Internal Carotid Artery Thrombus Research Articles

Carotid Artery Dissection Caused by an Elongated Styloid Process: A Case Report

Eagle’s syndrome is caused by an elongated styloid process or calcified stylohyoid ligament that interferes with adjacent structures. Herein, we present the case of a 26-year-old man who presented to the emergency department due to sudden onset pain in the right occipital area, dysarthria, left hemiparesis, and left arm paresthesia. Computed tomography (CT) angiography revealed an intimal flap and thrombus in the proximal right internal carotid artery (ICA), indicative of carotid artery dissection, as well as direct contact between the styloid process and ICA on both sides. The patient underwent anticoagulation with intravenous heparin for 7 days, followed by 75 mg of clopidogrel per day. Following treatment, the patient gradually improved and was discharged with slight paresthesia in the left arm two weeks after symptom onset. Carotid artery dissection is a rare manifestation of Eagle’s syndrome caused by an elongated styloid process.

Abstract 115: Carotid Intraluminal Thrombus Obscuring Underlying Carotid Web: Case Report

Introduction Carotid webs (CaW) have been increasingly recognized as a unique cause of recurrent ischemic strokes.1 They are defined as thin, intraluminal, shelf‐like lesions along the posterior aspect of the carotid bulb.1,2 Despite more awareness and ongoing studies into their pathogenesis, diagnosis, and management,3 they are still overlooked in clinical practice as a primary carotid ischemic etiology. Our case describes a patient with right extracranial internal carotid artery (ICA) thrombus secondary to later‐diagnosed CaW on close follow‐up imaging. Methods We report a 55‐year‐old African American man with history of hypertension, type 2 diabetes mellitus and hyperlipidemia presented with acute onset slurred speech and left facial droop (FP). His last known well was 24 hours prior to presentation, and NIHSS upon arrival was 3 (FP 2, dysarthria 1). CT angiography (CTA) of the head and neck demonstrated a nearly occlusive thrombus of the distal right M2 segment MCA as well as non‐hemodynamic stenosis of the proximal right ICA with possible underlying sidewall filling defect‐appearing lesion concerning for a posterior wall thrombus without underlying atherosclerosis at the bulb or otherwise. The patient was admitted to the neurovascular intensive care unit and started on aspirin and high‐risk heparin drip. His MRI Brain demonstrated multiple acute/subacute right MCA territory strokes, predominately in the right posterior insula, right frontal lobe, and right posterior corona radiata. His stroke workup was otherwise unrevealing, and he was discharged on apixaban 5mg BID. Results Close surveillance follow‐up imaging with CTA head and neck was planned and obtained one month later, which demonstrated resolution of the filling defect that was obscuring the currently visualized underlying right CaW pocket (Figure‐1). The prevalence of CaWs has been reported to be between 1.2% and 2.5% of patients with acute ischemic stroke. CaWs are most frequently seen in younger, female patients, and patients with these lesions are at increased risk of recurrent stroke.4,5 Determining the optimal management for these lesions remains essential, but the available data thus far have not been conclusive. Most patients are treated with antiplatelet therapy, but some elect to treat with anticoagulation due to the focal hemostasis caused by CaWs.6 However, multiple studies have suggested that medical management alone is likely not sufficient in reducing the recurrent stroke risk caused by CaWs.5,7 Neuro‐interventional procedures including carotid artery stenting have been reported as secondary prevention strategies in patients with recurrent strokes.5,7,8 Although data regarding the rate of recurrence of strokes secondary to these lesions remains unclear, the current data does suggest benefit and safety in pursuing carotid stenting to prevent recurrent strokes.5‐8 Conclusion In young patients with proximal ICA thrombosis without underlying atherosclerosis or other conventional stroke risk factors, CaW should be considered among other differentials including hypercoagulable status. Following acute medical management, short‐term surveillance imaging is essential to confirm or rule out the diagnosis. In our case, the patient’s proximal ICA thrombus resolved after short course of anticoagulation and was determined to be secondary to the obscured underlying CaW.

Importance of assessment of carotid plaques in the managementof acute ischemic stroke: floating intracarotid plaque

Mobile atheromatous plaques affecting large arteries are a major risk factor for embolic strokes. We report a case of extensive embolic cerebral infarction secondary to a vulnerable internal carotid artery plaque. A 67-year-old female was admitted with sudden left-sided weakness. A computed tomography brain scan revealed early ischemic changes in the right middle cerebral territory. The ultrasound Doppler showed soft mobile plaque with thrombus in the right internal carotid artery causing 90% stenosis. Magnetic resonance imaging brain scan performed later showed extensive right cerebral infarction. A computed tomography angiogram revealed ulcerated non-occlusive soft tissue plaque in the right internal carotid artery. She was also diagnosed with bladder cancer during this admission and was managed medically due to her performance status. Unstable vulnerable plaques can be symptomatic even in the absence of significant carotid stenosis. Hence, early identification of the plaque vulnerability, using new imaging modalities, and its medical stabilization can help to reduce the risk of cerebrovascular insults. The etiopathogenesis of inflammation within unstable vulnerable plaques and its concordance with inflammatory markers is still unclear. It is feasible in our case the malignantprocess could also be contributing to the inflammation within the blood vessels promoting vulnerability of the plaques.

A Free-Floating Internal Carotid Artery Thrombus and Acute Ischemic Stroke

Acute management of stroke with carotid free-floating thrombus (FFT) needs careful monitoring to proactively prevent the additional risk of infarction, and reducing intracranial bleeding is the primary goal. No management guidelines are available for this rare clinical condition. Here we presented a case study of a patient presenting with a carotid FFT with acute left-sided weakness. The patient was managed with anticoagulation alone, and the patient was discharged to return home in stable condition and good functional status with mild disability in the patient's left arm. In conclusion, carotid FFT is a rare clinical condition with underlying heterogeneous etiologies and individual-level bleeding risk stratification. Medical and surgical options are considered on a case-by-case basis.

Acidente vascular cerebral isquêmico secundário a Carotid Web: Relato de Caso

Background: The carotid web is a rare type of myofibrous dysplasia which is receiving increased attention for being a risk factor of ischemic stroke. It is a rare carotid artery disease, and its incidence is about 0,62%. The carotid web presents as a membrane located inside the arterial lumen, protruding from the posterior wall of the carotid sinus or the starting portion of the internal carotid artery. In some cases, thrombus can be seen on the carotid web. This occurs due to blood stasis and platelet activation, resulting in thrombosis which can embolize intracranially. Case presentation: 40 years-old female presents with transient left paresthesia and paresis, lasting 60 minutes. Weeks after, she presented a stronger and transient event, associated with dysarthria and rhyme deviation. Magnetic resonance investigation showed ischemic stroke in the middle cerebral artery area and thrombus in the right internal carotid artery, and angiography evidenced the presence of a probable atherosclerotic plaque in the right carotid sinus, attached to a fresh thrombus. She started anticoagulation therapy. In control exam, the arterial area in the right carotid sinus was identified without the presence of thrombus, allowing a better characterization of a membrane attached to the posterior wall of the internal carotid artery, coming up with features compatible with carotid web. Due to the recurrence of neurological deficits, besides being transitory, it was opted for endovascular treatment, aiming to avoid the evolution of a transient neurological deficit to a permanent one. She was submitted to angioplasty and maintained on double antiagregation due to stent and, until the moment, did not present any new neurovascular events. Conclusion: The relevancy of this report is due to carotid web being an under-recognized cause of cryptogenic stroke that should always be suspected when there is recurrent infarction in the territory of one internal carotid artery.

Teaching NeuroImages: A fuzzy determination of stroke onset

A 73-year-old man with hypertension presented with left hemiparesis and left hemineglect of unclear duration. CT with angiography of the head and neck showed subacute infarcts of the right frontal lobe and a right internal carotid artery thrombus, with corresponding perfusion abnormalities that would have qualified him for thrombectomy (figure).1 On closer examination, his facial hair asymmetry suggested a matured hemineglect to his left face. Based on the unenhanced imaging findings and facial hair asymmetry, we estimated his stroke onset to be more than 24 hours prior to evaluation, thereby disqualifying him for thrombectomy.

Iron Deficiency Anemia with Reactive Thrombocytosis Associated with Internal Carotid Artery Thrombus and Ischemic Infarction (P2-10.004)

Iron Deficiency Anemia with Reactive Thrombocytosis Associated with Internal Carotid Artery Thrombus and Ischemic Infarction (P2-10.004)

Endovascular treatment of acute intracranial large-vessel occlusion caused by a thrombus in the cervical internal carotid artery

Endovascular treatment of acute intracranial large-vessel occlusion caused by a thrombus in the cervical internal carotid artery

Cardio-Cerebral Infarction, Free-Floating Thrombosis and Hyperperfusion in COVID-19

Cardio-cerebral infarction, which refers to an acute ischemic stroke (AIS) and acute myocardial infarction (AMI) that occur concurrently, is an uncommon phenomenon with a grave prognosis. Intraluminal carotid thrombus (ICT) is an infrequently encountered cause of ischemic stroke and can be associated with an underlying hypercoagulable state. One severe yet prevalent complication of infection with Coronavirus Disease 2019 (COVID-19) is thrombosis from multi-pathway inflammatory responses. Here, we present a unique case of cardio-cerebral infarction, with a free-floating intraluminal thrombus in the left internal carotid artery, in the setting of recent COVID-19 infection, and with the etiology of both events attributed to a COVID-19 hypercoagulable state. CT perfusion imaging also showed an interesting imaging finding of hyperperfusion, which is believed to be a form of dysfunctional cerebral autoregulation.

Acute Hemispheric Stroke: Full Remission Following Surgical Thrombectomy

IntroductionCarotid occlusion because of embolisation or as a distal extension of thrombus formation in an ulcerated plaque can be the cause of a devastating stroke, caused by sudden occlusion of the internal carotid artery (ICA). Often, invasive treatments are not an option because of the limited time frame. In rare situations of acute stroke onset and admission to therapy within six hours however, aggressive recanalisation may be considered. This technical note demonstrates surgical transcatheter embolectomy of intra-extra cranial ICA by reducing inflow by placing a clamp on the common carotid artery (CCA) before puncture cranial to the clamp.Patient and techniqueA 67 year old man was admitted as an emergency seven hours after an acute hemispheric stroke with paraplegia of his left arm and full consciousness. An immediate duplex scan showed more than 90% stenosis of the carotid bifurcation with low echolucent plaque material extending proximally up to the intracranial ICA. CT angiography confirmed the stenosis and a sub-occlusive thrombosis of the ICA up to the M1 segment of the middle cerebral artery (MCA). Because the onset of clinical symptoms was more than six hours previously, the patient was not within the clinical window for endovascular therapy. Following interdisciplinary consensus, surgical over the wire thrombectomy with endarterectomy with complete removal of the thrombus and subsequent thrombo-endarterectomy of the carotid bifurcation and bovine patch plasty was performed. The patient was discharged with statin and antiplatelet treatment on the second post-operative day with full remission of symptoms.ConclusionsImmediate surgical transcatheter recanalisation of acute intra-extracerebral ICA thrombus with inflow reduction can be a valid procedure to improve cerebral circulation, leading to full remission of stroke symptoms.

Trials and Frontiers in Carotid Endarterectomy and Stenting.

Based on the strength of randomized trials from the 1990s, major societal guidelines recommend carotid endarterectomy (CEA) for severe (≥70%), symptomatic carotid stenosis if an operative stroke/death rate of <6% can be maintained (history and major trials in carotid revascularization are summarized in the online-only Data Supplement).1–4 Though the benefit is less evident, most guidelines also recommend consideration of CEA for 50% to 69% symptomatic stenosis.2–4 There are subtle differences in recommendations regarding carotid artery stenting (CAS) in symptomatic patients. Some guidelines stipulate that CEA should be preferred over CAS in patients with severe (≥70%) symptomatic carotid stenosis,2,5 especially if >70 years old,4 whereas others position CAS as an alternative.1,3 Though the risk of operative stroke/death is higher with CAS, major randomized clinical trials (RCTs) report event rates under the recommended 6% cutoff for both treatment modalities. Regarding asymptomatic disease, CEA is recommended for patients with stenosis ≥60% to 70% in highly selected patients as long as operative stroke/death rates <3% can be maintained.1 A predicted life expectancy of at least 3 to 5 years has also been suggested.2 The 3% threshold has been easily met by CEA cohorts in the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial; 1.4%)6 and the ACT1 (Asymptomatic Carotid Trial; 1.7%),7 suggesting that an even lower threshold may be appropriate. Controversially, some guidelines have recommended that CAS can be considered in highly selected patients with asymptomatic carotid stenosis ≥60% to 70%,1,4,8 whereas others argue that the evidence remains insufficient.2 The lack of consensus in the management of asymptomatic carotid stenosis is reflective of an ongoing need for high-quality RCT data to guide practice. ### CEA Operative Stroke Risk and High Risk Designation Most clinical trials in carotid revascularization have focused …

ダビガトランとアスピリン内服で内頸動脈可動性血栓が消失した非弁膜症性心房細動合併アテローム血栓性脳梗塞の1 例

ダビガトランとアスピリン内服で内頸動脈可動性血栓が消失した非弁膜症性心房細動合併アテローム血栓性脳梗塞の1 例

Extensive Mobile Thrombus of the Internal Carotid Discovered After Intravenous Thrombolysis: What Do I Do Now?

This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.

Can Shape Analysis Differentiate Free-floating Internal Carotid Artery Thrombus from Atherosclerotic Plaque in Patients Evaluated with CTA for Stroke or Transient Ischemic Attack?

Patients presenting with transient ischemic attack or stroke may have symptom-related lesions on acute computed tomography angiography (CTA) such as free-floating intraluminal thrombus (FFT). It is difficult to distinguish FFT from carotid plaque, but the distinction is critical as management differs. By contouring the shape of these vascular lesions ("virtual endarterectomy"), advanced morphometric analysis can be performed. The objective of our study is to determine whether quantitative shape analysis can accurately differentiate FFT from atherosclerotic plaque. We collected 23 consecutive cases of suspected carotid FFT seen on CTA (13 men, 65 ± 10 years; 10 women, 65.5 ± 8.8 years). True-positive FFT cases (FFT+) were defined as filling defects resolving with anticoagulant therapy versus false-positives (FFT-), which remained unchanged. Lesion volumes were extracted from CTA images and quantitative shape descriptors were computed. The five most discriminative features were used to construct receiver operator characteristic (ROC) curves and to generate three machine-learning classifiers. Average classification accuracy was determined by cross-validation. Follow-up imaging confirmed sixteen FFT+ and seven FFT- cases. Five shape descriptors delineated FFT+ from FFT- cases. The logistic regression model produced from combining all five shape features demonstrated a sensitivity of 87.5% and a specificity of 71.4% with an area under the ROC curve = 0.85 ± 0.09. Average accuracy for each classifier ranged from 65.2%-76.4%. We identified five quantitative shape descriptors of carotid FFT. This shape "signature" shows potential for supplementing conventional lesion characterization in cases of suspected FFT.

Extended Cerebral Infarction Due to Preoperative Free-Floating Thrombus in Right Internal Carotid Artery Complicated with Acute Type-A Aortic Dissection

A 59-year-old man, who has cutaneous polyarteritis nodosa, presented with sudden onset of excruciating neck pain and syncope. Chest CT disclosed a Stanford type a acute aortic dissection. He rapidly lost consciousness and cardiac tamponade caused a drop in blood pressure. Emergency ascending aortic replacement proceeded under deep hypothermic circulatory arrest with antegrade selective cerebral perfusion and the cerebral blood supply was monitored throughout the procedure. However, post-operative brain CT imaging revealed extensive right hemispheric brain infarction. A large thrombus was identified in the right internal carotid artery. Whether the mechanism of brain ischemia associated with the aortic dissection was hemodynamic ischemia or thromboembolism remained unclear. We considered that thrombectomy might be needed before selective cerebral perfusion.

Unexpected Arterial Recanalization after Decompressive Hemicraniectomy

We report a 43-year-old patient with malignant embolic ischemic stroke in the right middle cerebral artery (MCA), treated by decompressive hemicraniectomy. Cerebrovascular ultrasound detected a subtotally occluding thrombus in the right internal carotid artery and a partial occlusion of the ipsilateral MCA. After the surgery, complete recanalization of the affected vessels was observed.

Carotid Artery Stenting in Patients with Critical Stenosis of Proximal Internal Carotid Artery and Large Distal Arterial Thrombus: 2 Case Reports

근위부 경동맥 협착으로 인해 급성 뇌경색이 발생한 경우, 뇌 졸중의 악화를 방지하고 이후에 생길 뇌졸중의 재발을 예방하 기 위한 목적으로 경동맥 스텐트설치술을 시행할 수 있다. 그러 나 스텐트설치술의 시행 시기에 대해서는 아직 명확히 정립된 기준이 없는 실정이다. 발병 3시간 혹은 6시간 내 초급성 시기 에 내원한 경우에는, 정맥내 혈전용해술을 시행하면서 동시에 응급 경동맥 스텐트설치술을 시행하고, 필요한 경우 동맥내 혈 전용해술을 함께 시행하는 방법이 성공적이라고 보고되고 있다 (1). 그러나 이 시기 이후의 급성 혹은 아급성 경색 환자의 경우 스텐트설치술의 시행 시기를 결정하기 어렵다. 경동맥 내막절 제술의 경우 이전에는 증상 발생 약 6~8주 이후에 시행하는 것으로 널리 받아들여졌으나, 최근에는 1~4주 이내에 시행하 였을 때 성공적인 결과를 얻는 것으로 보고되었다(2, 3). 또한, 경동맥 협착 환자 중 원위부 혈관에 협착이나 혈전에 의한 다 발병소(tandem lesion)를 보이는 경우 그 치료 방법을 결정하 는 것은 더 어렵고, 이전의 연구들은 대부분 원위부 협착에 의 한 다발병소를 보인 경우이고 혈전에 의한 경우는 거의 보고된 적이 없다. 저자들은 급성 뇌졸중으로 발현하였고 근위부 경동맥의 중 증 협착과 함께 원위부 경동맥에 많은 양의 혈전을 동반하는 다발병소를 보인 2명의 환자에게서 3~4주 동안의 항응고제 혹은 항혈소판제, 엄격한 혈압 조절, 지질 저하제를 통한 치료 후 원위부의 혈전이 소실되어 경동맥 스텐트설치술을 성공적으 로 시행하였고 이를 보고하고자 한다.

1184

Case Reports: 56 year old female developed post-operative heparin induced thrombocytopenia after surgery for bowel obstruction. Patient had aortic thrombus on CT scan and was taken to OR for endovascular stenting of thrombus. In PACU, patient developed right-sided weakness and aphasia requiring re-intubation with 7.0 endotracheal tube. CT showed left internal carotid artery thrombus and patient was taken to interventional radiology for intra-arterial tPA injection. Despite intervention, patient developed massive left sided hemorrhagic stroke. Patient was brain dead on clinical exam and plans were made to conduct an apnea test. Pt. had been maintained on FIO2 of 40%. Prior to apnea test, pt was placed on FIO2 of 100% for 10 min. Patient was normothermic, in normal acid-base balance, and hemodynamically stable prior to of apnea test. The apnea test was conducted using flow-by O2 at 5 liters/min delivered through tubing inserted 6 cm down ETT. After 1 minute, pt. became hypotensive and tachycardic and apnea test had to be aborted. Pulse ox did not fall below 99%. A second attempt of the apnea test was made with similar hemodynamic results. Flexible bronchoscopy was performed to evaluate for any possible endotracheal tube obstruction or airway source of hemodynamic changes. No occlusion of endotracheal tube was noted during evaluation of airway and patient had no pulmonary pathology. Due to the hemodynamic changes experienced during both apnea tests, the brain death exam was aborted and pt. underwent confirmatory three-vessel angiography which showed no brain flow. Discussion: The patient developed hypotension and tachycardia after 1 minute despite no fall in pulse oximetry. Thus, possible development of auto-peep due to the O2 insufflated down ETT was considered, leading to decreased preload and hypotension. Fiberoptic evaluation of the ETT revealed no obstruction or decrease in intra-luminal diameter, as can occur with dried out secretions inside ETT. While insufflation of O2 during apnea test is helpful in mitigating desaturation, this case brings up a possible complication of this technique.

Asymptomatic free-floating thrombus of the internal carotid artery

Abstract Free-floating thrombus (FFT) of the internal carotid artery, which is almost always symptomatic and is usually discovered by ultrasound or angiography performed after a transient cerebrovascular event, is a highly uncommon diagnosis. Here, we report a case of an asymptomatic freefloating internal carotid artery thrombus most probably caused by an atherosclerotic plaque rupture. It was detected by carotid ultrasound and was treated with eversion endarterectomy without any neurologic complications. Six weeks after surgery, the patient is doing well.

Transient floating thrombus of the internal carotid artery associated with the JAK2V617F mutation

Essential thrombocythemia (ET) is a myeloproliferative disorder (MPD) characterized by sustained elevated platelets. Cerebrovascular disorders can be a complication of ET, with thromboses of cerebral veins occurring more frequent than those of arteries [1, 2]. We describe a 33-year-old woman with no cardiovascular risk factors who experienced an acute ischemic stroke in the left middle cerebral artery territory (MCA). The carotid duplex on admission showed a free-floating thrombus (FFT) in the left internal carotid artery (Fig. 1a, b) that was not producing flow aceleration. However, the thrombus disappeared 2 h later without any clinical deterioration, as shown by a second carotid duplex. The arteriography confirmed these results (Fig. 1c). A brain infarction in the left MCA territory was observed on MRI (Fig. 1d). Peripheral blood showed a platelet count of 505 9 10/L. Additional studies, including an extensive battery of tests for coagulopaties and a complete cardiology study, were negative. The JAK2 mutation was detected in peripheral blood samples by a multiple allelespecific PCR (MAS-PCR). The thrombocytosis decreased spontaneously, as the platelet count dropped from 487 9 10/L at 3 months to 452 9 10/L after 6 months. Bone marrow aspiration showed clustered hyperlobulated megakaryocytes. She was diagnosed with MPD and specifically ET. Antiplatelet treatment was initiated as secondary stroke prevention. The patient presented a good outcome, with progressive neurological improvement. The presence of a mobile FFT in the internal carotid artery as cause of brain ischemia is infrequent and its prevalence and natural history are not well understood. The main associated pathologies are hypercoagulability, carotid dissections, trauma and plaque, although in many cases the association is not identified [3]. Philadelphia-negative MPD, especially ET and polycythemia vera (PV) may be associated with thrombi development, although they are produced more frequently in veins than in arteries [1, 2]. Recent diagnostic criteria for ET have lowered the platelet threshold from 600 9 10/L to 450 9 10/L [4]. Therefore, since the platelet count is not always highly elevated at the time of stroke, the diagnosis of ET is difficult. In our case, a complicated carotid thrombus was the initial presentation of an ET even in presence of mild thrombocythemia. The acquired Janus kinase 2 V617F mutation (JAK2) was recently identified in patients with MPDs [5]. This mutation has been found in more than 90% of patients with PV and in approximately 50% of those with ET, which led to a recent update of the diagnostic algorithms for MPDs, including the JAK2 mutation as a major criterion [4]. The risk of arterial thrombosis is significantly increased in patients with MPDs and the JAK2 mutation (OR 2.49, 95% CI 1.71–3.61) [1] independently of the V617F allele burden [6]. To the best of our knowledge, the presence of mobile floating thrombi in the extracranial carotid arteries associated with the presence of P. Martinez-Sanchez (&) R. Cazorla-Garcia J. Medina-Baez B. Fuentes E. Diez-Tejedor (&) Department of Neurology and Stroke Center, IdiPAZ Research Institute, La Paz University Hospital, Autonoma University of Madrid, Paseo de la Castellana 261, 28046 Madrid, Spain e-mail: patrindalo@hotmail.com