Cerebral Venous Infarction Research Articles

Hemorrhagic cerebral venous infarction after vein injury during intraoperative lesion resection: incidence, hemorrhagic stages, risk factors and prognosis.

Cerebral venous infarction (CVI) after vein injury during intraoperative lesion resection is associated with intracranial hemorrhage. We conducted this study to identify the incidence, clinical and imaging features, and prognosis of hemorrhage CVI. We performed a retrospective analysis of patients with confirmed CVI after vein injury who underwent craniotomy in our hospital. Postoperative clinical symptoms were observed, and imaging features were compared between patients with and without intracranial hemorrhages through CT examination. Variables were analyzed using univariate and multivariate regression analyses. Among 2,767 patients who underwent craniotomy, 93 cases of injured veins were identified intraoperatively. Hemorrhagic CVI was found in 38% (35/93). Multivariate analysis revealed that midline approach, meningioma, postoperative seizures, disorders of consciousness and interval in hours < 72 h were identified as predictors of hemorrhagic CVI. After 3 months of follow-up, the prognosis was poor in 15 cases (16%, 15/93), including death (two cases), vegetative survival (four cases), and severe disability (nine cases). Hemorrhagic CVI, as a critical complication after venous injury, can have disastrous consequences. Do not injure known veins intraoperatively. In case of injury, requisite remedial measures should be adopted during and after surgery.

403 Malignant Cerebral Venous Infarction: Decompressive Craniectomy Versus Medical Treatment

INTRODUCTION: Cerebral venous thrombosis (CVT) is a common stroke in young adults and is associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are these patients' most common causes of death. METHODS: In this retrospective study, Patients with the following inclusion criteria have entered the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive mid-position pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered the study. 23 patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils’ reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P &lt; 0.001). A favorable outcome (modified Rankin scale score 0e2) was achieved in 52% of the DC group and 0% of the MG group (P &lt; 0.001). CONCLUSIONS: Our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcomes in most patients.

A study on correlation between neuroimaging and maternal outcome in eclampsia

Background: Hypertensive disorders remain among the most significant complications of pregnancy. Neurological complications of eclampsia are a major contributor to morbidity and mortality that is associated with eclampsia. Neuroimaging studies have revolutionized visualization of hypertensive encephalopathy aids in timely intervention and a favorable maternal and perinatal outcome. Aims and Objectives: (1) To study the spectrum of neuroimaging findings in patients with eclampsia. (2) To correlate these findings with the maternal outcome. Materials and Methods: A prospective observational study was undertaken in the Department of Obstetrics and Gynecology, Mysore Medical College and research institute Mysore, for 18 months. All the eclamptic mothers during the study were included in the study. They were studied in terms of neuroimaging and its correlation with maternal outcomes. Results: The incidence of eclampsia was 7.14% which is relatively high, attributed to the fact that being a tertiary care center many cases are referred. Higher incidence was seen in primigravida (72.4%) and lower maternal age of 18–20 years (48%). Cesarean section was indicated in 50% of deliveries indicating immediate action was necessary for better fetomaternal outcome. They presented with varied imminent symptoms such as headache in 20.4%, vomiting in 22.4%, and visual blurring in 22.4%. About 50% presented with altered sensorium. On non-contrast computed tomography brain, 64.3% (63) had normal findings, 17.3% (17) had posterior reversible encephalopathy syndrome (PRES) with a sensitivity of 68.42% and specificity of 85%, whereas on magnetic resonance imaging (MRI) brain, 36.26% had no abnormalities, 40.81% had PRES with a sensitivity of 86.84%, and specificity of 85%. About 58.6% had an uneventful maternal outcome. The others were hemolysis, elevated liver enzymes, and low platelet syndrome seen in 9.18% of patients, acute kidney injury in 6.12%, postpartum hemorrhage seen in 5.1%. The maternal mortality rate was 7.66%, the most common cause of death was intracranial hemorrhage. Conclusion: The common neuroimaging findings in eclampsia are cerebral edema, PRES, cerebral venous thrombosis, infarcts, hemorrhage, and hypertensive leukoencephalopathy. Although some abnormalities seen in neuroimaging studies are incidental and transient without chronic neurologic sequelae, both CT and MRI findings correlate with the clinical presentation and maternal outcome but MRI correlates better compared to CT and can be a better imaging modality in eclampsia patients and is indicated in all patients of eclampsia.

Retraction: Cerebral Venous Infarct After Recovery From COVID-19 Pneumonia.

[This retracts the article DOI: 10.7759/cureus.19763.].

Dural Arteriovenous Fistulas With or Without Cerebral Venous Thrombosis: A Cross-Sectional Analysis of 511 Patients.

Recent studies suggest a bidirectional relationship of dural arteriovenous fistula (DAVF) with cerebral venous thrombosis (CVT). We aimed to compare the characteristics of patients with DAVF with or without CVT and to analyze the risk factors for the coexistence of CVT in a DAVF population. A total of 511 adult patients with DAVF were enrolled consecutively in our hospital from February 2019 through November 2022. Demographic data, clinical manifestations, and imaging characteristics were reviewed in detail. The patients with DAVF were divided into two groups: DAVF with CVT (DAVF-CVT) group and without CVT (DAVF alone) group. Univariate logistic regression and multivariate logistic regression were used to analyze the risk factors for the coexistence of CVT and DAVF. CVT was found in 19.8% of patients with DAVF. In univariate analysis, compared with the DAVF-alone group, the DAVF-CVT group was more likely to have tinnitus ( P = .001), blurred vision ( P < .001), visual field loss ( P = .001), focal neurological deficits ( P = .002), seizures ( P = .008), and cognitive impairment ( P = .046) and less likely to have spinal cord/brain stem dysfunction ( P = .004). In addition, there were significant differences in age ( P = .009), sex ( P = .019), the occurrence of venous cerebral infarction ( P = .001), and DAVF location ( P < .001) between the two groups. Furthermore, multivariate analysis showed that blurred vision, venous cerebral infarction, large sinus DAVF, and multiple DAVF were risk factors for the coexistence of CVT in patients with DAVF, with the odds ratio of 2.416 (95% CI 1.267-4.606, P = .007), 6.018 (95% CI 1.289-28.100, P = .022), 5.801 (95% CI 2.494-13.496, P < .001), and 5.640 (95% CI 2.122-14.989, P = .001), respectively. CVT occurred in approximately one fifth of patients with DAVF. Blurred vision, venous cerebral infarction, large sinus DAVF, and multiple DAVF may be the risk factors for predicting the coexistence of CVT in patients with DAVF.

Palinacousis after Cerebral Venous Thrombosis in the Temporoparietal Lobe

Palinacousis is a rare auditory phenomenon characterized by the persistence of sounds beyond their actual duration. It has been associated with various brain conditions such as stroke, tumor, and seizure in the temporoparietal lobe. We present a case report of a 43-yearold man who developed palinacousis following cerebral venous thrombosis and seizure with lesions including the left auditory cortex. This case highlights the intriguing relationship between cerebral venous infarction, seizure, and the development of palinacousis in specific brain regions.

The safety and effectiveness of lumbar drainage for cerebrospinal fluid leakage after spinal surgery

PurposeCerebrospinal fluid (CSF) leakage is a frequent complication after spinal surgery. The lumbar drainage procedure (LDP) is the preferred method for early closure of a dural tear. This study was conducted to assess the safety and effectiveness of LDP after spinal surgery. Materials and MethodsWe retrospectively reviewed 122 patients (55 male and 67 female) who underwent LDP after spinal surgery between January 2010 and June 2021. LDP was performed on patients with suspected CSF leakage due to a dural tear during spinal surgery or in whom mixed-color CSF was observed in the hemo-drain after surgery. LDP was performed aseptically by a resident according to our institution’s protocol, and the amount drained was from 200cc to 300cc per day. Absolute bed rest was maintained during the lumbar drainage period. The hemo-drain was opened to confirm that CSF was no longer mixed or oozing, at which time the lumbar drain was removed. Culture was performed at the drain tip when the lumbar drain was removed. ResultsThe spinal surgery level was cervical in 23 patients, thoracic in 27 patients, and lumbar in 72 patients. The mean duration of the indwelling lumbar drain was 7.2 days (2 days–18 days), and the mean amount of drainage was 1198.2cc (100cc–2542cc). Among the 122 patients, the CSF leakage in 101 patients was resolved with the initial procedure, but 21 patients required re-insertion. Of those 21 patients, improper insertion due to a technical problem occurred in 15 patients, poor line fixation occurred in 2 patients, and CSF leakage was again observed after removal of the lumbar drain in 4 patients. In only 1 case was open surgery done after LDP because follow-up magnetic resonance imaging showed a suspected infection. During lumbar drainage, 76 patients used antibiotics, and 46 patients did not. Four patients showed bacterial growth in the tip culture, and 3 of them had been using antibiotics. All 4 of those patients were treated without complications and discharged. Among the 122 patients, 1 patient was discharged with left hemiparesis due to cerebral venous infarction (CVI) and hemorrhage after LDP, and 1 patient underwent re-operation because the CSF collection was not resolved. ConclusionsNo major complications such as systemic infection, deep vein thrombosis, or aspiration pneumonia occurred during the lumbar drainage, except for 1 patient (0.8%) with CVI caused by over-drainage. One patient (0.8%) required open surgery after LDP, but no cases of systemic infection occurred while maintaining lumbar drainage, irrespective of antibiotic use. In conclusion, LDP is a safe and effective treatment for CSF leakage after spinal surgery.

Integrated Management of Cerebral Sinus Venous Thrombosis, Venous Infarcts, and Acute Left Ventricular Failure in Postpartum: A Comprehensive Case Report

Integrated Management of Cerebral Sinus Venous Thrombosis, Venous Infarcts, and Acute Left Ventricular Failure in Postpartum: A Comprehensive Case Report

Characteristics of cerebral venous thrombosis in patients from two university hospitals in Colombia between 2018-2020

Describir las características clínicas, demográficas y radiológicas, y los factores de riesgo de una serie de pacientes con trombosis venosa cerebral de dos hospitales de Colombia. Materiales y métodos. Es un estudio descriptivo retrospectivo de pacientes hospitalizados, atendidos en el servicio de neurología de dos hospitales de Bogotá desde diciembre de 2018 hasta diciembre del 2020. Se incluyeron 33 pacientes. Las frecuencias más altas correspondieron a mujeres en edad fértil, en puerperio (n=7; 33,3 %) y pacientes con patologías autoinmunes (n=10; 30,3 %). El síntoma inicial más común fue la cefalea (n=31; 93,9 %), seguido de focalización neurológica (n=9; 27,2%) y crisis epiléptica (n=8; 24,2 %). El 51 % (n=17) de los pacientes tuvo un examen físico normal. El infarto venoso cerebral se presentó en el 21,1 % (n=7), la hemorragia subaracnoidea en el 12,1 % (n=4) y el hematoma intraparenquimatoso en el 9 % (n=3) del total de pacientes. El 60,6 % (n=20) quedó con nivel independiente en la escala funcional de Barthel. Ningún paciente falleció. Se encontraron características sociodemográficas, clínicas y radiológicas similares a lo reportado en la literatura mundial. Con respecto a las diferencias, se encontró en nuestro estudio compromiso de la circulación venosa cerebral profunda en un porcentaje ligeramente mayor a lo descrito, pero sin aumento de complicaciones, ni mortalidad.

Neuroprotective effects of pravastatin in cerebral venous infarction in a rat model.

Pravastatin sodium is reported to have multiple beneficial effects in cerebral atherosclerosis and neuronal injury; however, the preventive effects on cerebral venous ischemia are still unknown. Herein, we aimed to examine the neuroprotective effects of transoral prior administration of pravastatin sodium against cerebral cortical venous ischemia with suppression of apoptosis. Thirty 8-week-old male Wistar rats were divided equally into two study groups (n=15 vs. n=15); the pravastatin group was fed 1% pravastatin sodium with their usual diet for 2 weeks, while the control group only received the usual diet. Two-vein occlusion (2VO) model was applied for this study, and two adjacent cortical veins in each animal were permanently occluded photochemically with rose bengal dye. During photo-thrombosis, regional changes of the cerebral blood flow (CBF) in area of the venous ischemia were recorded. At 48-h after 2VO, animals were euthanized using perfusion fixation, and we histologically measured ratios of infarcted area to contralateral hemisphere, and counted Bax- and Bcl-2-positive cells in the penumbra to investigate the implications for apoptosis. The ratio of infarcted area was significantly decreased in the pravastatin group compared to the control group (P<0.01). The number of Bax-positive cells also decreased significantly in the pravastatin group (P<0.01). In contrast, immunolabeling for Bcl-2 was essentially negative in all areas in both groups. There were also no significant differences in regional CBF changes after 2VO between the two groups (P=0.13). Pre-emptive administration of pravastatin sodium mixed in the food has neuroprotective effects against cerebral cortical venous ischemia with suppression of apoptosis associated with inhibition of Bax expression but has little influence on regional CBF.

Case 313: Cerebral Venous Infarct Due to Internal Cerebral Vein Thrombosis in the Setting of COVID-19 Infection

A 45-year-old woman presented to the emergency department of an outside hospital with shortness of breath and cough. Five days after initial presentation, the patient presented again to the same emergency department with worsening headache and progressive left arm and left leg weakness. She was transferred to the neuroscience intensive care unit of our hospital with concern for an intracranial abnormality based on her work-up at the outside hospital. Her past medical history was notable only for a large uterine fibroid. In our hospital, CT of the brain and chest and MRI of the brain, including perfusion studies, were performed. Additionally, CT venography of the brain was performed.

Abstract Number ‐ 280: A Unique Case of Pial AVF Presenting as Hemispheric Cerebral Edema

Introduction To describe a unique case of pial arteriovenous fistula presenting as left hemispheric cerebral edema with hemianopsia, sensory change and ataxia. Methods Case report Results Our patient is a 38 year old male with a history of diabetes, hyperlipidemia and congenital deafness with a left cochlear implant who presented to an outside hospital for visual complaints. Non‐contrast CT of the head was negative at that time; he could not obtain an MRI due to his cochlear implant. He developed worsening right hemianopia and aphasia, prompting his transfer to our facility. Upon arrival, repeat imaging was done, including a CTA of the head and neck. This revealed a large region of hypodensity involving the left PCA and distal MCA territories. An MRI was attempted but artifact from his implant obscured visualization of the left hemisphere. Post‐contrast CT was negative for evidence of tumor. CT venogram was negative for veno‐occlusive disease. He complained of worsening headache and demonstrated worsening word‐finding ability. He received100g total of mannitol divided across 3 boluses which improved his symptoms mildly. Over the following days he began to become ataxic and clumsy in the right upper extremity and his headache worsened further and he began to develop focal seizures electrographically localized to the left parietal lobe. Repeat CTA demonstrated expanding hypodensity with marked vascular engorgement in the left hemisphere. He underwent 6‐vessel digital subtraction angiography (DSA) of the head which revealed gross left hemispheric venous congestion with early filling of the left hemispheric venous system by a parasagittal pial ateriovenous fistula believed to be responsible for his hemispheric edema. He was discharged on acetazolamide and acetaminophen for headache management and plans for outpatient follow‐up and potential intervention. Follow‐up DSA revealed improvement in his venous congestion and reduction in the degree of his early venous filling with some symptomatic improvement by medical management. Conclusions Pial arteriovenous fistulae (pAVF) are a rare entity and can present in a variety of ways, with symptomatic intracranial hemorrhage and ischemia being two of the most common. This case illustrates an unusual instance of hemispheric edema initially mistaken for venous infarct caused by a pAVF, and prompts the physician to consider angiography and further exploration when initial workup for cerebral edema and/or venous infarct is initially unrevealing.

Homocystinuria Presenting as Ectopia Lentis and Thrombotic Manifestations in Two Siblings: A Case Series

AbstractHomocystinuria (HCU) is an autosomal recessive metabolic disorder due to a defect in cystathionine beta synthase activity which results in homocysteine accumulation in the body. We report a case series of two siblings,11-year-old girl and 3-year-old boy, studied retrospectively. They were born to a nonconsanguineous parents and diagnosed as a case of HCU based on the presence of ectopia lentis and development of cerebral venous thrombosis and infarction. Child who presented late with paresis had delayed developmental milestones with low intelligence quotient (IQ), while the second child diagnosed at a younger age had relatively normal IQ and cognitive development. Serious clinical sequelae such as life-threatening thromboembolic events at a young age and mental retardation can be prevented by early screening and prompt treatment of the patients detected to have HCU.

Usefulness of the Multimodal Fusion Image for Visualization of Deep Sylvian Veins.

The preoperative assessment of cerebral veins is important to avoid unexpected cerebral venous infarction in the neurosurgical setting. However, information is particularly limited regarding deep Sylvian veins, which occasionally disturb surgical procedures for cerebral anterior circulation aneurysms. The predictability of detecting deep Sylvian veins and their tributaries using a modern multimodal fusion image was aimed to be evaluated. Moreover, 51 patients who underwent microsurgery for unruptured cerebral aneurysms with Sylvian fissure dissection were retrospectively reviewed. The visualization of the four components of the deep Sylvian veins in conventional computed tomography (CT) venography and multimodal fusion images was evaluated. To compare the detection accuracy among these radiological images, the sensitivity and specificity for the detection of each of the four venous structures were calculated in comparison with those of intraoperative inspections. The kappa coefficients were also measured and the inter-rater agreement for each venous structure in each radiological image was examined. In all veins, the multimodal fusion image exhibited a high detection rate without statistical difference from intraoperative inspections (P = 1.0). However, CT venography exhibited a low detection rate with a significant difference from intraoperative inspections in the common vertical trunk (P = 0.006) and attached vein (P = 0.008). The kappa coefficients of the fusion image ranged from 0.73 to 0.91 and were superior to those of CT venography for all venous structures. This is the first report to indicate the usefulness of a multimodal fusion image in evaluating deep Sylvian veins, especially for the detection of nontypical, relatively small veins with large individual variability.

Inflammation and Severe Cerebral Venous Thrombosis.

Cerebral venous thrombosis (CVT) is a rare type of venous thromboembolism (VTE). It is an important cause of stroke in young adults and children. Severe CVT, which is characterized by cerebral venous infarction or hemorrhage, seizures, or disturbance of consciousness, has more severe clinical manifestations and a worse prognosis. It is commonly believed that the onset of severe CVT gave credit to venous return disorder, with the underlying pathogenesis remaining unclear. There is increasing evidence suggesting that an inflammatory response is closely associated with the pathophysiology of severe CVT. Preclinical studies have identified the components of neuroinflammation, including microglia, astrocytes, and neutrophils. After CVT occurrence, microglia are activated and secrete cytokines (e.g., interleukin-1β and tumor necrosis factor-α), which result in a series of brain injuries, including blood-brain barrier disruption, brain edema, and cerebral venous infarction. Additionally, astrocytes are activated at the initial CVT stage and may interact with microglia to exacerbate the inflammatory response. The extent of cerebral edema and neutrophil recruitment increases temporally in the acute phase. Further, there are also changes in the morphology of inflammatory cells, expression of inflammatory mediators, and inflammatory pathway molecules with CVT progression. Lately, some clinical research suggested that some inflammation-related biomarkers are of great value in assessing the course, severity, and prognosis of severe CVT. Moreover, basic and clinical research suggested that anti-inflammatory therapy might hold promise in severe CVT. This study reviews the current literature regarding the involvement of inflammation in the pathophysiology and anti-inflammatory interventions of severe CVT, which would contribute to informing the pathophysiology mechanism and laying a foundation for exploring novel severe CVT therapeutic strategies.

Risk factors influencing cerebral venous infarction after meningioma resection

BackgroundCerebral venous infarction (CVI) is a serious complication after meningioma resection. The risk factors of postoperative cerebral venous infarction after surgical resection of meningioma can be determined through large samples and this study can add evidence to the literature.MethodsThe clinical and imaging data of 1127 patients with intracranial meningiomas who underwent resection in our hospital were retrospectively collected and analyzed. CVI was evaluated by postoperative imaging and clinical manifestations. Univariate and multivariate analyses were performed to identify risk factors associated with CVI.ResultsOverall, 4.7% (53/1127) of patients experienced CVI after meningioma resection. Multivariate analysis revealed superficial meningioma, moderate to severe peritumoral edema, peritumoral critical vein and WHO grade II-III as independent predictors of a postoperative CVI. After timely intervention, the symptoms were clearly alleviated in one month, and the prognosis was good, but injury to key veins could cause irreversible neurological disorders.ConclusionsIntraoperative protection of veins is the primary way to prevent CVI. The present study identified several significant and independent risk factors for postoperative venous infarction, thereby enabling the identification of high-risk patients who require special attention during clinical and surgical management.

A Case Report Symptoms Improvement of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVT) is a rare cause of stroke, a life-threatening disorder that occurs in approximately 0,5-1% of all stroke incidents. Various clinical presentations, risk factors, and neuroimaging findings of this disease may cause a delay in the early diagnosis and treatment of CVT. We discuss a case of a 34-year-old female who was admitted to the emergency room (ER) with the onset of a generalized tonic-clonic seizure with a progressive headache in the occipitotemporal region. Based on head CT, there was multiple hyperdense and cerebral venous infarction in the posterior left parietal lobe. D-dimer evaluation, there was an increasing level of D-dimer (&gt;10.000 ng/mL). The patient was treated with the primary therapy heparin. After 15 days of being hospitalized, the patient was discharged without any sequelae.&#x0D; Keywords: CVT, heparin, stroke

An Integrated Approach on the Diagnosis of Cerebral Veins and Dural Sinuses Thrombosis (a Narrative Review).

(1) Objective: This review paper aims to discuss multiple aspects of cerebral venous thrombosis (CVT), including epidemiology, etiology, pathophysiology, and clinical presentation. Different neuroimaging methods for diagnosis of CVT, such as computer tomography CT/CT Venography (CTV), and Magnetic Resonance Imaging (MRI)/MR Venography (MRV) will be presented. (2) Methods: A literature analysis using PubMed and the MEDLINE sub-engine was done using the terms: cerebral venous thrombosis, thrombophilia, and imaging. Different studies concerning risk factors, clinical picture, and imaging signs of patients with CVT were examined. (3) Results: At least one risk factor can be identified in 85% of CVT cases. Searching for a thrombophilic state should be realized for patients with CVT who present a high pretest probability of severe thrombophilia. Two pathophysiological mechanisms contribute to their highly variable clinical presentation: augmentation of venular and capillary pressure, and diminution of cerebrospinal fluid absorption. The clinical spectrum of CVT is frequently non-specific and presents a high level of clinical suspicion. Four major syndromes have been described: isolated intracranial hypertension, seizures, focal neurological abnormalities, and encephalopathy. Cavernous sinus thrombosis is the single CVT that presents a characteristic clinical syndrome. Non-enhanced CT (NECT) of the Head is the most frequently performed imaging study in the emergency department. Features of CVT on NECT can be divided into direct signs (demonstration of dense venous clot within a cerebral vein or a cerebral venous sinus), and more frequently indirect signs (such as cerebral edema, or cerebral venous infarct). CVT diagnosis is confirmed with CTV, directly detecting the venous clot as a filling defect, or MRI/MRV, which also realizes a better description of parenchymal abnormalities. (4) Conclusions: CVT is a relatively rare disorder in the general population and is frequently misdiagnosed upon initial examination. The knowledge of wide clinical aspects and imaging signs will be essential in providing a timely diagnosis.

Use of intra-dural thrombolysis in a case of extensive pediatric Cerebral Sinus Venous Thrombosis (CSVT) and Venous infarction (P14-5.002)

Use of intra-dural thrombolysis in a case of extensive pediatric Cerebral Sinus Venous Thrombosis (CSVT) and Venous infarction (P14-5.002)

Expression of Concern

Expression of Concern