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Interventional
Neuroradiology
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General Information
Interventional
neuroradiology involves the treatment of cerebrovascular disorders
by endovascular methods. That is, the pathological condition
is assessed and treated through blood vessels, most often through
a tiny incision in the groin. There are many diseases which
may be treated in this fashion, such as cerebral aneurysms,
vascular malformations and stroke. Typically, the site of pathology
in the brain is reached by advancing a skinny long tube (microcatheter)
from the groin into the head utilizing special digital fluoroscopic
guidance technique. Once the site of pathology is reached,
various different types of treatment may be administered through
the microcatheter, depending on the disease process.
For
aneurysms, small metallic coils are placed into the aneurysmal
sac sealing it off from the inside and preventing further bleeding.
For
acute strokes, clot dissolving medicine can be injected directly
into a blood clot which is occluding an artery and thereby reestablishing
blood flow to the brain. The damage to the brain and the surrounding
area can be limited.
Vascular
malformations, which are abnormal connections of blood vessels
that are prone to bleed, can be closed off using a variety of materials,
including coils, plastic particles or acrylic polymers.
Interventional
neuroradiology is sometimes referred to as endovascular neurosurgery
and there are many procedures done by the neuroradiologist that
can achieve results similar to traditional neurosurgical operations.
However, the recovery time after endovascular surgery is usually
shorter than surgical treatment. There are risks of complications,
but in general the morbidity is less with endovascular than with
open surgical procedures. It should be noted that not all patients
can be treated with endovascular methods and the optimal treatment
for a particular patient requires a close working relationship
between the neurosurgeon and the interventional neuroradiologist
in order to select the most appropriate treatment. |
Balloon
Occlusion of CC Fistula A
communication between the carotid artery and the cavernous
sinus is a caroticocavernous sinus fistula (CC fistula).
This could either be due to a dural arteriovenous malformation
or be due to trauma. The treatment is to put an inflatable
balloon into the fistula and thereby occlude the abnormal
communication. The treatment is done by an interventional
neuroradiologist.
For further information see http://www.emedicine.com/med/byname/
caroticocavernous-fistula.htm |
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Celiac Ganglion Block
| Pain in cancer patients is a frequent chronic symptom that decreases the quality of life and restrict activities. Pain occurs in 90% of patients with advanced cancer. Control and palliation of pain is the principle aim of therapy in patients with inoperable cancer. Tumors originate from upper abdominal areas such as pancreas, stomach, duodenum, proximal bowel, liver, and biliary tract. These tumors may cause severe abdominal pain but often do not respond satisfactorily to medical treatment or radiotherapy. Percutaneous celiac ganglia block is a good alternative for patients with inoperable abdominal malignancy who need a high dose of energetics. Celiac ganglia block is performed via an anterior approach under CT guidance. We use a 22-gauge Chiba needle that enters the skin in the upper abdomen and reaches the pre-aortic area between the origin of the celiac trunk and the superior mesenteric artery just anterior to the abnormal aorta. A 50mm mixture of alcohol and contrast is injected. This mixture should be approximately 50% alcohol, 5% contrast, and the rest normal saline. Pain is expected to decrease significantly in approximately 95% of patients after the procedure. The main complication is the self-limiting diarrhea that occurs in up to 75% of patients. This is usually gone by 48 hours.
Ref: Akhan O, Ozmen MN, Basgun N, Akinci D, Oguz O, Koroglu M, Karcaaltincaba M. Long-term results of celiac ganglia block: correlation of grade of tumoral invasion and pain relief. AJR Am J Roentgenol. 2004 Apr;182(4):891-6. [Medline] |
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Cervical Epidural Steroid Injection
| Epidural injection can be made for pain that has not responded to conservative management. It is often helpful for several weeks and occasionally for several months. It is done on an out patient basis and requires no specific patient preparations. |
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CT,
Ultrasound, and Fluoroscopically Guided Biopsies
| When
a lesion is detected on an imaging study and is not palpable,
imaging guidance is often necessary for biopsy. CT,
ultrasound, and/or fluoroscopy can be used to guide a needle to
the correct
place and obtain a small piece of tissue at this location. For
spine biopsies we often use fluoroscopy and for soft tissue lesions
adjacent to the spine, face or skull base we often use CT guidance.
For lesions more superficially in the soft tissues, ultrasound
is usually the best option. |
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Disc
Aspiration and Abscess Drainage
Radiographically
guided disc aspiration and abscess drainage are minimally invasive
procedures used to obtain material for culture and to drain
pus. It is done under light sedation and often yields material
that can help determine if an infection is going on and which
is the best antibiotic treatment.
Abscess
related to the spine can be drained in a similar fashion
as intra-abdominal abscesses. Fluoroscopic or CT guidance
is often used.
For further
information see http://www.rcr.ac.uk/index.asp?PageID=516,
and http://www.drgenie.com/Procedures/aaa/a11.html. |
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Embolization of Nosebleed
Endovascular
embolization of nosebleed has evolved to the standard
treatment for those nose bleeds that do not respond to conservative
treatment methods. It is done via the internal maxillary and
facial
arteries and by suing embospheres or particles. It is a noninvasive
and effective method to stop nose bleeds that have not stopped
with
compression, cauterization, or other conservative measures. |
Embolization of Vertebral Body
For surgical treatment of highly vascular tumor or metastases, embolization can be helpful to facilitate the surgical procedure and reduce blood loss. The embolization is done via a microcatheter after the distal branches have been blocked with coils. |
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Epidural Blood Patch for Spinal Headache
Incidence
of Spinal Headache
The chances of having a spinal headache depend on many
factors including age, weight and size of needle used for the procedure. A spinal
headache may occur up to 5 days after the lumbar puncture. This headache is often
described as a headache like no other, being more severe when the patient is
in
the upright position and gets better when they are lying down.
Conservative Management
Conservative management includes adequate hydration to
try to increase CSF pressure. Sometimes this is accomplished by IV hydration
or drinking things high in caffeine, such as Mountain Dew soft drink, to produce
a
vasoconstriction and try to increase CSF pressure in this way. Another treatment
may be strict
bed rest for 24-48 hours.
Blood Patch
If conservative treatment fails, active treatment is
required such as a blood patch. This is done by inserting an needle into the
same space or a space just next to the space that was used for the lumbar puncture
and injecting autologous blood. Relief from the spinal headache is often felt
very quickly, and sometimes immediately after the blood patch is complete. Normal
activities may be resumed shortly after the blood patch has had time to congeal.
Very rarely does the blood patch not provide relief for the patient, but if it
does not work the procedure may have to be repeated. Success rates for blood
patches are 90% for the first blood patch, and 95% for the second blood patch.
Blood patches are performed for treatment of a persistent
headache (spinal headache) and nausea that sometimes follows a spinal puncture.
These symptoms do not occur frequently. The blood patch procedure consists of
an injection at the spinal tap site of a small quantity of autologous blood.
The introduction of this blood acts to patch the hole in the dura (the outer
membrane of the spinal cord) that was created by the needle at the time of myelography.
Contraindications to performing a blood patch include
septicemia, localized infection at the area of insertion, and active neurological
disease. |
Glue
Embolization
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| It
is sometimes necessary to permanently occlude a major artery
(such as the carotid artery on one side) in order to treat
an abnormality of the blood vessels or in order for the surgeon
to remove a tumor that has grown around the artery. If this
is necessary, a test is performed (temporary test occlusion)
to make sure that it is safe to block off this artery (most
people can tolerate having one carotid artery blocked off).
For this test, a catheter is placed into an artery (usually
in the leg, like for an angiogram of the heart) and a catheter
with a small balloon on the tip is threaded through this into
the artery of interest. The balloon is inflated, stopping the
blood flow in that artery. Neurological tests are performed
every few minutes to see if there are symptoms. If there are
none, the artery can be permanently occluded. This may be done
in a similar way. A catheter is threaded up into the artery
and material is injected to block off the flow. The type of
material used depends on which artery is being occluded and
on the particular circumstance. |
Intraarterial
Chemotherapy of Tumors
| Most
chemotherapy is given through a vein and circulates around
the whole body. Some brain tumors and tumors of the head and
neck (throat cancer, for example) can be treated more selectively.
A catheter can be placed into an artery (usually in the leg,
like for an angiogram of the heart) and threaded up to the
artery or arteries supplying the tumor. A higher dose of chemotherapy
can be given through this catheter directly to the tumor. Another
drug is given through a vein to neutralize the chemotherapy
drug before it circulates through the whole body. Many of the
symptoms associated with chemotherapy (anemia, weakening of
the immune system, loss of hair, nausea) can be decreased when
this method is used. The patient can usually go home the next
day. |
Intrathecal
Chemotherapy
Chemotherapy
uses anticancer or cytotoxic drugs to destroy cancer cells.
They usually work by disrupting the
growth of cancer cells. As they circulate in the blood they
can reach cancer cells wherever they are located in your body.
Most chemotherapy drugs are given directly into the blood stream
either as an injection into a vein or into a bag of fluid through
a drip. Some drugs can be taken by mouth such as temozolomide,
procarbazine, and lomustime. A few chemotherapy drugs such
as methortrexate can be introduced into the spinal fluid with
an injection into the spinal canal in the lumbar region. This
is known as intrathecal chemotherapy. The chemotherapy agent
mixes with the spinal fluid and circulates throughout the brain.
Intrathecal
chemotherapy is often used to treat or prevent neoplastic
disease to the subarachnoid space. Injection is done under
fluoroscopic
guidance. There are strict national guidelines for the
safe administration of intrathecal chemotherapy.
For
more information see http://www.411cancer.com/syndication/veContent.jsp?ArticleID=nhl_aug02&ArticleTypeID=NEWS,
http://www.doh.gov.uk/intrathecalchemotherapy/,
and
http://www.info.doh.gov.uk/doh/point.nsf/WByTitle/?SearchView&Query=intrathecal%20chemotherapy&SearchMax=100.
Intrathecal
therapy is done in conjunction with the medical oncologist who
has the primary responsibility for the patient's cancer treatment.
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Intracranial
Angioplasty for Stenosis and Vasospasm Intracranial
angioplasty is used to widen blood vessels in the brain.
A blood vessel can be narrowed due to vasculitis which is
an inflammation of the vessel due to arthrosclerotic disease
and to vasospasm. Angioplasty is used for focal stenosis
secondary to arthrosclerotic disease and to also to vasospasm
that often occurs after an aneurysm has ruptured and there
has been subarachnoid hemorrhage.
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Intra- and Extra-cranial Stent Placement
Intra-
and extra-cranial stents are placed in stenotic vessels in
order to open up and allow free-flow of blood. The stent placement
is often performed in collaboration with the general angiography
section in our hospital.
For more information see http://www.pslgroup.com/dg/1f8c32.htm |
Lumbar Drain
Lumbar Epidural Injection
| Lumbar epidural steroid and anesthetic injections can be performed for severe pain that has not been resolved with conservative measures. A combination of local anesthetics and steroids often provides immediate relief of pain that may last several weeks and in occasional cases up to several months. The procedure is done on an outpatient basis with very little risk. |
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Nerve
Root Blocks
Diagnostic and therapeutic injections of the nerve roots are performed for diagnostic purposes and also when combined with steroids for permanent/semi-permanent pain relief.
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Petrosal
Sinus Sampling
| The pituitary gland is located at the base of the brain. Many pituitary tumors produce hormones that cause symptoms (the symptoms depend on which hormone is produced). These symptoms may appear before the tumor is large enough to put pressure on surrounding structures, sometimes before the tumor is large enough to be seen on an MRI or CT scan. Blood tests will reveal high levels of the hormone. If a tumor is suspected but cannot be seen, a test can be performed to see if the hormone is coming from the pituitary gland. This is called petrosal sinus sampling. |
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| The petrosal sinuses are the veins at the base of the skull that drain the pituitary. A catheter is placed into a vein in each leg (like for an angiogram of the heart) and threaded up into the jugular vein on either side of the neck. A tiny catheter is then threaded through each of these catheters into the petrosal sinus on both sides of the pituitary gland. Blood samples are taken from both catheters, as well as from the blood circulating through the body to measure the levels of the hormone. A drug can be given to make the pituitary gland produce more of the hormone if necessary. The patient can go home later the same day. If the tests reveal that the blood from the pituitary has higher levels of the hormone than the rest of the body, then a tiny tumor is probably present. If one side is higher than the other, the tumor is on that side of the gland. The surgeon can then find the tumor to remove it. |
Preoperative
Embolization of Head, Neck, and Cranial Tumors
  
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Many
of the tumors that occur in the head, neck, and spine have
a large blood supply. This can make surgical removal of these
tumors difficult and risky. These tumors include meningiomas
(tumors of the covering of the brain), paragangliomas or glomus
tumors (tumors associated with nerves of the head and neck),
juvenile nasopharyngeal angiofibromas (tumors of the nose that
occur in young males), head and neck cancers, and tumors of
the bones of the spine (vertebrae). When surgery is planned,
a catheter can be placed into an artery (usually in the leg,
like for an angiogram of the heart) and a tiny catheter threaded
up through this to the artery or arteries supplying the tumor.
Material is injected to block off the blood supply to the tumor
(this is called embolization). There are many different kinds
of materials available for this, depending on the type of tumor,
its location, and the size of the blood vessels. This is usually
performed within a few days before surgery. Sometimes, especially
in the case of tumors of the vertebrae (or other bones), a
needle is inserted through the skin directly into the bone
containing the tumor and material is injected to block the
blood supply or kill the tumor.
For further information see http://www.urmc.rochester.edu/smd/Rad/neurocases/Neuro502.htm |
Pudendal
Nerve Block
The
pudendal nerve provides the majority sensations and functions
of the external genitals, the urethra, the anus, and perineum.
It also controls the external anal sphincter and the sphincter
muscles of the bladder. Image-guided pudendal nerve block
is the most important diagnostic test following history and
physical examination for patients with suspected
pudendal neuralgia. The nerve is blocked by a local anesthetic
to see if symptoms can be eliminated by numbing the nerve.
The block is done where
the nerve is passing between the two ligaments or in the Alcock's
canal.
Frequently
Asked Questions
- What
is Pudendal Nerve Entrapment?
Pudendal
nerve entrapment is a pain condition for no apparent reason
in the lower central pelvic areas. These are the anal
region, perineum, scrotum and penis or vulva. Pain
is worse upon sitting and less when standing or sitting
on a donut cushion
or toilet
seat. The pain could be stinging, burning, stabbing, aching,
knife-like, irritation,
cramping, spasm, tightness, crawling on the skin, twisting,
pins and needles, numbness, and hypersensitivity. The
pain is piercing and very comparable to a toothache. It often
starts in one place and progresses. Frequently there
is also urinary,
anal, or sexual dysfunction. The pain is often on both sides.
- What
causes pudendal nerve entrapment?
Pudendal nerve entrapment is caused by entrapment of the
pudendal nerve.
The initial constriction is often caused by pressure or
trauma. As the nerve swells it encounters a natural constraint.
Stretching or rubbing of the pudendal nerve can also cause pudendal
nerve entrapment.
- What
causes entrapment?
Pudendal nerve entrapment is usually
precipitated by prolonged sitting or trauma to the sitting
area, combined with a genetic
and developmental susceptibility.
Pudendal nerve entrapment is common in high mileage and
it is sometimes
called Cyclist's Syndrome.
- What
is Pudendal nerve entrapment frequently misdiagnosed as?
Prostatodynia, nonbacterial prostatitis, idiopathic
vulvodynia (idiopathic means unknown cause), idiopathic
orchialgia, idiopathic proctalgia, idiopathic penile pain
syndrome etc.
- What
are the most common symptoms of PNE?
The main symptom is pain with sitting. You feel great
in the AM until you sit for coffee, or drive to work.
You get better with lying down. The pain is in the distribution
of the pudendal nerve....genitalia, perineal or rectal. It
can be any combination of these areas depending on the part
of the nerve entrapped.
- What
are the treatment options?
1. Avoiding the offending factor that causes pain
2. Three sequential image-guided nerve
blocks, first with local anesthetics
and later
possibly combined with corticosteroids
3. Conservative medical treatment such as neurotin,
Elavil
4. Surgery with decompression of the nerves
is rarely done
- If
a patient suspects that they have pudendal what should
they do to
get help?
First, you need to make sure that
other possible conditions are ruled out. It is important
to have a complete workup.
Next is an image-guided nerve block and if
you get numb in the area of your pain and pain is gone you
have a good indication that you might
have pudendal neuralgia.
- Is
there a connection between pudendal neuralgia and spinal
disorders
and scoliosis?
No.
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Sacroplasty
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| Sacroplasty is similar to vertebroplasty but the cement is injected into the sacrum and the sacrum fracture instead of the vertebral body. It is done for insufficiency fractures to reduce pain and improve stability. |
Salivary
Gland: Removal of Stone and Duct Dilatation
| Stones
and stenosis of the duct from the major salivary glands can
cause inflammation and obstruction of the gland. These symptoms
can occur as often as with every meal and causes pain, function
and
social problems. In a few cases we have successfully removed
stones and dilated the duct using interventional techniques
similar to those
used for widening the heart arteries. The images show the parotid
gland with severe stenosis of the Stensen's duct and after successful
removal of a stone and dilatation there is normal caliber. |
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SI
and Facet Joint Injection
Facet joint injection is a long-lasting steroid (“injection”) into the facet joints, primarily of the lumbar spine. Facet joints are located on each
side of the vertebra and injection of local anesthetics
and steroids can reduce inflammation and provide pain
relief.
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The actual injection only takes a few minutes and consists of a mixture of local anesthetic and steroids. The injection itself does not hurt. Doctors use fluoroscopy to insure the needle is correctly placed before medicine is injected. The patient can usually return to normal activity the following day. There is an immediate effect from the local anesthetic which wears off over a few hours. The cortisone starts to work in about 3 to 7 days and it can last up to a few months. Several injections may be necessary over a period of a few weeks to 6 months. |
This is a safe procedure with minimal complications or side-effects. The most common side-effect is temporary pain. However it also includes infection, bleeding, worsening of symptoms, spinal or epidural blocks. Multiple injections may have a side-effect of cortisone itself, including weight gaining, increase in blood sugar (many diabetic patients), water retention, and suppression of the body’s own natural production of cortisone. These are uncommon side-effects.
Contraindication would be if you were allergic to any medication used or if you are heavily anti-coagulated (Coumadin®).
If there is a favorable response to intra-articular injections then a more permanent technique can be considered. Facet neurolysis (Rhizolysis) is commonly performed in the lumbar and cervical region of the spine. A radio-frequency lesion generator is producing irreversible destructive lesions of the medial branch blocking the passage of the painful message from the affected faceted joint to the central nervous system.
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Superior Hypogastric Block
The superior hypogastric plexus is an extension of the aortic plexus in the retroperitoneal place below the aortic bifurcation. It is situated anterior to the L5-S1 disk space. It contains almost exclusively sympathetic fibers. Superior hypogastric block may be useful in patients with gynecologic disorders in whom pain may or may not be dependent on the menstrual cycle. The most common causes of pain in these patients are endometriosis, adhesions, and chronic inflammation. Other patients who may benefit from this procedure are those with interstitial cystitis, irritable bowel syndrome and/or chronic pain after a surgical procedure such as supra-public prostatectomy.
Superior hypogastric block is done under fluoroscopy with the patient in a prone position. The success for an ablative procedure is approximately 50% pain reduction and 40% reduction in opiate medication lasting at least 3 weeks. So overall there is approximately 50% success. This is, however, still encouraging since these are end-stage pain patients in whom nothing else has been helpful.
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Temporary
Test Occlusion
It
is sometimes necessary to know if a major artery supplying
the brain (such as one of the carotid arteries) can be safely
blocked off (occluded) permanently. This may be necessary during
surgery to remove certain tumors that grow around the artery
or to treat certain abnormalities of the vessels (such as trauma
to the artery producing a hole or abnormal connection to a
vein [fistula]). Most people can tolerate having one carotid
artery occluded because there are connections between the major
arteries (the carotid and vertebral arteries) inside the head
at the base of the brain. A test can be performed to find out
this information (temporary test occlusion). A catheter is
placed into an artery (usually in the leg, like for an angiogram
of the heart) and threaded up to the arteries supplying the
brain and an angiogram is performed. A catheter with a small
balloon on the tip is then positioned in the artery of interest.
The balloon is inflated, stopping the blood flow in that artery.
A dose of blood thinning medicine is given through a vein just
before this so that the blood does not clot when the flow stops.
The patient is examined every few minutes to see if there are
any symptoms (similar to those of a stroke). If there are,
the balloon is immediately deflated, restoring flow. If there
are no symptoms, medicine may be given to temporarily lower
the blood pressure to make sure no symptoms occur. The agent
used for a nuclear medicine brain scan may also be given just
after the balloon is inflated. A brain scan can then be performed
after the test; it will show what the blood flow to the brain
looked like when the balloon was inflated. If there are no
symptoms, the balloon is usually deflated after about 30 minutes
and removed. If treatment of the patient's condition is not
scheduled for the same hospital visit, the patient can go home
later the same day.
For more information go to http://www.asitn.org/guest/guest.php?page=about&view=clinical§ion=cs-03. |
Thrombectomy for Acute Stroke
©Concentric Medical
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In August of 2004 the FDA approved the Merci Thrombectomy device for treatment of acute stroke. This "corkscrew like" device can be inserted into the fine arteries of the brain and can be used to retrieve a clot similar to pulling a cork out of a wine bottle. The treatment is done via a puncture of the femoral artery in the groin, and via a small plastic catheter the corkscrew is advanced into and passed through the clot. Once identified, the flow in the internal carotid artery is reversed and the clot can be pulled out. This FDA approved device has a 53% success rate and when successful can result in a tremendous improvement of prognosis. The risk includes bleeding, further stroke, and death.
For more information go to http://www.concentric-medical.com/News.html |
WADA
Test for Brain Function
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It
is sometimes necessary to know which side of the brain (hemisphere)
controls speech. Often, this information is needed when surgery
for epilepsy is planned. A test called the WADA test can be
performed. The electrodes and wires for an electroencephalogram
(EEG, a test that looks at brain waves) are placed on the scalp.
The neurologist performs a baseline examination and asks the
patient to remember three objects. A catheter is then placed
into an artery (usually in the leg, like for an angiogram of
the heart) and threaded up to the arteries supplying the brain
and an angiogram is performed. The catheter is then left in
the carotid artery on the side of interest. |
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drug is injected through the catheter causing that side of
the brain to stop working
briefly. This is done while the EEG is monitored and the neurologist
examines
the patient. The
neurologist then performs several tests of the patient's memory,
ability to understand, and ability to speak. The drug wears
off quickly (before the end of the test). The patient can go
home later the same day. |
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