Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile.

BACKGROUND: Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions. METHODS: A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded. RESULTS: There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%. CONCLUSION: In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

First pass results of mechanical thrombectomy with two-drop zone NeVaTM device.

BACKGROUND: Occlusive thrombi in acute ischemic stroke can be in various types which limits the success of the thrombectomy. The NeVaTM (Vesalio, Nashville, Tennessee) thrombectomy device was originally designed for all types of clot. Our aim was to evaluate the efficacy and safety of the NeVaTM device for mechanical thrombectomy. METHODS: Retrospective review of prospectively collected mechanical thrombectomy database revealed 145 patients who had fullfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamp at each stage, and patient outcome. IV thrombolytics application, pre and post-intervention imaging findings, device related adverse event and any type of intracranial hemorrhage were recorded. RESULTS: There was female pre-dominance (54.5%). Median presenting national institutes of health stroke scale (NIHSS) was 16 (IQR, 3-32). 88 MCA-m1 (60,6%), 43 ICA-tip (29,6%), 11 MCA-m2 (7,5%), 2 ACA (1,4%) and 1 basilar (0,7%) occlusions were underwent for mechanical thrombectomy. Median procedure time was 25 min (IQR, 7-136). First-pass reperfusion scores were mTICI 0-2a 22.7%, mTICI 2b 23.4%, mTICI 2c 17.9% and mTICI 3 35.9%. Mean number of pass was 1,84 ± 1,14. Final mTICI 2b-3 score was 97.9% and TICI2c-3 score was 87.6%. No device related adverse event occurred. The mean 24-h NIHSS score was 6 (IQR 0-33). CONCLUSION: In conclusion, the NeVa thrombectomy device offers a high rate of first-pass success along with favorable safety profile. Larger series and multi-center studies are needed for further investigation.

The strategies for coping with stress of epilepsy patients.

OBJECTIVE: This study aims to compare the styles of coping with stress between patients with epilepsy and healthy individuals and to examine the effects of clinical features on methods of coping with stress. METHODS: The study enrolled 120 patients diagnosed with epilepsy. Forty healthy individuals were included as control group. Sociodemographic and clinical characteristics of the patients were recorded. The patients and controls completed the Coping Strategies with Stress Inventory (COPE), which comprises 60 items distributed into 15 scales. The COPE scores of the patients and controls were compared. RESULTS: Comparing the COPE scores of the patients and controls, the substance use score was higher in the controls. In terms of gender, seeking instrumental social support, active coping, seeking emotional social support, acceptance, and emotion-focused total coping scores were higher in women among patients. In terms of marital status, the positive reinterpretation and growth score of single patients was significantly higher than that of married patients. In patients with a history of febrile convulsions, the active coping, seeking emotional social support, and denial scores were higher. In terms of treatment, for the patients receiving polytherapy, the suppression of competing activities, focus on and venting of emotions, and dysfunctional total coping scores were higher than in patients receiving monotherapy. CONCLUSION: Epilepsy and stress are intertwined conditions. Epilepsy patients, confronted with stress, avoided using alcohol and substances compared to healthy individuals. There were differences among epilepsy patients according to gender, marital status, febrile convulsion history, number of medications, and approaches to coping with stress.

The inflammatory markers and prognosis of cervicocephalic artery dissection: a stroke center study from a tertiary hospital.

OBJECTIVE: Cervicocephalic artery dissection (CeAD) is the most common cause of ischemic stroke in young adults. Although the exact cause is unknown, inflammation is thought to have a role. Here, we investigated the relationship between CeAD and inflammation. METHODS: Patients diagnosed with CeAD in our stroke center were evaluated retrospectively, and their demographic and clinical features were recorded. The C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell, neutrophil and lymphocyte counts, platelet/lymphocyte ratio (PLR), and neutrophil/lymphocyte ratio (NLR) were recorded on admission. Modified Rankin scores (mRS) were noted on admission and at 6 months to evaluate the dependency status and functional outcome of each patient. RESULTS: Of the 95 patients in the study, 70 (73.7%) were male, and the mean age was 44.4 ± 9.8 years. Patients with high WBC count, ESR, PLR, and NLR frequently had mRS scores of 3-6 at admission; these differences were significant (p = 0.04, p = 0.02, p = 0.04, and p = 0.02, respectively). At 6 months, patients with high CRP and ESR at admission also had significantly poorer prognoses (p < 0.001, p = 0.002, respectively). PLR and NLR values were higher in patients with mRS of 3-6. But there were no significant differences between the good and poor prognosis groups regarding PLR and NLR (p = 0.22, p = 0.05, respectively). CONCLUSION: Inflammation may have a role in the prognosis of CeAD, and inflammatory markers can be evaluated as auxiliary tests for determining prognosis.

Do interictal EEG findings reflect cognitive function in juvenile myoclonic epilepsy?

PURPOSE: This study investigated the relationship between frontal lobe cognitive function and frontal focal electroencephalography (EEG) findings in patients with juvenile myoclonic epilepsy (JME). METHODS: The study enrolled 60 patients diagnosed with JME and followed at the Epilepsy Outpatient Clinic of the University of Health Sciences, Bakirkoy Psychiatric Hospital, and 30 healthy volunteers. Demographic and clinical features were recorded. Frontal lobe cognitive functions were tested in both groups. Video-EEG recordings of patients with JME were evaluated. The presence and duration of generalized discharges, the presence and lateralization of focal findings, and the presence of generalized discharges during hyperventilation and photic stimulation were recorded during EEG. Cognitive function test results were compared between the two groups, and the relationship between the EEG findings and cognitive function was investigated. RESULTS: The study included 35 (58.3%) female and 25 (41.6%) male patients and 17 (56.7%) female and 13 (43.3%) male healthy controls. The mean ages of the group with JME and controls were 28.3 ±â€¯8.6 (16-50) and 31.3 ±â€¯7.9 (17-45) years, respectively. Patients with JME performed more poorly on the frontal lobe cognitive tests than controls (p < 0.05). Patients whose generalized discharges were longer than 1 s performed more poorly on tests evaluating attention and made more perseverative errors (p < 0.05). There was no significant correlation between the presence of focal EEG findings and the scores on frontal lobe cognitive functions tests in the group with JME (p > 0.05). CONCLUSION: Frontal lobe cognitive functions are affected in patients with JME. The cognitive effects were more pronounced in patients with prolonged generalized discharges on EEG.

The Review of Transient Ischemic Attack Patients: An Experience of a Clinic about Diagnosis and Follow-up.

OBJECTIVES: Transient Ischemic Attack (TIA) is due to a temporary lack of adequate blood and oxygen to the brain. TIAs typically last less than 24 hours. 10-15% of ischemic stroke patients have a history of TIA. 18% of them experience an ischemic stroke within 90 days, and the ABCD2 scoring system is used to estimate the risk. Our study aims to investigate the risk factors, the etiology, the lesion occurrence on MRI and the near-term risk of stroke of patients on whom TIA was diagnosed. METHODS: In this study, 124 patients were included between January 2012 and January 2018. Sixty-eight of the 124 patients were male. The history of patients was questioned; systemic and neurological examinations were made. The stroke risk factors and TIA duration were noted and ABCD2 scores were calculated. All the patients' blood samples, including glucose and lipid profile, were studied. They received CT, DWI MRI, electrocardiography, transthoracic echocardiography, ultrasound and/or MR angiography of the cervical arteries. RESULTS: One hundred twenty-four patients were included in this study, and 56 patients were female. The mean age was 63.04±16.77. Hypertension was the most common risk factor (50.8%). Twenty-seven patients were on antithrombotic; six patients were on anticoagulant therapy, while 91 patients were not receiving any antiaggregan therapy. ABCD2 scores were significantly higher on the antithrombotic therapy group (p=0.019). In 52 patients ABCD2 score was below 4, and in 72 patients, the score was greater than 4. In 67.7% of patients, no etiology was found. An ischemic lesion was detected in 16.9% of the patients. 58 % of the patients were discharged on anticoagulant therapy. Five patients developed ischemic stroke. CONCLUSION: The risk factors of ischemic stroke and TIAs are similar factors. The etiology of TIAs cannot be found out in most of the patients. Thus, the patients are discharged with oral anticoagulant treatment.

Does restricted diffusion in the splenium indicate an acute infarct?

OBJECTIVE: Although splenial lesions are rare, they are frequently associated with ischemic infarcts, antiepileptic drug toxicity or abrupt discontinuation, viral encephalitis, and metabolic disturbances. In this study, we evaluated clinical and imaging findings and aetiology in 16 patients with splenium lesions. METHODS: Between 2013 and 2017, patients with splenium lesions were examined. Magnetic resonance imaging (MRI) was performed using a 1.5-T unit with fluid attenuation inversion recovery sequences. Additionally, diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps were examined. RESULTS: The patients were 11 males and 5 females; the mean age was 52.3 ± 20.3 (22-87) years. The patients were admitted with the following conditions: consciousness disorder (n = 7, 43.7%), headache (n = 3, 18.7%), seizure (n = 3, 18.7%), ataxia (n = 3, 18.7%), hemiparesis (n = 4, 25%), meaningless speech (n = 2, 12.5%), fever (n = 3, 18.7%), perioral numbness (n = 1, 6.2%), and diplopia (n = 1, 6.2%). Hyperintensity in the splenium was observed in DWI sequences in all patients on MRI. Fourteen patients (87.5%) showed hypointensity in the same region on ADC. In patients with ischemic infarcts, the splenium lesions were most commonly observed in the area of the posterior cerebral artery (n = 4, 25%). MRI showed splenial signal changes in DWI sequences in all patients. Hyperintensity in the splenium was observed in DWI sequences in all patients on MRI. Fourteen patients (87.5%) showed hypointensity in the same region on ADC. The aetiologies were defined as multiple sclerosis (n = 1, 6.2%), ischemic infarction (n = 4, 25%), tuberculous meningitis (n = 3, 18.7%), viral encephalitis (n = 2, 12.5%), hypernatremia (n = 1, 6.2%), brain tumour (n = 1, 6.2%), Marchiafava-Bignami syndrome (n = 1, 6.2%), head trauma (n = 1, 6.2%), substance use (n = 1, 6.2%), and epilepsy (n = 1, 6.2%). CONCLUSION: Not every diffuse restriction observed on MRI indicates an ischemic stroke. Although radiologic images of the splenium may suggest acute ischemic infarction, the actual cause may be another pathology. Therefore, the symptoms and aetiologies of patients with splenium lesions should be considered and investigated from a wide range of perspectives.

Profile of Syrian Asylum-Seekers from Neurological Clinic in a Tertiary Center.

BACKGROUND: The humanitarian response for Syria has been largely managed either from within Syria or from neighboring countries, particularly Turkey. This study was aimed at determining the sociodemographic and clinical profiles of Syrian asylum-seekers admitted to our clinic, changes in patient number across years, and the percentage of patients on follow-ups. METHODS: Syrian patients who were admitted to the neurology outpatient clinics, neurology emergency department (ED), and hospitalized in the neurology clinics were included in the study. Age, gender, number of admissions, year of admissions, chief complaints, diagnoses, and follow-up percentages of patients were recorded. RESULTS: The total number of Syrian patients who were first admitted to our hospital and consulted from other clinics, were found to be 763 (ED: 609 [79.8%], outpatient: 134 [17.6%] consultation: 20 [2.6%]). A total of 543 (96.1%) of the patients with a neurological disorder did not come to the follow-ups even though their conditions required regular follow-ups. The most common complaints were headache (24.2%), fainting (16.1%), weakness (11.9%), and dizziness (10%). CONCLUSION: Most of the patients admitted to our hospital did not come to the follow-ups and information regarding their treatments could not be obtained. Even though the Republic of Turkey provided the Syrian asylum-seekers with free medical care, utilization of these resources may be limited because of socioeconomic issues.

Internal Carotid Artery Agenesis with an Intercavernous Anastomosis: A Rare Case.

BACKGROUND: Agenesis of the internal carotid artery (ICA) is a rare vascular anomaly that was first observed postmortem. Various anastomoses supply the distal vessels at the site of agenesis. Of these anastomoses, an intercavernous anastomosis is very rare. This paper presents a patient with ischemic stroke in whom we discovered left ICA agenesis and an ipsilateral intercavernous anastomosis. CASE: A 58-year-old man with a history of myocardial infarction and diabetes mellitus presented with sudden-onset difficulty in speaking, numbness on the left side of the face, and weakness of the left arm and leg. Neurological examination revealed dysarthria, left facial paralysis, left hemiparesis, and bilateral absence of the plantar reflexes. Diffusion-weighted magnetic resonance imaging showed a right middle cerebral artery (MCA) infarction. On cranial and cervical magnetic resonance angiography, the left ICA could not be seen distal to the bifurcation; the left MCA was supplied through an intercavernous anastomosis between the right ICA and the left ICA. Cranial computed tomography (CT) revealed the absence of the left carotid canal. Digital subtraction angiography led to a diagnosis of left ICA agenesis with an intercavernous anastomosis. The patient was discharged on acetylsalicylic acid and warfarin. CONCLUSION: ICA agenesis with an intercavernous anastomosis is a rare vascular anomaly that should be differentiated from secondary causes of ICA stenosis and occlusions by showing agenesis of the carotid canal on cranial CT.

The evaluation of the relationship between risk factors and prognosis in intracerebral hemorrhage patients.

BACKGROUND AND PURPOSE: Patients were assessed in terms of risk factors, hematoma size and localization, the effects of spontaneous intracerebral hemorrhage (ICH) on mortality and morbidity, and post-stroke depression. METHODS: The present study evaluated the demographic data, risk factors, and neurological examinations of 216 ICH patients. The diagnosis, volume, localization, and ventricular extension of the hematomas were determined using computed tomography scans. The mortality rate through the first 30 days was evaluated using ICH score and ICH grading scale. The Modified Rankin Scale (mRS) was used to determine the dependency status and functional recovery of each patient, and the Hamilton Depression Rating Scale was administered to assess the psychosocial status of each patient. RESULTS: The mean age of the patients was 65.3±14.5 years. The most common locations of the ICH lesions were as follows: lobar (28.3%), thalamus (26.4%), basal ganglia (24.0%), cerebellum (13.9%), and brainstem (7.4%). The average hematoma volume was 15.8±23.8 cm3; a ventricular extension of the hemorrhage developed in 34.4% of the patients, a midline shift in 28.7%, and perihematomal edema, as the most frequently occurring complication, in 27.8%. Over the 6-month follow-up period, 57.9% of patients showed a poor prognosis (mRS: ≥3), while 42.1% showed a good prognosis (mRS: <3). The mortality rate over the first 30 days was significantly higher in patients with a low Glasgow Coma Scale (GCS) score at admission, a large hematoma volume, and ventricular extension of the hemorrhage (p=0.0001). In the poor prognosis group, the presence of moderate depression (39.13%) was significantly higher than in the good prognosis group (p=0.0001). CONCLUSION: Determination and evaluation of the factors that could influence the prognosis and mortality of patients with ICH is crucial for the achievement of more effective patient management and improved quality of life.

A rare cause of cerebral venous thrombosis: cryptococcal meningoencephalitis.

Cryptococcal meningoencephalitis (CM) is a serious central nervous system infection caused by Cryptococcus neoformans, seen mostly in immunocompromised hosts and less in immunocompetent patients. The vast majority of cryptococcosis cases are seen as human immunodeficiency virus infections with advanced immunosuppression. Meningitis and meningoencephalitis are the most common clinical manifestations. Nevertheless, immunocompetent patients with CM are rarely reported. Cerebral venous sinus thrombosis is a rare complication of CM. Here, we report an immunocompetent patient with CM from a non-endemic area, who presented with an acute onset and atypical symptoms associated with cerebral venous thrombosis.

Misdiagnosis in JME: Still a problem after 17 years?

PURPOSE: Juvenile myoclonic epilepsy (JME) is one of the most common and recognizable idiopathic generalized epilepsy with its characteristic clinical and EEG features. We think despite the well defined diagnostic criteria, and increasing awareness, misdiagnosis in JME may still be a problem. The present study aims to determine misdiagnosis in JME and to compare the results with our previous study reported in 1998. METHODS: Two hundred JME patients examined at epilepsy outpatient clinics of Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurologic and Neurosurgical Diseases between the years 2014-2015 were enrolled. Medical records of all patients were evaluated retrospectively; demographical, clinical and electrophysiological data and causes of misdiagnosis were collected from chart reviews. RESULTS: Of 200 JME patients, 49 were misdiagnosed at first medical evaluation. The most common presenting seizure types were generalized tonic clonic seizure and myoclonia in misdiagnosed patients and correctly diagnosed patients, respectively. EEG revealed generalized spike wave and polyspike-wave discharges in 52% of the misdiagnosed patients. Unfortunately the physician was a neurologist in 87.8% of cases with misdiagnoses. Nearly half of 49 misdiagnosed patients were prescribed an inappropriate antiepileptic drug, and the other half were prescribed none. CONCLUSIONS: Comparing our new results with the ones in 1998, misdiagnosis rate was less and time to put a correct diagnosis was shorter. However, proper diagnosis at first sight is still a problem among neurologists even the typical EEG changes are present.

A cross-sectional evaluation of home health service in patients with chronic neurologic diseases in a province of Turkey.

In this study, we aimed to compare patients' characteristics, comorbid risk factors, medical supplies, and caregivers' demographics between stroke patients and patients with other chronic neurological diseases receiving home health services. In our study, between November 2013 and March 2014, chronic neurological disease (CND) patients having home health services were enrolled in the study. During patient visits, patients were assessed by the questionnaire comprising the modified Rankin scale (mRS), Barthel index, Zarit caregiver burden scale, and mini nutritional assessment (MNA). Stroke patients were classified as Group I, and the other neurologic diseases as Group II. A total of 202 patients including stroke patients (n = 112), dementia (n = 64), Parkinson's disease (n = 17), motor neuron disease (n = 4), brain cancer (n = 2), cerebral palsy (n = 1), multiple sclerosis (n = 1), and head trauma (n = 1) answered the questionnaire. The mean age of Group I (61K:51E) was 76.6 ± 9.1 years; the Group II (28M:62F) was 80.9 ± 12.3 years. The mean age of Group I was significantly lower than Group II (p = 0.005) and the number of male patients in Group I was significantly higher (p = 0.001). The educational status between the two groups was not significantly different in terms of duration of illness and addiction. There was no difference between the two groups in terms of Zarit caregiver burden scale, Barthel index, and mRS. The presence of malnutrition (MNA < 17) was significantly lower in Group I (p = 0.007). There was no difference between stroke patients and other CND patients group in terms of caregiver burden and psychosocial status except for malnutrition. Being careful on nutritional support and providing appropriate nutritional support in other CND patients are expected to increase the life quality.

The Role of Patent Foramen Ovale in Cryptogenic Stroke.

INTRODUCTION: Almost one-third of ischemic strokes has an unknown etiology and are classified as cryptogenic stroke. Paradoxical embolism because of a patent foramen ovale (PFO) is detected in 40%-50% of these patients. Recently, PFO has been reported as a risk factor for patients of all age groups. METHODS: In this study, 1080 ischemic stroke patients admitted to our clinic (2011-2013) were retrospectively evaluated. Age, sex, risk factors, complete blood count, vasculitis, biochemical and hypercoagulability tests, magnetic resonance imaging, magnetic resonance angiography, transthoracic echocardiography, transeosophageal echocardiography (TEE) findings, and therapeutic approaches were evaluated. RESULTS: The age range of the participants (seven male and four female patients) was 20-60 years (mean=43.09±11.13 years). Hemiparesis (n=10), diplopia (n=2), hemianopsia (n=2), and dysarthria (n=2) were the main findings of the neurological examinations. Patient medical history revealed hypertension (n=3), asthma (n=1), deep venous thrombosis (n=1), and smoking (n=4). Diffusion-weighted imaging showed middle cerebral artery (n=8) and posterior cerebral artery (n=3) infarctions. In one case, symptomatic severe carotid stenosis was detected. In eight cases, TEE showed PFO without any other abnormalities, but PFO was associated with atrial septal aneurysm in two cases, and in one case it was associated with ventricular hypokinesia and pulmonary arterial hypertension. Antiplatelet therapy was applied to nine patients and percutaneous PFO closure operation to two patients. In a 2-year follow-up, no recurrent ischemic stroke was recorded. CONCLUSION: PFO, especially in terms of the etiology of cryptogenic stroke in young patients, should not be underestimated. We want to emphasize the importance of TEE in identifying potential cardioembolic sources not only in young but also in all ischemic stroke patients with unknown etiology; we also discuss the controversial management options of PFO.

Baloon angioplasty for venous sinus stenosis in a idiopathic intracranial hypertension case.

The Idiopathic Intracranial Hypertension (IIH) is a well characterised condition with intractable headaches, visual obscurations, and papilloedema as dominant features, mainly affecting obese women. With the advent of magnetic resonance (MR) venography and increased use of cerebral angiography, there has been recent emphasis on the significant number of patients with IIH found to have associated non-thrombotic dural venous sinus stenosis. This has led to a renewed interest in endovascular stenting and angioplasty as a treatment for IIH in patients non-responsive to medical treatment. We present a patient without known risk factors for IIH and non-responsive to treatment. The 19-year-old woman presented with headache and diplopia. She was diagnosed with IIH since she was five years of age and had been non-responsive to lumbar cerebrospinal fluid (CSF) drainage and acetazolamide treatment. MR venography revealed thin calibration of transverse sinus. Digital subtraction angiography (DSA) venous phase also revealed 50% stenosis of transverse sinus, 50% stenosis of left proximal sigmoid sinus and 90% stenosis of its distal part leading to obstruction of left transverse sinus outflow and forced directed drainage of left hemisphere to the anterior region.

The clinical & neurophysiological study of leprosy.

OBJECTIVES: The aim of this study was to evaluate neurological and neurophysiological features of leprosy. METHODS: Seventy seven hospitalized leprosy patients (52 male, 25 female) were examined neurological and neurophysiologically between 2010 and 2012. Standard procedures were performed for evaluating sensory and motor conduction studies to all patients. Motor studies were carried out on median, ulnar, tibial and common peroneal nerves. Sensory studies were carried out on median, ulnar and sural nerves. Sympathetic skin response (SSR) recordings on both hands and feet, and the heart rate (R-R) interval variation (RRIV) recordings on precordial region were done in order to evaluate the autonomic dysfunction. RESULTS: The mean age was 59.11±14.95 years ranging between 17 and 80 years. The mean duration of disease was 35.58±18.30 years. Clinically, the patients had severe deformity and disability. In neurophysiological examinations, sensory, motor conduction studies of the lower extremities were found to be more severely affected than upper, and sensory impairment predominated over motor. Abnormal SSRs were recorded in 63 (81.8%) cases of leprosy. Abnormal RRIVs were recorded in 41 (53.2%) cases and abnormal RRIVs with hyperventilation were recorded in 55 (71.4%) cases of leprosy. Significant differences were found between SSR and sensory conduction parameters of median, ulnar nerves as well as motor conduction parameters of median, ulnar and peroneal nerves (p<0.05). CONCLUSION: Peripheral nervous system dysfunction is accompanied by autonomic nervous system dysfunction in leprosy patients. Sympathetic involvement may predominate over parasympathetic involvement.