
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Affiliation(s)
| | | | | | - Hiroshi Igaki
- Radiology, The University of Tokyo Hospital, Tokyo, Japan
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