Cerebrovascular Disease

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Cerebrovascular Disease

  1. 1. Cerebrovascular disease & Strokes Dr. Osman Sadig Bukhari
  2. 2. <ul><li>Stroke is: </li></ul><ul><li>- is za 3 rd commonest cause of death </li></ul><ul><li>- 2/1000/year </li></ul><ul><li>- male > females </li></ul><ul><li>- uncommon before 40years except with: </li></ul><ul><li>- trauma </li></ul><ul><li>- cardiac diseases e.g RHD </li></ul><ul><li>- congenital vascular abn </li></ul><ul><li>- inflammatory arteritis </li></ul><ul><li>- vascular disease </li></ul><ul><li>- SS anaemia </li></ul>
  3. 3. <ul><li>Cerebral circulation </li></ul><ul><li>Cerebral vascular diseases comprise: </li></ul><ul><li>1- Thromboembolic infarction ( thrombosis and </li></ul><ul><li>embolism) </li></ul><ul><li>2- Intracerebral haemorrhage (ICH) </li></ul><ul><li>3- Subarachnoid haemorrhage (SAH) </li></ul><ul><li>4- Extradural hage & subdural haematoma </li></ul><ul><li>5- Cortical venous & dural venous sinus thromb </li></ul>
  4. 6. <ul><li>Stroke is either due to: </li></ul><ul><li>1- Infarction (ischemic) (80-85%) </li></ul><ul><li>- thrombosis </li></ul><ul><li>- embolism </li></ul><ul><li>2- Haemorrhage (15-20%): </li></ul><ul><li>- intracerebral </li></ul><ul><li>- subarachnoid </li></ul><ul><li>Site of stroke </li></ul><ul><li>- internal capsule - brainstem </li></ul><ul><li>- cerebral cortex - basal ganglia </li></ul><ul><li>- cerebellum </li></ul>
  5. 7. <ul><li>Mechanism of stroke: </li></ul><ul><li>1- Cerebral infarction (Ischemic) </li></ul><ul><li>- thrombosis at za site of atheroma </li></ul><ul><li>- embolism to a cerebral artery from </li></ul><ul><li>- extracranial vessels </li></ul><ul><li>- heart </li></ul><ul><li>* cerebral oedema may complicate infarction </li></ul><ul><li>and impair blood supply & cause further </li></ul><ul><li>damage </li></ul>
  6. 8. <ul><li>2- Cerebral haemorrhage </li></ul><ul><li>- subarachnoid haemorrhage </li></ul><ul><li>- ruptured beri aneurysm </li></ul><ul><li>- ruptured AVM </li></ul><ul><li>- intracerebral haemorrhage </li></ul><ul><li>- rupture of perforating vessels weakened </li></ul><ul><li>by HT or atheromatous degeneration </li></ul><ul><li>( micro aneurysm= 0.8-1.0 mm) </li></ul><ul><li>- rupture of aneurysms or AVM </li></ul><ul><li>* SAH arterial spasm & cerebral infarction </li></ul><ul><li>* ICH may extend to subarachnoid space. </li></ul>
  7. 9. <ul><li>* Disability from stroke depends on the </li></ul><ul><li>site & extent of damage </li></ul><ul><li>* Cerebellar hage can be fatal if there is </li></ul><ul><li>compression of brain stem. </li></ul>
  8. 10. <ul><li>Clinical classification of stroke </li></ul><ul><li>1- Completed stroke </li></ul><ul><li>focal neurological episodes with sympto </li></ul><ul><li>lasting > 24hrs. </li></ul><ul><li>- Major stroke </li></ul><ul><li>- Minor stroke ( recovery in 1-2Ws) </li></ul><ul><li>2- Evolving stroke </li></ul><ul><li>symptoms worsening gradually or in </li></ul><ul><li>stepwise fashion over hrs or days </li></ul><ul><li>( DD= tumour, SDH) </li></ul><ul><li>3- Transient ischemic attack (TIA) </li></ul><ul><li>symptoms lasting < 24hrs. </li></ul>
  9. 11. <ul><li>Disorders causing stroke </li></ul><ul><li>comprises:- </li></ul><ul><li>1- Thromboembolic disease (infarction </li></ul><ul><li>- atherosclerosis </li></ul><ul><li>- arteriosclerosis (HT, degenerative) </li></ul><ul><li>- embolism (20%) </li></ul><ul><li>- arteritis (syph, TA, PAN, SLE) </li></ul><ul><li>- dissection (spontaneous, traumatic) </li></ul><ul><li>- Vasospasm (migraine, SAH, angiogr) </li></ul><ul><li>- hyper viscosity (PRV) </li></ul><ul><li>- anti phospholipid syndrome </li></ul><ul><li>- SS disease - hypotension - OCPs </li></ul>
  10. 12. <ul><li>2- Haemorrhage </li></ul><ul><li>- intracerebral 50% </li></ul><ul><li>- sub arachnoid 50% </li></ul><ul><li>- AVM </li></ul><ul><li>- Beri aneurysms </li></ul><ul><li>- Degenerative aneurysms </li></ul><ul><li>- HT arteriolar aneurysms </li></ul><ul><li>- Mycotic aneurysms </li></ul><ul><li>- Anticoagulants, thrombolytic therapy </li></ul><ul><li>- Bleeding disorders (ITP, DIC, haemop </li></ul><ul><li>- Alcohol, cocaine, amphetamine) </li></ul>
  11. 13. <ul><li>Risk factors for stroke </li></ul><ul><li>1- Non modifiable factors </li></ul><ul><li>- age - gender </li></ul><ul><li>- race - hereditary </li></ul><ul><li>2- Modifiable factors </li></ul><ul><li>- arterial HT - cardiac diseases </li></ul><ul><li>- DM - cigarette smoking </li></ul><ul><li>- Hyperlipidaemia - Thrombocythemia </li></ul><ul><li>- polycythemia - Physical inactivity </li></ul><ul><li>- Obesity - OCPs </li></ul><ul><li>- High alcohol intake - trauma </li></ul><ul><li>- Peripheral vascular disease </li></ul>
  12. 14. <ul><li>Transient ischemic attacks TIA </li></ul><ul><li>Definition : focal neurological symptoms </li></ul><ul><li>(due to cerebral ischemia) wz symptoms </li></ul><ul><li>lasting < 24hrs. </li></ul><ul><li>Causes : </li></ul><ul><li>- emboli or PL material from extracranial </li></ul><ul><li>arteries </li></ul><ul><li>- cardiac emboli </li></ul><ul><li>- severe stenosis of a major artery + </li></ul><ul><li>haemdynamic disturbance ( e.g V/basilar </li></ul><ul><li>- small infarcts, hage, brainstem tumours and SDH can cause TIA </li></ul>
  13. 15. <ul><li>Clinical features: </li></ul><ul><li>Carotid system Vertebrobasilar syst </li></ul><ul><li>- amaurosis fugax - diplopia, vertigo, vomiting </li></ul><ul><li>- aphasia -dysphagia, dysarthria </li></ul><ul><li>- hemiparesis - facial numb & weakness </li></ul><ul><li>- hemisensory loss - ataxia, nystagmus </li></ul><ul><li>- hemianopic visual - hemisensory loss </li></ul><ul><li>loss - hemianopic visual </li></ul><ul><li>loss </li></ul><ul><li>- transient global </li></ul><ul><li>amnesia & confusion </li></ul><ul><li>- tetraparesis, coma, and </li></ul><ul><li>cortical blindness. </li></ul>+ evidence of underlying disease
  14. 16. <ul><li>* TIAs may herald completed stroke and </li></ul><ul><li>25% of pts wz completed stroke recall </li></ul><ul><li>previous TIA </li></ul><ul><li>* TIAs require to investigate za underlying </li></ul><ul><li>cause & prevent to reduce za completed </li></ul><ul><li>stroke </li></ul><ul><li>* 40% of pts wz TIAs suffer completed </li></ul><ul><li>stroke in 5 years. </li></ul><ul><li>* 25% of pts wz TIAs die from stroke or </li></ul><ul><li>coronary heart disease. </li></ul>
  15. 17. <ul><li>* management of TIAs </li></ul><ul><li>- identify risk factors & correct </li></ul><ul><li>- antiplatelets reduce za risk of stroke </li></ul><ul><li>by 25%. </li></ul><ul><li>- anticoagulants for definite cardiac </li></ul><ul><li>source of thromboembolism. </li></ul><ul><li>- carotid endarterectomy reduce za risk </li></ul><ul><li>of stroke by 75%. </li></ul>
  16. 18. <ul><li>Clinical features of stroke </li></ul><ul><li>Depends on za site & extent </li></ul><ul><li>1- Acute focal neurological deficit : </li></ul><ul><li>- Hemiparesis +/- dysphasia is the </li></ul><ul><li>commonest presentation. Weakness 1 st </li></ul><ul><li>and recovery takes place over days, Ws </li></ul><ul><li>or months. </li></ul><ul><li>- Hypotonia, depressed reflexes and </li></ul><ul><li>extensor reflex occur initially, followed </li></ul><ul><li>later by hypertonia & hyper reflexia. </li></ul><ul><li>- Monoparesis or dysphasia occur wz cortical </li></ul><ul><li>lesions </li></ul><ul><li>- Hemianaethesia & visual fields defects </li></ul>
  17. 19. <ul><li>- With brain stem lesions C/f depends on </li></ul><ul><li>the structures involved and leads to </li></ul><ul><li>coma due to damage to reticular </li></ul><ul><li>activating system. The cardinal feature </li></ul><ul><li>is ipsilateral nuclear signs and </li></ul><ul><li>contralateral signs of pyramidal & S/T </li></ul><ul><li>tract lesions signs ( crossed ). </li></ul><ul><li>- With severe strokes flaccid paralysis is </li></ul><ul><li>accompanied by HA, vomiting, seizures </li></ul><ul><li>gaze paresis, impaired consciousness </li></ul><ul><li>+/- papilloedema 2ndry to cerebral </li></ul><ul><li>oedema </li></ul><ul><li>- Ataxia & hemisensory loss occur with deeply </li></ul><ul><li>seated lacunar infarcts. </li></ul>
  18. 20. <ul><li>2- Dementia : </li></ul><ul><li>gradual decline in intellectual fn, sp </li></ul><ul><li>in ischemic strokes, with or without </li></ul><ul><li>sensorimotor limb deficit or gait disord </li></ul><ul><li>3- SAH: </li></ul><ul><li>- HA. Neck stiffness & vomiting </li></ul><ul><li>- with or without focal neurological defi </li></ul><ul><li>4- Diseases of cerebral circulation </li></ul><ul><li>** General med ex wz PR & rhythm, BP, </li></ul><ul><li>peripheral vessels, carotid bruits, heart </li></ul><ul><li>ex & complete neurological ex leads to </li></ul><ul><li>correct diagnosis. </li></ul>
  19. 21. <ul><li>Differential diag of acute stroke </li></ul><ul><li>1- cerebral tumours </li></ul><ul><li>2- subdural haematoma </li></ul><ul><li>3- cerebral abscess, cysts </li></ul><ul><li>4- Todd's paralysis </li></ul><ul><li>5- demyelinating disorders </li></ul><ul><li>6- hypoglycemia </li></ul><ul><li>7- encephalitis </li></ul><ul><li>8- hysterical conversion </li></ul>
  20. 22. <ul><li>Investigation of stroke </li></ul><ul><li>1- Investigations to confirm the diagnosis </li></ul><ul><li>( ? Ischemic, ? Hagic)= CT brain, MRI, </li></ul><ul><li>and L puncture. </li></ul><ul><li>2-Investigations to establish za underlying </li></ul><ul><li>disease = ECG, Echo, CXR, MRA, Doppler US, </li></ul><ul><li>carotid angiography. </li></ul><ul><li>3- Investigations to identify risk factors = </li></ul><ul><li>CBC, blood sugar, lipid profile, serology </li></ul><ul><li>for syphilis, clotting studies, serology for </li></ul><ul><li>collagen diseases, blood cultures for </li></ul><ul><li>SBE is suspected, sickling test, tests for </li></ul><ul><li>thrombophilia (protein C & S, anti thrombin 3 </li></ul>
  21. 23. <ul><li>Management of stroke </li></ul><ul><li>The aim is :- </li></ul><ul><li>1- To minimize brain damage </li></ul><ul><li>2- To reduce disability through rehabilitati </li></ul><ul><li>3- Tom prevent complications </li></ul><ul><li>4- To treat za underlying cause. </li></ul><ul><li>5-To prevent za recurrence of stroke </li></ul><ul><li>6- To refer pts wz SAH to neurosurgery. </li></ul><ul><li>** To admit or not depends on za clinical </li></ul><ul><li>state & facilities at home ( TIAs & min </li></ul><ul><li>stroke at home) </li></ul>
  22. 24. <ul><li>** General measures: </li></ul><ul><li>- ABC </li></ul><ul><li>- nursing care </li></ul><ul><li>- fluid balance & nutrition </li></ul><ul><li>- urinary cath if not continent </li></ul><ul><li>- physiotherapy, occupational, speech </li></ul><ul><li>and psychotherapy </li></ul><ul><li>** Specific therapy: </li></ul><ul><li>1- Med treatment </li></ul><ul><li>- anti hypertensives not given at the </li></ul><ul><li>start unless very high (> 180/110) </li></ul><ul><li>as some pts show reactive increase in BP. </li></ul><ul><li>It is gradually lowered after za 1 st week </li></ul>
  23. 25. <ul><li>- Anti platelets reduce za incidence of </li></ul><ul><li>stroke by 25% e.g. aspirin 75-300mg </li></ul><ul><li>dipyridamol 75 tds, clopidogrel </li></ul><ul><li>- Anti coagulants only if there is a </li></ul><ul><li>source of emboli & avoided in za 1 st </li></ul><ul><li>2Ws following infarction. It may be </li></ul><ul><li>used in evolving stroke, but C/I in </li></ul><ul><li>intra cranial hage & cerebral tumours </li></ul><ul><li>which should be rouled out by CT </li></ul><ul><li>- Thrombolysis (tpA) in USA given </li></ul><ul><li>within 3hrs. </li></ul><ul><li>- Manitol 200ml 20% & dexamethazone </li></ul><ul><li>reduce mortality in pts with brain oedema </li></ul><ul><li>2ndry to severe stroke. </li></ul><ul><li>- Baclofe n (GABA antagonist) for spasticity </li></ul>
  24. 26. <ul><li>2- Surgical treatment </li></ul><ul><li>- carotid endarterectomy in TIAs and </li></ul><ul><li>minor stroke when stenosis is > 70% </li></ul><ul><li>reduce incidence of stroke by 75%. </li></ul><ul><li>Avoided over 65 years. </li></ul><ul><li>- surgical evacuation of haematoma if </li></ul><ul><li>accessible & if pat continue to deteriorate e.g cerebellar hage to prevent brainstem compression. </li></ul><ul><li>3- Rehabilitation </li></ul><ul><li>- identify risk factors & treat </li></ul><ul><li>- TR 2ndry depression </li></ul>
  25. 27. <ul><li>Prognosis </li></ul><ul><li>- 25% die as a direct result of stroke. </li></ul><ul><li>More in hagic stroke. </li></ul><ul><li>- 50-75% who survive stroke achieve fnal </li></ul><ul><li>independency in 3Ms </li></ul><ul><li>- poor outcome in pts wz deep coma and </li></ul><ul><li>dense hemiplegia </li></ul><ul><li>- recurrent stroke in5-10%/ year </li></ul><ul><li>- patient may die of cardiovascular dis. </li></ul>
  26. 28. <ul><li>Complications of acute stroke </li></ul><ul><li>- pneumonia - dehydration </li></ul><ul><li>- hyponatraemia - hypoxaemia </li></ul><ul><li>- hypoglycemia - DVT </li></ul><ul><li>- seizures - subluxation of joints </li></ul><ul><li>- frozen shoulder - pressure sores </li></ul><ul><li>- UTI - constipation </li></ul>
  27. 29. <ul><li>Lateral medullary syndrome </li></ul><ul><li>- due to occlusion of PICA or vertebral art. </li></ul><ul><li>- there is ipsilateral ataxia, nystagmus, </li></ul><ul><li>facial numbness, palatal palsy, diplopia </li></ul><ul><li>(6 th CN) & Horners </li></ul><ul><li>- contralateral S/T signs. Hemiparesis rare </li></ul><ul><li>- often vertigo. </li></ul><ul><li>Weber syndrome </li></ul><ul><li>- ipsilateral 3 rd cranial N palsy </li></ul><ul><li>- contralateral pyramidal </li></ul>
  28. 30. <ul><li>Pontine hage </li></ul><ul><li>- impaired consciousness </li></ul><ul><li>- hyperpyrexia </li></ul><ul><li>- pinpoint pupils </li></ul><ul><li>- paresis </li></ul><ul><li>Visual cortical infarcts </li></ul><ul><li>- cortical blindness </li></ul><ul><li>- hemianopia </li></ul><ul><li>Lacunar infarcts </li></ul><ul><li>- <1.5 cm </li></ul><ul><li>- commonly HT </li></ul><ul><li>- pure motor, sensory or cerebellar </li></ul>
  29. 31. <ul><li>Multi infarct dementia </li></ul><ul><li>- stepwise gradual intellectual loss </li></ul><ul><li>- pseudobulbar palsy </li></ul><ul><li>- Parkinsonian gait. </li></ul><ul><li>Water shed infarcts </li></ul><ul><li>- multiple infarcts at border zones betwee </li></ul><ul><li>areas supplied by cerebral arteries </li></ul><ul><li>following prolonged periods of cerebral </li></ul><ul><li>ischemia </li></ul><ul><li>- cortical blindness </li></ul><ul><li>- amnesia </li></ul><ul><li>- intellectual impairment. </li></ul>
  30. 32. <ul><li>Cerebellar hage </li></ul><ul><li>- headache is severe & occipital </li></ul><ul><li>- brainstem symptoms may occur e.g </li></ul><ul><li>diplopia, vertigo wz rapid deterioration of </li></ul><ul><li>conswciousness </li></ul><ul><li>- may cause acute hydrocephalus </li></ul><ul><li>- immediate surgical evacuation of haemat </li></ul>
  31. 33. <ul><li>Subarachnoid hage (SAH) </li></ul><ul><li>- 10% of strokes </li></ul><ul><li>- Causes : </li></ul><ul><li>- Berry aneurysm 70% </li></ul><ul><li>- AVM 10% </li></ul><ul><li>- rare causes </li></ul><ul><li>- extension of I/C hage - anticoagul </li></ul><ul><li>- rupture of atheromatous vessel </li></ul><ul><li>- bleeding disorders - brain tumou </li></ul><ul><li>- acute bact meningitis - arteritis SLE </li></ul><ul><li>- spinal AVM - co arcitation of Ao </li></ul><ul><li>- APKD - Marfan’s </li></ul>
  32. 34. <ul><li>Berry aneurysm: </li></ul><ul><li>- post & ant communicating arteries </li></ul><ul><li>- middle cerebral art </li></ul><ul><li>- basilar, PICA, retinal & intra cavernous </li></ul><ul><li>carotid art </li></ul><ul><li>- bleeds </li></ul><ul><li>- pressure on surrounding structures e.g. </li></ul><ul><li>3 rd CN </li></ul><ul><li>AVM: </li></ul><ul><li>- developmental anomaly within za brain </li></ul><ul><li>- SAH </li></ul><ul><li>- focal neurological deficits & epilepsy. </li></ul>
  33. 35. <ul><li>Clinical features : </li></ul><ul><li>- occurs during exertion high Bp </li></ul><ul><li>- sudden severe occipital headache </li></ul><ul><li>- neck stiffness & +ve Kerning sign </li></ul><ul><li>- fever & vomiting </li></ul><ul><li>- photophobia & irritability </li></ul><ul><li>- consciousness may be lost & seizures </li></ul><ul><li>may develop </li></ul><ul><li>- sub hyaloid hage & papilloededema </li></ul><ul><li>- focal neurological signs (ischemia from </li></ul><ul><li>arterial spasm & bleeding into brain </li></ul><ul><li>- CT diagnostic </li></ul><ul><li>- LP if CT is –ve (hagic) </li></ul><ul><li>- look for bruits over head & eyes </li></ul><ul><li>- DD= meningitis, migraine, meningism, C malar </li></ul>
  34. 36. <ul><li>Complications : </li></ul><ul><li>- hydrocephalus due to obstruction of </li></ul><ul><li>subarachnoid space by clots. </li></ul><ul><li>- intra cranial arterial spasm & neurological deficits </li></ul><ul><li>Management: </li></ul><ul><li>- Immediate : bed rest, control of HT, </li></ul><ul><li>dexamethazone if brain oedema </li></ul><ul><li>- Specific: refer to neurosurgical unit as </li></ul><ul><li>soon as diag is proven.? Angiography, </li></ul><ul><li>clipping of za neck of aneurysm </li></ul><ul><li>micro embolization, focal R/T & surgery for AVM </li></ul>
  35. 37. <ul><li>Prognosis: </li></ul><ul><li>-50% early mortality </li></ul><ul><li>- 10-20% die from rebleeding within 2Ws </li></ul><ul><li>- comatosed pts & those wz severe </li></ul><ul><li>neurological deficit carry bad prognosis. </li></ul>
  36. 38. <ul><li>Cerebral venous thrombosis </li></ul><ul><li>- Uncommon </li></ul><ul><li>- Causes patchy hagic ischemia & ICP </li></ul><ul><li>- predisposing factors </li></ul><ul><li>- dehydration - hypotension </li></ul><ul><li>- polythycemia - pregnancy </li></ul><ul><li>- Anti phospholipid syndrome - OCP </li></ul><ul><li>- Severe intercurrent infection </li></ul><ul><li>- Para nasal sinusitis - Facial skin infection </li></ul><ul><li>- Otitis media - mastoiditis </li></ul><ul><li>- meningitis -Subdural embyema </li></ul><ul><li>- Fracture skull - penetrating head inury </li></ul>
  37. 39. <ul><li>1- Cortical venous thrombosis </li></ul><ul><li>- fever </li></ul><ul><li>- focal cerebral dysfunction: </li></ul><ul><li>- epilepsy - hemiparesis </li></ul><ul><li>- dysarthria </li></ul><ul><li>2- Cerebral venous sinus thrombosis </li></ul><ul><li>Depends on za sinus involved </li></ul><ul><li>a- cavernous sinus: Often bilateral </li></ul><ul><li>- pt very ill, headache, ptosis, </li></ul><ul><li>proptosis, ophthalmoplegia, fever </li></ul><ul><li>papilloedema, sensation ophth V </li></ul>
  38. 40. <ul><li>b- Superior sagittal sinus: </li></ul><ul><li>headache, seizures, papilloedema, </li></ul><ul><li>+/- advancing motor & sensory def </li></ul><ul><li>c- Transverse sinus: </li></ul><ul><li>hemiparesis, seizures, & papilloedem </li></ul><ul><li>spreading to jugular foramen </li></ul><ul><li>X1, X, X11 palsies. </li></ul><ul><li>Investigations </li></ul><ul><li>- CT, MRA to detect occluded v or sinus </li></ul><ul><li>- CSF under pressure </li></ul>
  39. 41. <ul><li>Treatment </li></ul><ul><li>- broad spectrum antibiotics </li></ul><ul><li>- drain infected site ( sinus, middle ear) </li></ul><ul><li>- dexamethazone for brain oedema </li></ul><ul><li>- anticoagulants early on may limit the </li></ul><ul><li>spread of thrombosis. </li></ul>
  40. 42. <ul><li>Chronic subdural haematoma (SDH) </li></ul><ul><li>- affects elderly & alcoholics even with </li></ul><ul><li>minor head trauma </li></ul><ul><li>- fluctuating headache, drowsiness and </li></ul><ul><li>confusion </li></ul><ul><li>- focal signs: hemiparesis, hemisensory </li></ul><ul><li>loss </li></ul><ul><li>- seizures, papilloedma, stupor & coma </li></ul><ul><li>- fatal if untreated </li></ul><ul><li>- conservative TR hoping that spontaneous </li></ul><ul><li>stopping of bleeding, otherwise burr hole. </li></ul>
  41. 43. <ul><li>Extradural hage </li></ul><ul><li>- due to tearing of middle meningeal art </li></ul><ul><li>following linear skull vault fracture. </li></ul><ul><li>- brief loss of consciousness (concussion) </li></ul><ul><li>followed by lucid interval of recovery </li></ul><ul><li>- with progressive hemiparesis, stupor and </li></ul><ul><li>rapid transtentorial coning with ipsilat </li></ul><ul><li>dilated pupil followed by dilatation of </li></ul><ul><li>of za other, quadriparesis & death if </li></ul><ul><li>untreated. </li></ul><ul><li>- prompt CT & MRI if suspected & urgent </li></ul><ul><li>neurosurgery. </li></ul>
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