Abstract TP154: Arcuate Fasciculus Integrity and Outcome of Post-stroke Aphasia: A 6-month Follow-up DTI Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Chorong Bae ◽  
Yoonhye Na ◽  
Minjae Cho ◽  
Yu Mi Hwang ◽  
Woo-Suk Tae ◽  
...  
Keyword(s):  
Structural Changes ◽  
Diffusion Tensor ◽  
Mean Diffusivity ◽  
Type I ◽  
Type Ii ◽  
Arcuate Fasciculus ◽  
Type Iii ◽  
Post Stroke ◽  
Fiber Number

Objectives: We evaluated the changes of arcuate fasciculus (AF), an important connecting pathway for language function, using DTI at 1-month and 6-month after stroke and investigated the relationship between structural changes of AF and improvement of post-stroke aphasia. Methods: We collected data from the STroke Outcome Prediction (STOP) database that is prospective data collecting system for functional recovery prediction after stroke based on neuroimaging study. Twenty-six patients with aphasia (PWA) who had first-ever stroke, presence of aphasia evaluated by Western Aphasia Battery (WAB) and no previous neurological or psychiatric diagnosis. The WAB and DTI data within 1 month (initial) and 6 months after (follow-up) stroke onset were used for analysis. And fractional anisotropy (FA), mean diffusivity (MD), fiber number (FN) and differences (Δ) at two time points of these parameters were obtained in bilateral AF in diffusion tensor tractography (DTT). Three types (I: not reconstructed, II: disrupted, discontinued or shallow, III: preserved) of classification according to integrity of AF was also included. Results: DTT parameters of bilateral AF showed statistically significant decrease in FA and increase in MD. Types of AF were changed in 6 patients (23%): 3 patients from type III to type II, 2 patients from type II to type I, and 1 patient from type II to type III. In Pearson’s correlation analysis, significant correlation was observed between 6-mon aphasia quotient (AQ) and parameters of left AF; positive correlation with FA (r=0.707, p<0.001), and negative correlation with MD (r=-.540, p<0.001). However, there was no correlation between 6-mon AQ score and FN of left AF, and all parameters of right AF. In addition, ΔDTT parameters were not correlated with either 6-mon AQ or ΔAQ. Conclusions: The AF changes over time not only in dominant but also in nondominant hemispheres in patients with aphasia after stroke. But amount of changes (Δ) in AF parameters were not associated with language recovery. Acknowledgement: This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (No. 2019R1A2C2003020).

scholarly journals Perforator preservation technologies (PPT) based on a new neuro-interventional classification in endovascular treatment of perforator involving aneurysms (piANs)

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Chen Li ◽  
Ao-Fei Liu ◽  
Han-Cheng Qiu ◽  
Xianli Lv ◽  
Ji Zhou ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Saccular Aneurysm ◽  
Type I ◽  
Type Ii ◽  
Fusiform Aneurysm ◽  
Type Iii ◽  
Perforating Artery ◽  
Protection Technology ◽  
Perforating Arteries

Abstract Background Treatment of perforator involving aneurysm (piAN) remains a challenge to open and endovascular neurosurgeons. Our aim is to demonstrate a primary outcome of endovascular therapy for piANs with the use of perforator preservation technologies (PPT) based on a new neuro-interventional classification. Methods The piANs were classified into type I: aneurysm really arises from perforating artery, type II: saccular aneurysm involves perforating arteries arising from its neck (IIa) or dome (IIb), and type III: fusiform aneurysm involves perforating artery. Stent protection technology of PPT was applied in type I and III aneurysms, and coil-basket protection technology in type II aneurysms. An immediate outcome of aneurysmal obliteration after treatment was evaluated (satisfactory obliteration: the saccular aneurysm body is densely embolized (I), leaving a gap in the neck (IIa) or dome (IIb) where the perforating artery arising; fusiform aneurysm is repaired and has a smooth inner wall), and successful perforating artery preservation was defined as keeping the good antegrade flow of those perforators on postoperative angiography. The periprocedural complication was closely monitored, and clinical and angiographic follow-ups were performed. Results Six consecutive piANs (2 ruptured and 4 unruptured; 1 type I, 2 type IIa, 2 type IIb, and 1 type III) in 6 patients (aged from 43 to 66 years; 3 males) underwent endovascular therapy between November 2017 and July 2019. The immediate angiography after treatment showed 6 aneurysms obtained satisfactory obliteration, and all of their perforating arteries were successfully preserved. During clinical follow-up of 13–50 months, no ischemic or hemorrhagic event of the brain occurred in the 6 patients, but has one who developed ischemic event in the territory of involving perforators 4 h after operation and completely resolved within 24 h. Follow-up angiography at 3 to 10M showed patency of the parent artery and perforating arteries of treated aneurysms, with no aneurysmal recurrence. Conclusions Our perforator preservation technologies on the basis of the new neuro-interventional classification seem feasible, safe, and effective in protecting involved perforators while occluding aneurysm.

A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias

Neurosurgery ◽  
2017 ◽  
Vol 81 (1) ◽  
pp. 29-44 ◽  
Author(s):  
Jörg Klekamp
Keyword(s):  
Structural Changes ◽  
Long Term Results ◽  
Type I ◽  
Type Ii ◽  
New Classification ◽  
Type Iii ◽  
Dural Sac ◽  
Spinal Cord Herniation ◽  
Dural Defects

Abstract BACKGROUND: The clinical significance of pathologies of the spinal dura is often unclear and their management controversial. OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results. METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed. RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery. CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.

Surgical treatment of the radial head is crucial for the outcome in terrible triad injuries of the elbow

2020 ◽  
Vol 102-B (12) ◽  
pp. 1620-1628
Author(s):  
Alexander Klug ◽  
Angela Nagy ◽  
Yves Gramlich ◽  
Reinhard Hoffmann
Keyword(s):  
Surgical Treatment ◽  
Radial Head ◽  
Independent Effect ◽  
Type I ◽  
Dash Score ◽  
Type Ii ◽  
Terrible Triad ◽  
Radial Head Fractures ◽  
Type Iii

Aims To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes. Methods Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible. Results At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures. Conclusion Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620–1628.

Surgical treatment of the radial head is critical to the outcome of Monteggia-like lesions

2019 ◽  
Vol 101-B (12) ◽  
pp. 1512-1519 ◽  
Author(s):  
Alexander Klug ◽  
Felix Konrad ◽  
Yves Gramlich ◽  
Reinhard Hoffmann ◽  
Kay Schmidt-Horlohé
Keyword(s):  
Surgical Treatment ◽  
Radial Head ◽  
Type I ◽  
Dash Score ◽  
Type Ii ◽  
Coronoid Fracture ◽  
Radial Head Arthroplasty ◽  
Type Iii ◽  
Clinical And Radiological Results

Aims The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results. Patients and Methods A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible. Results The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (sd 27) in extension/flexion and 155° (sd 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome. Conclusion Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

scholarly journals Use of Metaphyseal Sleeves in Revision Knee Arthroplasty

2017 ◽  
Vol 24 (2) ◽  
pp. 5-10
Author(s):  
M. V Girkalo ◽  
I. A Norkin
Keyword(s):  
Knee Arthroplasty ◽  
Surgical Intervention ◽  
Pain Syndrome ◽  
Type I ◽  
Type Ii ◽  
Short Term ◽  
Type Iii ◽  
Revision Knee Arthroplasty ◽  
Total Knee

Purpose. To study the short-term results of revision knee arthroplasty performed using metaphyseal sleeves. Patients and methods. During the period from 2013 to 2015 the total number of 40 patients was operated on. Type I femoral defects (by AORI classification) were diagnosed in 11 (27.5%), type II - in 26 (65.0%), type III - in 3 (7.5%) cases. Type I tibial defects were diagnosed in 2 (5.0%), type IIa - in 24 (65.0%), type IIb - in 11 (27.0%) and type III - in 3 (7.54%) cases. Metaphyseal femoral sleeves were used in 8 and metaphyseal tibial sleeve - in 40 patients. Results. Follow up period made up from 12 to 43 (mean 32.8) months. Excellent and good results by KSS scale were achieved in 30 (75.0%) of patients, by functional KSS scale - in 24 (60.0%) patients. Mean point by Knee Society Total Knee Arthroplasty Roentgenographic Evaluation scale in patients with femoral and tibial metaphyseal sleeves made up 2.35 versus 0.375 that confirmed the absence of progressive bone resorption. No one case of aseptic instability of the revision implant was observed. Repeated surgical intervention due to reinfection and knee joint contracture with pain syndrome was performed in 2 (5.0%) patients. Conclusion. The obtained data enable to recommend the use of metaphyseal sleeves for revision knee arthroplasty in patients with tibial and femoral defects of types II and III by AORI classification.

scholarly journals Functional outcome of 103 fractures of the proximal fifth metatarsal bone

2021 ◽  
Vol 26 (1) ◽  
Author(s):  
Patrick Pflüger ◽  
Michael Zyskowski ◽  
Michael Müller ◽  
Chlodwig Kirchhoff ◽  
Peter Biberthaler ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Rank Correlation ◽  
Metatarsal Bone ◽  
Outcome Analysis ◽  
Functional Score ◽  
Type I ◽  
Type Ii ◽  
Type Iii ◽  
Fifth Metatarsal Bone

Abstract Background Metatarsal fractures are common skeletal injuries of the lower extremity in adults. The majority involves the proximal fifth metatarsal bone. In the current literature, there still exists controversy regarding treatment recommendations for the different fracture entities. Methods All patients suffering from single fractures to the proximal fifth metatarsal bone between 2003 and 2015 were enrolled in this retrospective analysis. Only patients with a minimum follow-up of 12 months were included. The fractures were classified according to Lawrence and Botte (L&B). Data were collected via patient registry, radiographs and a standardized questionnaire (Foot and Ankle Outcome Score = FOAS). For outcome analysis, the nonparametric Mann–Whitney U test was performed and Spearman’s rank correlation coefficient calculated. Results In total, the functional outcomes of 103 patients suffering from fractures to the proximal fifth metatarsal bone were analyzed. L&B type I fractures (n = 13) had a FAOS score of 91 ± 23, L&B type II (n = 67) presented a score of 91 ± 15 and L&B type III (n = 23) a score of 93 ± 11. Surgically treated patients with an L&B type II fracture had no statistically significant better functional outcome in comparison to conservative management (p = 0.89). Operatively treated L&B type III fractures tended to have a better functional score (p = 0.16). The follow-up time was 58 (min: 15; max: 164) months. Conclusions Overall, the functional outcome following fractures to the proximal fifth metatarsal bone is satisfactory. Conservatively treated L&B type II fractures showed an equivalent functional outcome compared to surgical management. Patients with an L&B type III fracture mainly were treated surgically, but difference in FAOS score did not reach level of significance.

scholarly journals Clinical Significance of Hyperdense Lesions on Non-enhanced Brain CT Obtained Immediately after Arterial Revascularization in Acute Ischemic Stroke Patients

2021 ◽  
Vol 2021 ◽  
pp. 1-8
Author(s):  
Changbin Wang ◽  
Zudong Yin ◽  
Xinyi Zhang ◽  
Xiumin Zhao
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Significance ◽  
Type I ◽  
Type Ii ◽  
Contrast Extravasation ◽  
Arterial Revascularization ◽  
Brain Ct ◽  
Type Iii

Purpose. To analyze the characteristics of hyperdense lesions on brain CT conducted immediately after arterial revascularization (AR) in patients with acute ischemic stroke (AIS), track the outcome of those lesions and investigate their clinical significance. Materials and Methods. 97 AIS patients were enrolled in our study. Among them, 52 patients showed hyperdense lesions and were divided into three categories: type I, type II and type III according to the morphologic characteristics of hyperdense lesions. All patients underwent several follow-up CT/MR examinations to visualize the outcomes of the lesions. Results. Among the 52 patients, 22 showed contrast extravasation, 23 displayed contrast extravasation combined with hemorrhagic transformation (HT) and 7 confirmed symptomatic intracranial hemorrhage (SICH) in follow-up CT/MR. Among the without hyperdense lesions group, only 7 converted to hemorrhage, and no SICH occurred. All type I lesions showed contrast extravasation; 23 type II lesions turned to hemorrhage, 2 revealed SICH and 6 were pure contrast extravasation; all of the type III developed into SICH. Conclusion. Hyperdense lesions on non-enhanced brain CT obtained immediately after arterial revascularization (AR) exhibited varying features. Type I indicated a pure contrast extravasation. Type II and type III hyperdense lesions suggested higher incidence of HT, the presence of type III lesions indicated an ominous outcome.

Abstract P64: Longitudinal Brain Structural Changes After Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kyle C Kern ◽  
Clinton B Wright ◽  
Richard Leigh
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Stroke Volume ◽  
Brain Atrophy ◽  
Structural Changes ◽  
Diffusion Tensor ◽  
Brain Mri ◽  
Mean Diffusivity ◽  
Intracranial Volume ◽  
Post Stroke

Background: Stroke causes focal and diffuse structural brain changes that may contribute to subsequent cognitive decline and dementia. We hypothesize that MRI structural measures can detect continued cerebral degeneration over the first year after stroke. We identify predictors for progression of brain atrophy, leukoaraiosis and diffusion tensor imaging (DTI) metrics. Methods: Patients with ischemic stroke were enrolled prospectively in an observational study that included serial brain MRI. Patients underwent MRI FLAIR and DTI at the time of acute stroke and were followed for at least 9 months with multiple MRIs between 30 days and 15 months post-stroke. We used FLAIR to measure brain atrophy as the percent brain parenchymal fraction (BPF) of the total intracranial volume (TICV) and white matter hyperintensity volume (WMHV) as a percentage of TICV. DTI was used to calculate Peak Skeletonized Mean Diffusivity (PSMD), a global measure of white matter integrity previously validated in cerebral small vessel disease. Longitudinal changes in BPF, WMHV or PSMD were measured from 30 days post-stroke onward using linear regression models that included age, stroke volume, baseline BPF and WMHV as predictors. Results: Twenty-six patients had a median of 4 follow-ups over 9-15 months. Median age was 74 years (range 51-84) and 38% were women. Mean stroke volume was 4.5cc (0 - 30cc). Mean BPF was 78% (72 - 86%) and mean baseline WMHV was 1.1% (0.1 - 3.9%). BPF was associated with age and declined by 0.7% per year (t(111) = 2.7, p = 0.007). Progression was associated with baseline BPF (t(111) = -3.4, p < 0.001). WMHV in the non-stroke hemisphere was associated with age and increased by 0.10% per year (t(87) = -5.8, p < 0.001). Accumulation was associated with age (t(87) = 5.8, p < 0.001). PSMD was associated with baseline WMHV and had a relative increase of 1.9% per year in the non-stroke hemisphere and 4.5% in the stroke hemisphere (t(174) = -2.1, p = 0.03). Progression was associated with age (t(174) = 2.3, p = 0.03) and stroke volume (t(174) = 2.4, p = 0.02). Conclusions: During the months after ischemic stroke, BPF, WMHV and PSMD can detect persistent structural changes that may reflect later phases of stroke injury or ongoing contributions of aging, silent ischemia, or neurodegeneration.

scholarly journals An observational study into the management of arteriomegaly: a call for a revised classification system

2012 ◽  
Vol 94 (4) ◽  
pp. 250-255 ◽  
Author(s):  
JV Barandiaran ◽  
TC Hall ◽  
I Glaves ◽  
N El-Barghouti ◽  
EP Perry
Keyword(s):  
Observational Study ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia ◽  
Type I ◽  
Type Ii ◽  
Type Iii ◽  
Cerebrovascular Events ◽  
Progression Of Disease ◽  
Artery Disease

INTRODUCTION Arteriomegaly is the diffuse ectasia of arteries with or without aneurysmal disease. Patients with arteriomegaly have a higher incidence of morbidity including limb loss compared to patients with other arteriopathies. The aim of this observational study was to review the management of these patients in our institution. METHODS Radiologists and surgeons prospectively reviewed aortofemoral angiography. Patients with arteriomegaly were identified. Data relating to demographics, mode of presentation, risk factors, type of arteriomegaly, management and progression of disease were analysed. RESULTS Arteriomegaly was identified in 1.3% of patients (n=69) undergoing lower limb angiography in the study period. Of these, the majority (n=67) were men. The mean age was 74 years (range: 60–89 years) and 76% were smokers. Co-morbidities included coronary artery disease (55%), diabetes mellitus (20%), hypertension (45%) and cerebrovascular events (6%). Fortynine patients presented with critical limb ischaemia and eighteen patients were seen electively in the outpatients department with symptoms of intermittent claudication. Data were incomplete for two male patients and were therefore not included. At presentation, 22 patients were classified as Hoi lier type I, 5 were type II and 9 were type III. Thirty-one patients had arteriomegalic vessels but no aneurysmal disease. After a median follow-up duration of 76 months (range: 6–146 months), 34 patients progressed to type I, 2 to type II and 18 to type III. Thirteen remained without aneurysmal disease. Twenty-nine patients required angioplasty and twenty-eight required bypass surgery during this time. In total, 102 procedures were required for complicated disease. The limb salvage rate was 92%. Although 8 patients in our series died, the remaining 59 are under regular follow up. CONCLUSIONS This study illustrates the progressive nature of arteriomegaly. Results of the management of these patients in our institution are similar to those in the literature. We suggest an additional fourth category to Hollier’s classification that describes arteriomegalic disease without aneurysmal degeneration as this, too, deserves special management. Regular follow-up visits and early intervention for patients with arteriomegaly is advocated to reduce the high incidence of morbidity.

scholarly journals Use of Metaphyseal Sleeves in Revision Knee Arthroplasty

2017 ◽  
pp. 5-10
Author(s):  
M. V. Girkalo ◽  
I. A. Norkin
Keyword(s):  
Knee Arthroplasty ◽  
Surgical Intervention ◽  
Pain Syndrome ◽  
Type I ◽  
Type Ii ◽  
Short Term ◽  
Type Iii ◽  
Revision Knee Arthroplasty ◽  
Total Knee

Purpose.To study the short-term results of revision knee arthroplasty performed using metaphyseal sleeves.Patients and methods. During the period from 2013 to 2015 the total number of 40 patients was operated on. Type I femoral defects (by AORI classification) were diagnosed in 11 (27.5%), type II - in 26 (65.0%), type III - in 3 (7.5%) cases. Type I tibial defects were diagnosed in 2 (5.0%), type IIa - in 24 (65.0%), type IIb - in 11 (27.0%) and type III - in 3 (7.54%) cases. Metaphyseal femoral sleeves were used in 8 and metaphyseal tibial sleeve - in 40 patients.Results. Follow up period made up from 12 to 43 (mean 32.8) months. Excellent and good results by KSS scale were achieved in 30 (75.0%) of patients, by functional KSS scale - in 24 (60.0%) patients. Mean point by Knee Society Total Knee Arthroplasty Roentgenographic Evaluation scale in patients with femoral and tibial metaphyseal sleeves made up 2.35 versus 0.375 that confirmed the absence of progressive bone resorption. No one case of aseptic instability of the revision implant was observed. Repeated surgical intervention due to reinfection and knee joint contracture with pain syndrome was performed in 2 (5.0%) patients.Conclusion. The obtained data enable to recommend the use of metaphyseal sleeves for revision knee arthroplasty in patients with tibial and femoral defects of types II and III by AORI classification.

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