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Etter MM, Nguyen A, Brehm A, Aberle C, Tsogkas I, Guzman R, Dmytriw AA, Parra-Farinas C, Mascitelli JR, Pereira VM, Starke RM, Fragata I, Reis J, Wolfe SQ, Porto GB, Spiotta AM, Psychogios MN. Endovascular Treatment and Peri-interventional Management of Ruptured Cerebrovascular Lesions During Pregnancy : Case Series and Case-based Systematic Review. Clin Neuroradiol 2023; 33:833-842. [PMID: 37256319 PMCID: PMC10449989 DOI: 10.1007/s00062-023-01287-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/22/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE Hemorrhagic stroke, particularly occurring from ruptured cerebrovascular malformations, is responsible for 5-12% of all maternal deaths during pregnancy and the puerperium. Whether endovascular treatment is feasible and safe for both the mother and the fetus, is still a matter of debate. The main objective of this case series and systematic review was to share our multi-institutional experience and to assess the feasibility and safety of endovascular treatment during pregnancy, as well as the corresponding maternal and fetal outcomes based on currently available evidence. METHODS We report a case series of 12 pregnant women presenting with hemorrhagic stroke from ruptured cerebrovascular arteriovenous malformations or aneurysms who underwent endovascular treatment prior to delivery. A systematic literature review of pregnant patients with endovascular treated cerebrovascular malformations, published between 1995 and 2022, was performed. Clinical patient information, detailed treatment strategies, maternal and fetal outcomes as well as information on the delivery were collected and assessed. RESULTS In most patients the course was uneventful and an excellent outcome without significant neurological deficits (mRS ≤ 1) was achieved. Furthermore, the maternal outcome was not worse compared to the general population who underwent endovascular treatment of ruptured vascular brain lesions. Also, in most cases a healthy fetus was born. CONCLUSION Endovascular treatment of ruptured cerebrovascular malformations during pregnancy is safe and feasible regarding both aspects, the maternal and fetal outcomes. Still, a stronger knowledge base is needed to correctly approach future cases of intracranial hemorrhage in the pregnant population.
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Affiliation(s)
- Manina M Etter
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Anh Nguyen
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Christoph Aberle
- Department of Radiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ioannis Tsogkas
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, UK
| | - Carmen Parra-Farinas
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, UK
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Vitor Mendes Pereira
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Robert M Starke
- Jackson Health System, Lois Pope Life Center, Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - João Reis
- Department of Neuroradiology, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Stacey Quintero Wolfe
- Departments of Neurological Surgery and Radiology, Wake Forest, School of Medicine, Winston-Salem, NC, USA
| | - Guilherme B Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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2
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Hubbard ZS, Al Kasab S, Porto GB, Spiotta A. Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization. Interv Neuroradiol 2022; 28:639-643. [PMID: 34894830 PMCID: PMC9706259 DOI: 10.1177/15910199211065197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. METHODS We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. RESULTS Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. CONCLUSIONS Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.
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Affiliation(s)
- Zachary S Hubbard
- Division of Neurological Surgery, Medical University of South
Carolina, Charleston, SC, United States
| | - Sami Al Kasab
- Division of Neurological Surgery, Medical University of South
Carolina, Charleston, SC, United States
| | - Guilherme B Porto
- Division of Neurological Surgery, Medical University of South
Carolina, Charleston, SC, United States
| | - Alejandro Spiotta
- Division of Neurological Surgery, Medical University of South
Carolina, Charleston, SC, United States
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3
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Al Kasab S, Almallouhi E, Alawieh A, Chalhoub R, Sattur M, Bass E, Pullmann D, Porto GB, Lena JR, Kicielinski K, Spiotta AM. Impact of Increasing Aspiration Catheter Size and Refinement of Technique: Experience of Over 1000 Strokes Treated With ADAPT. Neurosurgery 2022; 91:80-86. [PMID: 35411873 DOI: 10.1227/neu.0000000000001937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We present longitudinal data regarding the outcomes and evolution of mechanical thrombectomy (MT) using a direct aspiration first pass technique. OBJECTIVE To evaluate the impact of increasing aspiration catheter size. METHODS This is a planned analysis of a prospective cohort study that enrolled all patients who underwent a direct aspiration first pass technique MT in a comprehensive stroke center from January 2013 to December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery or M1 segment of middle cerebral artery occlusion based on the aspiration catheter bore size (small [041, 054, 058, and 060 inch] vs medium [0.064 and 0.068 inch] and medium vs large [0.071, 0.072, and 0.074 inch]). RESULTS During the 8-year study period, a total of 1004 patients were included. Median age was 69 years, 49% were female patients, and 60.6% were White. Symptomatic hemorrhagic transformation was observed in 47 patients (4.7%), and 366 patients (36.5%) achieved the modified Rankin scale of 0 to 2 at 90 days after the stroke. For patients with intracranial internal carotid artery or M1 occlusion, medium-bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs 51.4%, P = .015) and had a faster groin-to-reperfusion time (16 vs 20 minutes, P = .001) when compared with small-bore catheters. However, these differences were not significant when comparing medium-bore with large-bore catheters. CONCLUSION Medium-bore catheters had better performance measures compared with small-bore catheters. However, large-bore catheters did not show significantly better performance results that suggest a plateau effect.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ali Alawieh
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Reda Chalhoub
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mithun Sattur
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric Bass
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Dominika Pullmann
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme B Porto
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan R Lena
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kimberly Kicielinski
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Sattur MG, Al Kasab S, Porto GB, Spiotta AM. Endovascular Treatment of Basilar Bifurcation Aneurysms With PulseRider-Assisted Coiling: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E109-E110. [PMID: 33861344 DOI: 10.1093/ons/opab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/03/2021] [Indexed: 11/12/2022] Open
Abstract
Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.
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Affiliation(s)
- Mithun G Sattur
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme B Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Porto GB, Hubbard Z, Al Kasab S, Almallouhi E, Starke R, De Leacy RA, Raper D, Rai A, Dumont T, Wolfe S, Jabbour P, Ogilvy CS, Park MS, Levitt M, Polifka A, Crowley R, Arthur AS, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Grossberg JA, Chowdhry S, Mokim M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios MN, Spiotta AM. Abstract P11: Clinical Utility of Aspects in Late Window Stroke Thrombectomy Patients: Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS).
Methods:
We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes.
Results:
3356 patients in the STAR database were reviewed and 347 (10.3%) of those underwent MT in the late window (table). Median age was 69, 189 (54.5%) were female, and 181 (52.2%) were white. 295 patients ASPECTS ≥6. In this group, 200 (68.8%) had M1 occlusion, and the remaining had ICA occlusion. Aspiration thrombectomy was used in 139 (47.1%) of patients. Successful reperfusion was achieved (mTICI≥2b) in 264 (76.1%). sICH was observed in 15 (5.1%). Excellent functional outcome (mRS 0-2) was observed in 124 (42%) patients. ASPECTS score was independently associated with favorable outcomes (aOR 1.2, 95% CI 1.1-1.4, P=0.006).
Conclusion:
Excellent outcomes are observed in patients with good ASPECT score presenting in the late window irrespective of perfusion criteria. Admission CT scan could be used to triage patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon Tae Kim
- Chonnam National Univ Hosp, NA, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Peter Kan
- Univ of Texas Med Branch at Galveston, Galveston, TX
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6
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Hubbard Z, Porto GB, Al Kasab S, Almallouhi E, Spiotta AM, De Leacy RA, Raper D, rai A, Dumont T, Wolfe S, Jabbour PM, Ogilvy CS, Park MS, Levitt M, Polifka A, Crowley R, Arthur AS, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Grossberg JA, Chowdhry SA, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios MN, Starke R. Abstract P500: Outcomes of Mechanical Thrombectomy in Patients With Low Aspects: Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Patients with poor baseline images were excluded from most clinical trials so the data about whether these patients could benefit from MT remains unknown. In this study, we aim to investigate the safety and efficacy of MT in patients with large vessel occlusion (LVO) and large core infarct (LCI).
Methods:
The Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We included thrombectomy patients presenting with LVO within 24 hours and with a LCI as defined by Alberta Stroke Program Early CT Score (ASPECTS) < 6. Patients presenting within 6 hours of last known normal (LKN) were considered in the early window and patients presenting after 6 hours were considered in the late window. 90-day outcomes were assessed. We used a logistic regression model to assess the factors associated with good 90-day outcome in patients in the early and late windows.
Results:
144 patients were included in this study (table). Median age was 69 and 92 (64%) patients were treated in the early MT window. ICA was the most common site of occlusion (48.6%) and ADAPT was used in 34.7%. Admission NIHSS was 17.5. Successful recanalization (TICI>2b) was achieved in 84.7% and median procedure time was 54 minutes. sICH hemorrhage was observed in 22 (15.3%). Median mRS was 4 at 90 days. Favorable outcome was observed in 41 patients (28.5%) and mortality occurred in in 59 (41%). There was no difference in 90-day functional outcome between patients in early and late windows. In patients presenting in the early window, age (aOR=0.905, p=0.0002) and baseline NIHSS (aOR=0.909, p=0.0423) were independently associated with 90-day outcome. In patients presenting in the late window, only age (aOR=0.934, p=0.0069) was independently associated with good outcome.
Conclusion:
More than one in four patients presenting with ASPECTS<6 may achieve functional independence at 90-day following MT. Patient age remains the main predictor of 90-day outcome in patients with low ASPECTS in both late and early windows.
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Affiliation(s)
- Zachary Hubbard
- Dept of Neurosurgery, Med Univ of South Carolina, Charleston, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ilko Maier
- Dept of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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Porto GB, Spiotta AM, Jauch EC. Abstract W P234: Blood Pressure Guideline Adherence in Patients With Severe Acute Cerebrovascular Events. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with acute cerebrovascular injuries (ischemic stroke, intracranial hemorrhages) require strict physiologic control, especially in the first hours of injury, to minimize clinical deterioration, morbidity, and death. This study aimed to assess inhospital physiologic parameter guideline compliance in these patient populations.
Methods:
This IRB approved observational cohort study monitored patients with severe cerebrovascular disease admitted to the neurocritical care unit using multiple channels of physiologic data continuously recorded using the BedMasterEX (Excel Medical Electronics Inc, FL) system. This platform continuously collected hemodynamic variables (blood pressure and heart rate via arterial catheter), body temperature, and blood oxygen saturation in 5 second intervals. Raw data were initially analyzed using descriptive statistics.
Results:
Fifty patients, 48% male, mean age 59.7 ±13.9 years (15 subarachnoid hemorrhages, 9 unruptured aneurysms, 6 ischemic strokes, 6 subdural hematomas, 4 intracerebral hemorrhages, 3 ischemic strokes, 1 arteriovenous malformation, 1 intraventricular hemorrhage, and 5 miscellaneous vascular injuries) were enrolled. Data acquired represented 2259 total hours of continuous blood pressure monitoring. As an example of guideline compliance, systolic blood pressure (SBP) were compared to current SBP guideline parameters and were on average outside of recommended ranges 29.4 ±30.19% of the patient’s monitoring period. We have found specifically for SBP management 6%, 28%, 18%, 12% and 36% of our patients were 99%, 90%, 80%, 70%, and <70% of the time within the specified SBP goals.
Conclusion:
Hemodynamic management of patients with cerebrovascular injuries, based on current guidelines, yielded optimal control of SBP in only 34% of patients (within parameters ≥90% of time). More detailed data analyses are underway and additional physiologic variables concurrently collected with those presented here are also being studied. Future studies will further evaluate these data for potential correlation between changes in hemodynamics and clinical outcomes (worsening neurological condition, hematoma growth, re-rupture of aneurysm, hemorrhagic conversion of stroke).
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Affiliation(s)
- Guilherme B Porto
- Div of Emergency Medicine, Med Univ of South Carolina, Charleston, SC
| | | | - Edward C Jauch
- Div of Emergency Medicine, Med Univ of South Carolina, Charleston, SC
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