1
|
Hernandez-Duran S, Walter J, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Müller SJ, Naser P, Rohde V, Schaefer JH, Senft C, Storch A, Unterberg A, Walter U, Wittstock M, Gessler F, Won SY. Necrosectomy Versus Stand-Alone Suboccipital Decompressive Craniectomy for the Management of Space-Occupying Cerebellar Infarctions-A Retrospective Multicenter Study. Neurosurgery 2024; 94:559-566. [PMID: 37800900 DOI: 10.1227/neu.0000000000002707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Space-occupying cerebellar stroke (SOCS) when coupled with neurological deterioration represents a neurosurgical emergency. Although current evidence supports surgical intervention in such patients with SOCS and rapid neurological deterioration, the optimal surgical methods/techniques to be applied remain a matter of debate. METHODS We conducted a retrospective, multicenter study of patients undergoing surgery for SOCS. Patients were stratified according to the type of surgery as (1) suboccipital decompressive craniectomy (SDC) or (2) suboccipital craniotomy with concurrent necrosectomy. The primary end point examined was functional outcome using the modified Rankin Scale (mRS) at discharge and at 3 months (mRS 0-3 defined as favorable and mRS 4-6 as unfavorable outcome). Secondary end points included the analysis of in-house postoperative complications, mortality, and length of hospitalization. RESULTS Ninety-two patients were included in the final analysis: 49 underwent necrosectomy and 43 underwent SDC. Those with necrosectomy displayed significantly higher rate of favorable outcome at discharge as compared with those who underwent SDC alone: 65.3% vs 27.9%, respectively ( P < .001, odds ratios 4.9, 95% CI 2.0-11.8). This difference was also observed at 3 months: 65.3% vs 41.7% ( P = .030, odds ratios 2.7, 95% CI 1.1-6.7). No significant differences were observed in mortality and/or postoperative complications, such as hemorrhagic transformation, infection, and/or the development of cerebrospinal fluid leaks/fistulas. CONCLUSION In the setting of SOCS, patients treated with necrosectomy displayed better functional outcomes than those patients who underwent SDC alone. Ultimately, prospective, randomized studies will be needed to confirm this finding.
Collapse
Affiliation(s)
| | - Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena , Germany
| | - Kara Hellmuth
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main , Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main , Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen , Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Sebastian Johannes Müller
- Department of Neuroradiology, Göttingen University Hospital, Göttingen , Germany
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart , Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen , Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main , Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena , Germany
| | - Alexander Storch
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg , Germany
| | - Uwe Walter
- Department of Neurology, University Medicine Rostock, Rostock , Germany
| | | | - Florian Gessler
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Medicine Rostock, Rostock , Germany
| |
Collapse
|
2
|
Won SY, Hernández-Durán S, Behmanesh B, Bernstock JD, Czabanka M, Dinc N, Dubinski D, Freiman TM, Günther A, Hellmuth K, Herrmann E, Konczalla J, Maier I, Melkonian R, Mielke D, Naser P, Rohde V, Senft C, Storch A, Unterberg A, Walter J, Walter U, Wittstock M, Schaefer JH, Gessler F. Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts. JAMA Neurol 2024:2815568. [PMID: 38407889 PMCID: PMC10897822 DOI: 10.1001/jamaneurol.2023.5773] [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] [Received: 07/20/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024]
Abstract
Importance According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. Objective To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. Design, Setting, and Participants In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Exposures Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). Main Outcomes and Measures The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Results Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Conclusions and Relevance Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.
Collapse
Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | | | - Bedjan Behmanesh
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Nazife Dinc
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Thomas M. Freiman
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Kara Hellmuth
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Göttingen, Germany
| | | | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Paul Naser
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Göttingen, Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital, Jena, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Matthias Wittstock
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Jan Hendrik Schaefer
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Rostock University Medical Center, Rostock, Germany
| |
Collapse
|
3
|
Won SY, Melkonian R, Behmanesh B, Bernstock JD, Czabanka M, Dubinski D, Freiman TM, Günther A, Hellmuth K, Hernandez-Duran S, Herrmann E, Konczalla J, Maier I, Mielke D, Naser P, Rohde V, Schaefer JH, Senft C, Storch A, Trnovec S, Unterberg A, Walter J, Walter U, Wittstock M, Dinc N, Gessler F. Cerebellar Stroke Score and Grading Scale for the Prediction of Mortality and Outcomes in Ischemic Cerebellar Stroke. Stroke 2023; 54:2569-2575. [PMID: 37551591 DOI: 10.1161/strokeaha.123.043478] [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: 04/05/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Several individual predictors for outcomes in patients with cerebellar stroke (CS) have been previously identified. There is, however, no established clinical score for CS. Therefore, the aim of this study was to develop simple and accurate grading scales for patients with CS in an effort to better estimate mortality and outcomes. METHODS This multicentric retrospective study included 531 patients with ischemic CS presenting to 5 different academic neurosurgical and neurological departments throughout Germany between 2008 and 2021. Logistic regression analysis was performed to determine independent predictors related to 30-day mortality and unfavorable outcome (modified Rankin Scale score of 4-6). By weighing each parameter via calculation of regression coefficients, an ischemic CS-score and CS-grading scale (CS-GS) were developed and internally validated. RESULTS Independent predictors for 30-day mortality were aged ≥70 years (odds ratio, 5.2), Glasgow Coma Scale score 3 to 4 at admission (odds ratio, 2.6), stroke volume ≥25 cm3 (odds ratio, 2.7), and involvement of the brain stem (odds ratio, 3.9). When integrating each parameter into the CS-score, age≥70 years and brain stem stroke were assigned 2 points, Glasgow Coma Scale score 3 to 4, and stroke volume≥25 cm3 1 point resulting in a score ranging from 0 to 6. CS-score of 0, 1, 2, 3, 4, 5, and 6 points resulted in 30-day mortality of 1%, 6%, 6%, 17%, 21%, 55%, and 67%, respectively. Independent predictors for 30-day unfavorable outcomes consisted of all components of the CS-score with an additional variable focused on comorbidities (CS-GS). Except for Glasgow Coma Scale score 3 to 4 at admission, which was assigned 3 points, all other parameters were assigned 1 point resulting in an overall score ranging from 0 to 7. CS-GS of 0, 1, 2, 3, 4, 5, 6, and 7 points resulted in 30-day unfavorable outcome of 1%, 17%, 33%, 40%, 50%, 80%, 77%, and 100%, respectively. Both 30-day mortality and unfavorable outcomes increased with increasing CS-score and CS-GS (P<0.001). CONCLUSIONS The CS-score and CS-GS are simple and accurate grading scales for the prediction of 30-day mortality and unfavorable outcome in patients with CS. While the score systems proposed here may not directly impact treatment decisions, it may help discuss mortality and outcome with patients and caregivers.
Collapse
Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Ruzanna Melkonian
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (J.D.B.)
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital, Goethe University Hospital, Frankfurt, Germany (M.C., J.K.)
| | - Daniel Dubinski
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Thomas M Freiman
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Albrecht Günther
- Department of Neurology (A.G.), Jena University Hospital, Germany
| | - Kara Hellmuth
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Silvia Hernandez-Duran
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University Hospital, Frankfurt am Main, Germany (E.H.)
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University Hospital, Frankfurt, Germany (M.C., J.K.)
| | - Ilko Maier
- Department of Neurology, Göttingen University Hospital, Germany (I.M.)
| | - Dorothee Mielke
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | - Paul Naser
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Veit Rohde
- Department of Neurosurgery, Göttingen University Hospital, Germany (S.H.-D., D.M., V.R.)
| | | | - Christian Senft
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Alexander Storch
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Svorad Trnovec
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Germany (P.N., A.U., J.W.)
| | - Uwe Walter
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Matthias Wittstock
- Department of Neurology (A.S., U.W., M.W.), University Medical Center Rostock, Germany
| | - Nazife Dinc
- Department of Neurosurgery (R.M., C.S., N.D.), Jena University Hospital, Germany
| | - Florian Gessler
- Department of Neurosurgery (S.-Y.W., B.B., D.D., T.M.F., K.H., S.T., F.G.), University Medical Center Rostock, Germany
| |
Collapse
|
4
|
Scherer M, Kausch L, Bajwa A, Neumann JO, Ishak B, Naser P, Vollmuth P, Kiening K, Maier-Hein K, Unterberg A. Automatic Planning Tools for Lumbar Pedicle Screws: Comparison and Validation of Planning Accuracy for Self-Derived Deep-Learning-Based and Commercial Atlas-Based Approaches. J Clin Med 2023; 12:jcm12072646. [PMID: 37048730 PMCID: PMC10094754 DOI: 10.3390/jcm12072646] [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] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: This ex vivo experimental study sought to compare screw planning accuracy of a self-derived deep-learning-based (DL) and a commercial atlas-based (ATL) tool and to assess robustness towards pathologic spinal anatomy. Methods: From a consecutive registry, 50 cases (256 screws in L1-L5) were randomly selected for experimental planning. Reference screws were manually planned by two independent raters. Additional planning sets were created using the automatic DL and ATL tools. Using Python, automatic planning was compared to the reference in 3D space by calculating minimal absolute distances (MAD) for screw head and tip points (mm) and angular deviation (degree). Results were evaluated for interrater variability of reference screws. Robustness was evaluated in subgroups stratified for alteration of spinal anatomy. Results: Planning was successful in all 256 screws using DL and in 208/256 (81%) using ATL. MAD to the reference for head and tip points and angular deviation was 3.93 ± 2.08 mm, 3.49 ± 1.80 mm and 4.46 ± 2.86° for DL and 7.77 ± 3.65 mm, 7.81 ± 4.75 mm and 6.70 ± 3.53° for ATL, respectively. Corresponding interrater variance for reference screws was 4.89 ± 2.04 mm, 4.36 ± 2.25 mm and 5.27 ± 3.20°, respectively. Planning accuracy was comparable to the manual reference for DL, while ATL produced significantly inferior results (p < 0.0001). DL was robust to altered spinal anatomy while planning failure was pronounced for ATL in 28/82 screws (34%) in the subgroup with severely altered spinal anatomy and alignment (p < 0.0001). Conclusions: Deep learning appears to be a promising approach to reliable automated screw planning, coping well with anatomic variations of the spine that severely limit the accuracy of ATL systems.
Collapse
Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Lisa Kausch
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
| | - Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Paul Naser
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Klaus Maier-Hein
- Division of Medical Image Computing, German Cancer Research Center (DKFZ) Heidelberg, 69120 Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| |
Collapse
|
5
|
Sarhan AR, Naser P, Naser J. COVID-19 aerodynamic evaluation of social distancing in indoor environments, a numerical study. J Environ Health Sci Eng 2021; 19:1969-1978. [PMID: 34721881 PMCID: PMC8542656 DOI: 10.1007/s40201-021-00748-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/17/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE Many countries worldwide have taken early measures to combat the spread of coronavirus SARS-CoV-2 by implementing social distancing measures. The main aim of the present work is to examine the feasibility of social distancing (i.e. 1.5 m) in closed spaces taking into account the possibility for airborne transmission of SARS-CoV-2. METHODS A 3D numerical model of human respiration activities, such as breathing and speaking within indoor environments has been simulated with CFD software AVL FIRE R2020. The Eulerian-Eulerian flow model coupled with k-Ɛ approach were employed. With regard to breathing mode, the infected individual is modelled to be breathing 10 times per minute with a pulmonary rate of 6 L/min with a sinusoidal cycle. The present investigation considered air and droplets/particles as separate phases. RESULTS The predicted results suggested that the social distancing (i.e. 1.5 m) is not adequate to reduce the risk of contracting diseases like COVID-19, especially when staying for a longer period in an indoor environment. The person directly facing the infected person inhaled more than 1000 aerosol droplets within 30 min. The results also showed approximately 65 % decrease in the number of inhaled droplets the room is well ventilated. CONCLUSIONS Within an indoor environment, 1.5 m distance will not be enough to protect the healthy individuals from the droplets coming from an infected person. Also, the situation may become worse with the change of the air ventilation system.
Collapse
Affiliation(s)
- A. R. Sarhan
- Department of Mechanical and Product Design Engineering, Swinburne University of Technology, Hawthorn, Victoria 3122 Australia
| | - P. Naser
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - J. Naser
- Department of Mechanical and Product Design Engineering, Swinburne University of Technology, Hawthorn, Victoria 3122 Australia
| |
Collapse
|
6
|
|