ENDOVASCULAR AND SURGICAL TREATMENT OF RUPTURED CEREBRAL ANEURYSMS IN PEDIATRIC PATIENTS

Neurosurgery ◽  
2008 ◽  
Vol 63 (5) ◽  
pp. 859-866 ◽  
Author(s):  
Michael F. Stiefel ◽  
Gregory G. Heuer ◽  
Anuj K. Basil ◽  
John B. Weigele ◽  
Leslie N. Sutton ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Condition ◽  
Pediatric Patients ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Multidisciplinary Treatment ◽  
Cerebral Aneurysms ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Fisher Grade ◽  
Good Clinical Condition

Abstract OBJECTIVE Pediatric cerebral aneurysms are rare. There are very few recent studies that focus on the multidisciplinary treatment of ruptured aneurysms. We reviewed our pediatric endovascular and surgical experience with ruptured cerebral aneurysms. METHODS Pediatric patients aged 16 years and younger who were admitted with a diagnosis of aneurysmal subarachnoid hemorrhage and treated at the Children's Hospital of Philadelphia were included in this analysis. RESULTS Twelve patients with 13 aneurysms (4 male patients and 8 female patients; age range, 4 months–16 years; mean age, 5.1 years), were admitted with subarachnoid hemorrhage during the past 12 years. The majority of patients were admitted in good clinical condition; 31% were in Hunt and Hess Grade II, and 31% were in Hunt and Hess Grade III. The remaining patients were in poor clinical condition and were in Hunt and Hess Grade IV (23%) or Grade V (15%). Computed tomography revealed that 15% of the patients were in Fisher Grade 2, 23% were in Fisher Grade 3, and 62% were in Fisher Grade 4. Endovascular techniques were used in the treatment of 5 aneurysms, and microsurgery was used in the treatment of 8 aneurysms. In the endovascular group, aneurysm sizes ranged from 2 to 35 mm (mean, 12.6 mm); 3 aneurysms were in the anterior circulation, and 2 were in the posterior circulation. In the microsurgery group, 6 aneurysms were in the anterior circulation, and 2 were in the posterior circulation; sizes ranged from 3 to 15 mm (mean, 6.8 mm). Sixty-nine percent of the patients were independent at follow-up. CONCLUSION Contemporary endovascular and microsurgical techniques can be used effectively to treat ruptured cerebral aneurysms in pediatric patients. In the time period studied, the techniques were equally effective when used in the appropriate patients.

scholarly journals Cerebral Arterial Fenestrations

2014 ◽  
Vol 20 (3) ◽  
pp. 261-274 ◽  
Author(s):  
Daniel L. Cooke ◽  
Charles E. Stout ◽  
Warren T. Kim ◽  
Akash P. Kansagra ◽  
John Paul Yu ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Digital Subtraction Angiography ◽  
Basilar Artery ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Database Search ◽  
Posterior Circulation ◽  
Digital Subtraction ◽  
Anterior Circulation ◽  
Anatomic Variant ◽  
Medline Database

Arterial fenestrations are an anatomic variant with indeterminate significance. Given the controversy surrounding fenestrations we sought their prevalence within our practice along with their association with other cerebrovascular anomalies. We retrospectively reviewed 10,927 patients undergoing digital subtraction angiography between 1992 and 2011. Dictated reports were searched for the terms “fenestration” or “fenestrated” with images reviewed for relevance, yielding 228 unique cases. A Medline database search from February 1964 to January 2013 generated 304 citations, 127 cases of which were selected for analysis. Cerebral arterial fenestrations were identified in 228 patients (2.1%). At least one aneurysm was noted in 60.5% of patients, with an aneurysm arising from the fenestration in 19.6% of patients. Aneurysmal subarachnoid hemorrhage or non-aneurysmal subarachnoid hemorrhage were present in 60.1% and 15.8%, respectively. For the subset of patients with an aneurysm arising directly from a fenestration relative to those patients with an aneurysm not immediately associated with a fenestration, the prevalence of aneurysmal subarachnoid hemorrhage was 66.7% vs. 58.6% (p = 0.58). Fenestrations were more often within the posterior circulation (73.2%) than the anterior circulation (24.6%), though there was no difference in the prevalence of aneurysms within these groups (61.1% vs. 60.7%, p = 1.0). Cerebral arterial fenestrations are an anatomic variant more often manifesting at the anterior communicating arterial complex and basilar artery and with no definite pathological relationship with aneurysms.

The poor prognosis of ruptured intracranial aneurysms of the posterior circulation

1995 ◽  
Vol 82 (5) ◽  
pp. 791-795 ◽  
Author(s):  
Wouter I. Schievink ◽  
Eelco F. M. Wijdicks ◽  
David G. Piepgras ◽  
Chu-Pin Chu ◽  
W. Michael O'Fallon ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Initial Period ◽  
Posterior Circulation ◽  
Medical Record Linkage ◽  
Anterior Circulation ◽  
Content Type ◽  
Clinical Series ◽  
Posterior Circulation Aneurysms ◽  
Fine Print

✓ The first 48 hours after aneurysmal subarachnoid hemorrhage are critical in determining final outcome. However, most patients who die during this initial period are not included in hospital-based studies. We investigated the occurrence of subarachnoid hemorrhage in a population-based study to evaluate possible predictors of poor outcome. All patients diagnosed with aneurysmal subarachnoid hemorrhage between 1955 and 1984 were selected for analysis of mortality in the first 30 days using the medical record—linkage system employed for epidemiological studies in Rochester, Minnesota. One hundred and thirty-six patients were identified. The mean age of these 99 women and 37 men was 55 years. Rates for survival to 48 hours were 32% for the 19 patients with posterior circulation aneurysms, 77% for the 87 patients with anterior circulation aneurysms, and 70% for the 30 patients with a presumed aneurysm (p < 0.0001). Rates for survival to 30 days were 11%, 57%, and 53%, respectively, in these three patient groups (p < 0.0001). Clinical grade on admission to the hospital, the main variable predictive of death within 48 hours, was significantly worse in patients with posterior circulation aneurysms than in others (p < 0.0001). The prognosis of ruptured posterior circulation aneurysms is poor. The high early mortality explains why posterior circulation aneurysms are uncommon in most clinical series of patients with subarachnoid hemorrhage. The management of incidentally discovered intact posterior circulation aneurysms may be influenced by these findings.

scholarly journals Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

2019 ◽  
Vol 130 (6) ◽  
pp. 1914-1921 ◽  
Author(s):  
Hubert Lee ◽  
Jeffrey J. Perry ◽  
Shane W. English ◽  
Fahad Alkherayf ◽  
Joanne Joseph ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Characteristic Curve ◽  
Univariate Analysis ◽  
Laboratory Data ◽  
Delayed Cerebral Ischemia ◽  
Clinical Prediction ◽  
Anterior Circulation ◽  
Fisher Grade

OBJECTIVEThe aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.METHODSPatients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.RESULTSOf 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67–0.78] vs 0.66 [95% CI 0.60–0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40–59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.CONCLUSIONSAmong patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

scholarly journals Risk Factors for Re-bleeding of Aneurysmal Subarachnoid Hemorrhage: Systemic Review and Meta Analysis

2014 ◽  
Vol 21 (1) ◽  
pp. 113-123
Author(s):  
Alfotih Gobran Taha ◽  
Fang Cheng Li ◽  
Xin Ke Xu ◽  
Shang Yi Zhang
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Subarachnoid Hemorrhage ◽  
Clinical Condition ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Systemic Review ◽  
High Systolic Blood Pressure ◽  
Aneurysm Size ◽  
Fisher Grade

Abstract Objective : The mortality of re-bleeding is high and patients surviving are usually in poor clinical condition and have a worse outcome than patients with single bleed. We performed an update systemic review and Meta-analysis to determine the most common risk factors for re-bleeding in aneurysmal subarachnoid hemorrhage patients. Method: We reviewed all publications on the risk factors of the re-bleeding or rerupture of already bled intracranial aneurysms. This Meta analysis included studies published from the year 2000 until 2013. Pooled mean difference was calculated for the continuous variables (Age), and pooled odds ratio (OR) was calculated for categorical factors. Heterogeneity was tested first. If it is significant (p<0.05), random effect model was applied, otherwise, fixed model was used. Software - Review manager was used to find pooled effects and perform significant test for each potential risk factor. Results : We identified 174 articles. Only 7 retrospective studies had met the inclusion criteria, with 2470 patients, 283 patients had aneurysmal re-bleeding. The weighted average rate of re-bleeding is 11.3% with 95% confidence interval [CI]: 10.1-12.6. Statistically significant risk factor for re-bleeding were sex (OR 1.46; 95% CI: 1.11, 1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40, 4.53), aneurysm size (OR 3.00; 95% CI: 2.06- 4.37), clinical condition (Hunt & Hess) (OR 4.94; 95% CI: 2.29, 10.68), and Fisher Grade (OR 2.29; 95% CI: 1.45, 3.61). Conclusion: Sex, high SBP, high Fisher Grade, aneurysm size larger than 10 mm, and patients with poor clinical condition (Hunt & Hess) were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention should be emphasized to eliminate the risk of re-bleeding and poor outcome.

Unruptured Cerebral Aneurysms Do Not Shrink When They Rupture: Multicenter Collaborative Aneurysm Study Group

Neurosurgery ◽  
2011 ◽  
Vol 68 (1) ◽  
pp. 155-161 ◽  
Author(s):  
Maryam. Rahman ◽  
Christopher S. Ogilvy ◽  
Gregory J. Zipfel ◽  
Colin P. Derdeyn ◽  
Adnan H. Siddiqui ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Previous History ◽  
Cerebral Aneurysms ◽  
Maximum Size ◽  
Posterior Circulation ◽  
Inclusion Criteria ◽  
Anterior Circulation ◽  
Clinical Databases ◽  
Before And After ◽  
Posterior Circulation Aneurysms

Abstract BACKGROUND: The International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (&lt; 7 mm) anterior circulation and posterior circulation aneurysms had a 0% and 2.5% risk of subarachnoid hemorrhage over 5 years, respectively. OBJECTIVE: To determine whether cerebral aneurysms shrink with rupture. METHODS: The clinical databases of 7 sites were screened for patients with imaging of cerebral aneurysms before and after rupture. Inclusion criteria included documented subarachnoid hemorrhage by imaging or lumbar puncture and intracranial imaging before and after cerebral aneurysm rupture. The patients were evaluated for aneurysm maximal height, maximal width, neck diameter, and other measurement parameters. Only a change of ≥ 2 mm was considered a true change. RESULTS: Data on 13 patients who met inclusion criteria were collected. The median age was 60, and 11 of the 13 patients (84.6%) were female. Only 5 patients had posterior circulation aneurysms. None of the aneurysms had a significant decrease in size. One aneurysm decreased by 1.8 mm in maximum size after rupture (7.7%). Six aneurysms had an increase in maximum size of at least 2 mm after rupture (46.2%) with a mean increase of 3.5 mm (± 0.5 mm). CONCLUSION: Unruptured aneurysms do not shrink when they rupture. The large percentage of ruptured small aneurysms in previous studies were likely small before they ruptured.

scholarly journals Risk factors for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage

Open Medicine ◽  
2020 ◽  
Vol 15 (1) ◽  
pp. 598-604
Author(s):  
Valentina Opancina ◽  
Snezana Lukic ◽  
Slobodan Jankovic ◽  
Radisa Vojinovic ◽  
Milan Mijailovic
Keyword(s):  
Risk Factors ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Medical Center ◽  
White Blood Cells ◽  
Cerebral Aneurysms ◽  
International Normalized Ratio ◽  
Cross Sectional Study ◽  
Cross Sectional

AbstractIntroductionAneurysmal subarachnoid hemorrhage is a type of spontaneous hemorrhagic stroke, which is caused by a ruptured cerebral aneurysm. Cerebral vasospasm (CVS) is the most grievous complication of subarachnoid hemorrhage (SAH). The aim of this study was to examine the risk factors that influence the onset of CVS that develops after endovascular coil embolization of a ruptured aneurysm.Materials and methodsThe study was designed as a cross-sectional study. The patients included in the study were 18 or more years of age, admitted within a period of 24 h of symptom onset, diagnosed and treated at a university medical center in Serbia during a 5-year period.ResultsOur study showed that the maximum recorded international normalized ratio (INR) values in patients who were not receiving anticoagulant therapy and the maximum recorded white blood cells (WBCs) were strongly associated with cerebrovascular spasm, increasing its chances 4.4 and 8.4 times with an increase of each integer of the INR value and 1,000 WBCs, respectively.ConclusionsSAH after the rupture of cerebral aneurysms creates an endocranial inflammatory state whose intensity is probably directly related to the occurrence of vasospasm and its adverse consequences.

scholarly journals Clinical condition of 120 patients alive at 3 years after poor-grade aneurysmal subarachnoid hemorrhage

2021 ◽  
Author(s):  
Anniina H. Autio ◽  
Juho Paavola ◽  
Joona Tervonen ◽  
Maarit Lång ◽  
Terhi J. Huuskonen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Condition ◽  
Hospice Care ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Blood Clot ◽  
Neurointensive Care ◽  
Intracerebral Hematoma ◽  
Poor Grade ◽  
Final Study ◽  
Study Population

Abstract Background To study the clinical condition of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients alive at 3 years after neurointensive care. Methods Of the 769 consecutive aSAH patients from a defined population (2005–2015), 269 (35%) were in poor condition on admission: 145 (54%) with H&H 4 and 124 (46%) with H&H 5. Their clinical lifelines were re-constructed from the Kuopio Intracranial Aneurysm Database and Finnish nationwide registries. Of the 269 patients, 155 (58%) were alive at 14 days, 125 (46%) at 12 months, and 120 (45%) at 3 years. Results The 120 H&H 4–5 patients alive at 3 years form the final study population. On admission, 73% had H&H 4 but only 27% H&H 5, 59% intracerebral hematoma (ICH; median 22 cm3), and 26% intraventricular blood clot (IVH). The outcome was favorable (mRS 0–1) in 45% (54 patients: ICH 44%; IVH clot 31%; shunt 46%), moderate (mRS 2–3) in 30% (36 patients: ICH 64%; IVH clot 19%; shunt 42%), and unfavorable (mRS 4–5) in 25% (30 patients: ICH 80%; IVH clot 23%; shunt 50%). A total of 46% carried a ventriculoperitoneal shunt. ICH volume was a significant predictor of mRS at 3 years. Conclusions Of poor-grade aSAH patients, 45% were alive at 3 years, even 27% of those extending to pain (H&H 5). Of the survivors, 75% were at least in moderate condition, while only 2.6% ended in hospice care. Consequently, we propose non-selected admission to neurointensive care (1) for a possibility of moderate outcome, and (2), in case of brain death, possibly improved organ donation rates.

scholarly journals Surgical treatment of intracranial aneurysms: six-year experience in Belo Horizonte, MG, Brazil

2004 ◽  
Vol 62 (2a) ◽  
pp. 245-249 ◽  
Author(s):  
Leodante Batista da Costa Jr ◽  
Josaphat Vilela de Morais ◽  
Agustinho de Andrade ◽  
Marcelo Duarte Vilela ◽  
Renato P. Campolina Pontes ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Surgical Treatment ◽  
Intracranial Aneurysms ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
The United States ◽  
Anterior Circulation ◽  
Common Location ◽  
Belo Horizonte ◽  
Spontaneous Subarachnoid Hemorrhage ◽  
Anterior Circulation Aneurysms

Spontaneous subarachnoid hemorrhage accounts for 5 to 10 % of all strokes, with a worldwide incidence of 10.5 / 100000 person/year, varying in individual reports from 1.1 to 96 /100000 person/year. Angiographic and autopsy studies suggest that between 0.5% and 5% of the population have intracranial aneurysms. Approximately 30000 people suffer aneurysmal subarachnoid hemorrhage in the United States each year, and 60% die or are left permanently disabled. We report our experience in the surgical treatment of intracranial aneurysms in a six year period, in Belo Horizonte, Minas Gerais, Brazil. We reviewed the hospital files, surgical and out-patient notes of all patients operated on for the treatment of intracranial aneurysms from January 1997 to January 2003. Four hundred and seventy-seven patients were submitted to 525 craniotomies for treatment of 630 intracranial aneurysms. The majority of patients were female (72.1%) in the fourth or fifth decade of life. Anterior circulation aneurysms were more common (94.4%). The most common location for the aneurysm was the middle cerebral artery bifurcation. The patients were followed by a period from 1 month to 5 years. The outcome was measured by the Glasgow Outcome Scale (GOS). At discharge, 62.1% of the patients were classified as GOS 5, 13.9% as GOS 4, 8.7% as GOS 3, 1.7% as GOS 2 and 14.8% as GOS 1.

Variation of patient characteristics, management, and outcome with timing of surgery for aneurysmal subarachnoid hemorrhage

2011 ◽  
Vol 114 (4) ◽  
pp. 1045-1053 ◽  
Author(s):  
Kelly B. Mahaney ◽  
Michael M. Todd ◽  
James C. Torner
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Management Practices ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Timing Of Surgery ◽  
Early Surgery ◽  
Outcome Variable ◽  
Optimal Time ◽  
World Federation ◽  
Time Interval ◽  
Fisher Grade

ObjectThe past 30 years have seen a shift in the timing of surgery for aneurysmal subarachnoid hemorrhage (SAH). Earlier practices of delayed surgery that were intended to avoid less favorable surgical conditions have been replaced by a trend toward early surgery to minimize the risks associated with rebleeding and vasospasm. Yet, a consensus as to the optimal timing of surgery has not been reached. The authors hypothesized that earlier surgery, performed using contemporary neurosurgical and neuroanesthesia techniques, would be associated with better outcomes when using contemporary management practices, and sought to define the optimal time interval between SAH and surgery.MethodsData collected as part of the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) were analyzed to investigate the relationship between timing of surgery and outcome at 3 months post-SAH. The IHAST enrolled 1001 patients in 30 neurosurgical centers between February 2000 and April 2003. All patients had a radiographically confirmed SAH, were World Federation of Neurosurgical Societies Grades I–III at the time of surgery, and underwent surgical clipping of the presumed culprit aneurysm within 14 days of the date of hemorrhage. Patients were seen at 90-day follow-up visits. The primary outcome variable was a Glasgow Outcome Scale score of 1 (good outcome). Intergroup differences in baseline, intraoperative, and postoperative variables were compared using the Fisher exact tests. Variables reported as means were compared with ANOVA. Multiple logistic regression was used for multivariate analysis, adjusting for covariates. A p value of less than 0.05 was considered to be significant.ResultsPatients who underwent surgery on Days 1 or 2 (early) or Days 7–14 (late) (Day 0 = date of SAH) fared better than patients who underwent surgery on Days 3–6 (intermediate). Specifically, the worst outcomes were observed in patients who underwent surgery on Days 3 and 4. Patients who had hydrocephalus or Fisher Grade 3 or 4 on admission head CT scans had better outcomes with early surgery than with intermediate or late surgery.ConclusionsEarly surgery, in good-grade patients within 48 hours of SAH, is associated with better outcomes than surgery performed in the 3- to 6-day posthemorrhage interval. Surgical treatment for aneurysmal SAH may be more hazardous during the 3- to 6-day interval, but this should be weighed against the risk of rebleeding.

scholarly journals Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2015 ◽  
Vol 77 (5) ◽  
pp. 786-793 ◽  
Author(s):  
◽  
Carole L. Turner ◽  
Karol Budohoski ◽  
Christopher Smith ◽  
Peter J. Hutchinson ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
White Blood Cells ◽  
Cerebral Injury ◽  
World Federation ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Poor Outcome ◽  
Fisher Grade ◽  
Good Grade

Abstract BACKGROUND: There remains a proportion of patients with unfavorable outcomes after aneurysmal subarachnoid hemorrhage, of particular relevance in those who present with a good clinical grade. A forewarning of those at risk provides an opportunity towards more intensive monitoring, investigation, and prophylactic treatment prior to the clinical manifestation of advancing cerebral injury. OBJECTIVE: To assess whether biochemical markers sampled in the first days after the initial hemorrhage can predict poor outcome. METHODS: All patients recruited to the multicenter Simvastatin in Aneurysmal Hemorrhage Trial (STASH) were included. Baseline biochemical profiles were taken between time of ictus and day 4 post ictus. The t-test compared outcomes, and a backwards stepwise binary logistic regression was used to determine the factors providing independent prediction of an unfavorable outcome. RESULTS: Baseline biochemical data were obtained in approximately 91% of cases from 803 patients. On admission, 73% of patients were good grade (World Federation of Neurological Surgeons grades 1 or 2); however, 84% had a Fisher grade 3 or 4 on computed tomographic scan. For patients presenting with good grade on admission, higher levels of C-reactive protein, glucose, and white blood cells and lower levels of hematocrit, albumin, and hemoglobin were associated with poor outcome at discharge. C-reactive protein was found to be an independent predictor of outcome for patients presenting in good grade. CONCLUSION: Early recording of C-reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome.

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