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Hi, Doctor Shim. Hello. Hi, Keegan. How are you? Thanks for joining us. I'm one of the committee members of I R Genius. Thank you. Thank you very much for having me. It's a pleasure. Thank you so much for your time. Thank you. Wait a little bit more. Some people to join. Yeah, it was still two minutes. Uh Very excited to hear your talk. Oh, thank you very much. I hope uh I hope it's to be uh as good as people expected to be. So, uh are you aware of Georgia Tree or a medical student or? I'm an F two, but I'll be starting ST one radiology in, in August. All right. All the best. Which dinner? Uh London? Okay. Where uh Imperial? Okay. You have uh prof Hammadi uh Is he big? And I are there? Yeah, he's the biggest awarded guy in Europe maybe. Wow. Okay, Saint Mary's. Yeah, that's good to know. Uh I will share my screen. Okay, perfect. Yes, I'll hand it over to you to um to stop presenting. Yeah, so you can still hear me. Okay. Good evening everyone. I'm Sam Hashem, one of the trainees at Birmingham and today, I'll be talking about stroke from back to it. I'd like to thank everyone at our juniors and I are uh bites for inviting me uh to give this talk. I hope you like it. I'm also a member of the Pairs RFs Committee. I have no disclosures. So the learning objectives from today is to know a little bit about the epidemiology of acute stroke, the common clinical presentations, the imaging diagnosis, as well as uh obviously, the mechanical thrombectomy technique, its indications uh complications after care and outcomes. So the burden and epidemiology of stroke is massive uh ischemic stroke uh constitutes 87% of of strokes. Uh and the rest is hemorrhagic or, or intracranial hemorrhage. It's um affected by the general cardiovascular risk factors like looking uh diabetes, dyslipidemia and uh and so on. Um It's, it's a seven million deaths happen every year from stroke. Half of these are attributed to uh ischemic insults. Uh It's the fourth, it's the fourth leading cause of death in the UK, the fifth in the United States and it's the single leading uh cause of complex disability. The incidence is about 6% about the above the age of 60 and in the US in 2020 there was a new case every four seconds. Um the lifetime risk has been increasing over the past couple of decades, most likely due to the aging population and the annual cost of stroke in the US was $45 billion in 2015 or 16. So obviously, it's a terrible condition. So the definition of stroke is acute neurological deterioration or insult due to reduced uh cerebral blood flow. Um uh The very common uh clinical manifestations can be uh summarized in the be fast, which is affection of the balance or the gate, affection of the eye movement or the visual field, infection of the facial uh movement or facial troop. And the A stands for arm weakness as stands for speech. This are three A or uh aphasia and T stands for it's time to call the ambulance. So um it's very important for obviously nonmedical people to be aware of these symptoms. So please, I urge you to uh orient everyone in your social circle around you of the early symptoms of stroke because time is bringing, it makes a lot of uh uh difference if the patient is treated as early as possible. So usually the journey of a stroke patient starts with a phone call from our amazing colleagues from the stroke team. Uh Some hospitals have an independent, usually the stroke centers have independent stroke teams which is uh different from the neurology team. Uh The most important bits of information that you expect to hear is the exact time of onset was, was the acute insult witnessed or not? Because unwitnessed uh strokes have an uncertain, uncertain time, which is very important. Was it a wake up stroke which means that the patient woke up with the stroke symptoms. And we actually, we don't know has it happened just after the patient started uh sleep or just before they woke up? So again, it adds a lot of uncertainty or was it an in house stroke in how stroke stands for strokes that happen in the hospital? Um either spontaneous or as a complication, the estrogenic complication from, from, from example, from a coronary intervention procedure. Um The second piece of information that you would expect to hear from your colleague is the exactly neurological deficit. Usually it's either right or left uh hemiplegia or in a paris is our three a or reduced level of consciousness. It's usually assessed as per the NIH S uh stroke scale. We will cover that later. And another very important piece of information is the baseline functional status of the patient where they independent before this new insult or not. And this has implications on how aggressive uh would we would be in managing the patient? Obviously, a very fit annual patient before the stroke would encourage us to be slightly more uh aggressive with the treatment. So um then comes the diagnosis part and um to be pragmatic, we have certain aims from doing brain imaging. We just don't do it for, for fun. Obviously, the first thing is, and the the very most important point is to exclude intracranial bleeding because obviously, this will contra indicate the main lines of treatment for stomach stroke. Um The second piece of information is uh the absence or presence of large vessel occlusion and by a large vessel, I mean, either the corroded arteries or its main branches, which are the uh middle cerebral artery or the anti oh several artery. This is for the anterior circulation for the perceived circulation of the brain or the vertebral basilar circulation. It would be one of the main pasir arteries. The third piece of information we need to see from imaging is the anatomy and this is very important to plan the procedure. Um Last thing is um complex or advanced imaging can help us a lot in trying to determine the onset of stroke when it's uncertain. So the first line is a plain head ct uh it's one of the most common radiological investigations. Uh and it's very easily and quickly answered the question and excludes intraocular hemorrhage. Um As you can see here, I hope you can see my mouse as you can see here, there is a large hyper dense bright spot on, on the head of this uh patient. And obviously, this is a country indication for uh from Wallace's or from back to me. Another important aspect that CT brain, the plain ct head can, can show us is the affected territory. The arterial territory. The brain is uh if you, if you may say it's like um arranged in like dermatomal pattern, I'd say or territorial fair pattern each territory has certain artery that uh when it gets included affects this territory, which is the A C A or anti oh several, the emcee of the middle circle and the PCA which is the uh procedure server. Um, a very important quantitative measure to assess the severity of the ischemic stroke. It's called the aspect score. Um and it's ranges from 0 to 10. 10 is normal zero. Sorry, this is from uh not zero, it can't be zero. Uh but it's a, it rains from sorry just a moment. Yeah. So a score below seven is uh predicts a worse outcome because it means there is a very large uh stroke. Another good sign of um acute stroke is called the hyper dense artery sign. If you see this CT slice, you can see here a hyperdense dot sign and this means there's a hyperdense blood clot within the basilar artery. The second mode of uh imaging is CT angiogram and this show us the vessels. If you look here at this image, this is a chronic uh CT scan of the brain and you can see all the vessels are opacified. Nice except for this vessel that is abrupt cut off this position. This is the right middle cerebral artery. If you compare it to the other side, you'll see the artery continuing as normal. Uh This is very important obviously to uh include or exclude the patient from, from getting mechanical thrombectomy. So if the patient has large vessel occlusion. Like the case in this uh gentleman, then the patient would be a candidate for mechanical thrombectomy. If the patient doesn't have large vessel occlusion, if it's like a microvessel or something, uh it's two peripheral to reach with the castor, then the patient would not be a candidate for mechanical from victory. Another important piece of information that we get from CT angiogram is the collateral circulation. This is important when we have uncertain or a slightly prolonged uh concert, maybe like a 10 hours uh concert. If we have, if city shows good collaterals around the cortex, this implies that this patient still have a viable brain tissue that can be saved and might still benefit from an extended window of mechanical thrombectomy. So the third aim, the aim of imaging or a third benefit that we can get from advanced imaging is trying to uh check if there is salvageable brain tissue, which is called a pin number. And this is usually detected by CT profusion studies. And it's usually a nice colorful map like this. But I think it might be slightly beyond uh today's uh scope to get into these details. But it's very helpful to let us know if there is still viable brain tissue that needs saving or is it just too late and there's no point of doing thrown back to me. Uh MRI has a role in acute stroke. Uh although in the UK, it's uh slightly underutilized, I'd say. And it's usually reserved for uh stroke mimics like maybe an acute exacerbation of uh multiple courses or uh or a case of encephalitis. Maybe so now in the era of uh activity and the era of artificial intelligence, um one of the four fronts of artificial intelligence in radiology is actually stroke imaging given the very heavy workload, uh uncle radiology commitment and the business of the radiologist rose overnight. Uh certain companies have released Softwares that can automatically analyze these uh city head to check for uh bleeds. They can tell you if there's a bleed or not, they can measure the aspect score and they can also uh detect large vessel occlusion and then they can recommend a decision either from back to me or not. And they can send notifications to mobile devices to all relevant teams, to the stroke team, to the interventionist and so on. Um It's very fancy and nice and it's definitely has been proven to save time. And as we said, time is brain because every minute thousands of brain cells high. So it might be worth investing in these technologies. So now after we have decided if the patient, so uh an ideal candidate for mechanical from victim is a patient who presented within six hours of onset, who has, who doesn't have a uh bleed obviously and has a large vessel occlusion as confirmed on uh the CT angiogram. Or if the patient has presented later has evidence of viable penumbra on CT profusion or an MRI. Uh um Obviously, this, this is an advanced procedure and it only happens in the stroke centers. So if there's no contra indication for I've intravenous strong policies, the patient usually receives the intravenous storm policies and then starts being transferred to a the most nearby stroke center. And the good news is even if from boluses is contra indicated. IV Trumbo's contra indicated mechanical thrombectomy can still be offered and it can still offer very good outcomes. So before you start the mechanical thrombectomy procedure, you always go through the W H O checklist as as any operation or surgery. Uh You can send the patient if you think the patient has capacity. If not, then it's a bit of uh interest or consent form for uh for the patient is the contrast allergy recorded or not. It's very important and it's not uncommon to miss important information when uh you are in a hurry. So obviously, always check if there's allergy. If there's severe contrast idea allergy, you can use gadolinium. Uh it's not as bright as uh as uh pacifying as the usual item but can be used and always obviously check that the required kit is present. Regarding the choice of anesthesia. There is equivocal uh evidence to suggest uh that local or general is better than the other institutional personal preferences, I think are the main uh player on this ground. General anesthesia obviously can cause a delayed starting the procedure but makes the rest of the procedure much easier local anesthesia. On the other hand, can, can make you start the procedure much quicker. But in certain situations, if the patient is combative or, or has a disturbance of consciousness, it can actually make the procedure challenging and prolonged. The next step that you need to check is the arterial access. Uh It's either femoral or read or radial access. Again, the uh imaging or the CT angiogram that you had previously will, will dictate if you will, if you need to go femoral or radial regarding the anatomy. Um uh The femoral is usually more familiar, everyone is familiar every interventionists uh like I R S or even cartilage is and I think the same goes for intervention reduce are more familiar with uh femoral access. Uh But sometimes it can be tricky if there is difficult anatomy of the aortic arch. Uh radial access is now more and more getting into, into main stream, practice. Some centers in the U S offer radial first approach for all patient's. And if it fails, they uh do femoral. Uh the advantage of the radial access would be less bleeding complications. It's a very small artery in a very easily compressible location on the wrist. Uh So it might be uh life saving in, in some conditions if, if the patient pleads. Um and it can help definitely with difficult our anatomy. The disadvantage of radial access is it has a learning curve. Uh We can have some logistic problems because sometimes the nurses are not used to the change in set up between radial and femoral access. And obviously, it cannot be used in smaller patient's like a since limb female who has a small radio, large after we secure the arteria access, whether it's femoral or radial, we then inserted the Castres up the to the aortic are sh and then to the occluded artery as identified on the city. Um And, and then we, we decide which from back to me device that we're using. Again, this depends on institutional and personal uh preferences. But there are two main categories of devices that can be used to uh suck clots out of the body. It's either aspiration castor which creates vacuum pressure at the castor tip uh to remove the clot or a stent retriever. So the aspiration castor contents, the the unit is this is a mechanical uh authorized aspiration unit. It has this container that collects the aspirated blood and it has this external tubing that stays outside of the patient. And then it has this internal tubing that you send all the way to the blocked artery and the vacuum pressure is is created and the constructive the other devices called the stent retriever. This is an illustration for the stent retriever. It's obviously very magnified. You can see it's consists of a metallic mesh like a stent like an unlike a bare metal stent and uh the struts or the fibers of or the filaments of this uh stent retriever entangles the clot. Uh and you leave this stent in place for like one minute and then you pull it and hopefully it, it pulls the clot out and very frequently we end up using both uh devices. So now to the front part cases, uh this is a 91 year old female who presented to the Queen Elizabeth Hospital, she has a new onset of uh age of aberration and she presented with acute right uh hemiplegia with reduced level of consciousness. Uh We attempted this procedure under local anesthetic. And as you can see here on this uh Anthropocene earlier digital subtraction, angiogram of the left common corroded artery. You can see the uh guiding custard tip here in the internal corroded artery and contrast is being injected. You can see here there is abrupt cut off of the contrast at the left middle cerebral artery and this is desert brain. This brain tissue of the temporal parietal look should be supplied by the M C A branches, but obviously, there is a schema here. And after successful from back to me using both uh the stent retriever and aspiration castor, we managed to open up the M C and all its three main branches as you can see here and we uh reap refused his chemical brain. So how would we define technical success from mechanical thrombectomy. It's assessed by what we can call a tiki score, which is short for from policies in to liberal infarction. Uh It's a scale from 0 to 3. It's just visual assessment of reperfusion on angiographic pictures and anything between to be or three is a successful outcome because zero stands for total occlusion and three stands for normal vascular appearance. Another case uh this is a 33 old male patient who presented with severe headache, uh witnessed by his wife while he collapsed and he presented with a very low G C S initially three but then slightly improved. And this is actually the case that you have seen uh initially that showed the hyperdense artery sign on this exile non non contrast. Uh CT head, the this corona uh city uh angiogram of the head shows basilar tip thrombus. You can see here a filling defect at the tip of the basilar artery just at, at its bifurcation between uh into the two prestigious referral arteries. You can see the corresponding angiographic picture. You can see uh this is an Anthropocene here, there's this obstruction angiogram picture with a catheter inserted, sorry through the uh left vertebral artery and the tip is in the basilar artery. After we managed to remove the thrombus from uh as allergic, this specially made a remarkable recovery over two days, nearly back to normal. Another case, quite interesting. This patient had TB and uh he had an aneurysm uh supplied by one of his bronchial arteries. Uh and he had a acute stroke during the uh during the authority bronchial artery procedure. And as you can see here on the sorry, on this side, as you can see, it is abrupt cut off of the right medicine several artery. And if you compare to the uh to the post, from back to the pictures, you can see the middle cerebral artery branches has been repre fused. Uh So after you finish the hopefully successful procedure, you uh you're intending to close the excess site. And the uh this can be used, this can be done either by manual compression or using a closure device, manual compression. I think it's a bit obsolete and stroke because the patient's are usually on from policies or on antiplatelets. Medication use a large sheets. So it's a bit risky to uh to uh perform only manual compression to division to be a higher risk of bleeding. Um Basically the only user manual compression now is if you have failed closure device, a very good having said that a very good manual compression device is for the film stop device. Uh it's basically like a plastic brace that you put around the patient's pelvis and it has a pump that you feel uh to press the groin. Um commonly closure devices are used and they can be broadly classified into either uh plugged mediated devices like uh the most common one is angio seal. It's very simple to use, but it's unsuitable for narrow or very diseased atherosclerotic femoral arches. Um The other commonly used devices, a social mediated device that actually creates a knot percutaneously at the arterial role. It's a bit fiddly to use. More complex. Definitely more complex than and you feel a lot of operators are not very familiar with using it, but it can be a particular useful with smaller vessels or diseased uh femoral arteries. Um Regarding human spaces for the radial artery, it's very simple. It's just a compression uh band wristband that is approved later on. Okay. It's not all butterflies things go wrong sometimes. Um address, address events from uh mechanical from Victa. Me include either exercise, adverse events or intracranial adverse events. Exercise is a generic complication that can happen in any uh and geographic procedure. Uh The range is about 2% either significant hemorrhage. So do aneurysm or activities, fistula arterial occlusion or even death if uh this would be very unfortunate for a patient to die in hospital from hemorrhage. But uh it's, it's not unheard of. Um That's why it's very important to frequently monitor the apps post uh procedure. Regarding the intracranial complications. Symptomatic intracranial hemorrhages occur in about 4%. Uh patient's uh asymptomatic hemorrhages happen in a uh about maybe 20% of patient's or more, but we're not really concerned about uh a symptomatic ones. Uh And by the way, these rates are similar uh for patients who receive IV thromboses without from victor uh arterial embolism to uh other traitors in the brain can happen and can be very unfortunate. Arterial dissection can happen with any angiographic procedures. And this can happen with mechanical thrombectomy in 14%. But to put it into context if mechanical thrombectomy uh doesn't happen, 26% of this patient tend to dog. So actually, uh it can be life saving Uh from uh from this perspective, the post operative follow up is obviously ct head at least at zero hour and at 24 hours post procedure to screen for any expanding intercranial hematoma is and for early detection, frequent ops, especially in the very first six hours after the procedure to monitor for any maybe uh subclinical uh retro present hematoma or a growing bleed. Obviously, you need to check the groin frequently and check the feet, make sure we have good pedal pulses. Sure, the feet are warm. Uh And this is to exclude closure device, malfunction causing femoral artery occlusion. Uh and obviously, neurological examination to monitor the the improvement of the patient or uh the deterioration. So broadly speaking, the clinical outcomes of mechanical thrombectomy are very, very encouraging. It's it's a very, very effective treatment the number needed. This means that every three patient's who are, who get mechanical from back to me, one of them gets a successful clinical outcome. Um and this is, this is a very good number and the lower the number needed to treat. Obviously, the better uh the treatment. Um the assessment is usually done by National Institute of Health Stroke scale. It's a clinical score. Uh trains is between zero and 42. 0 is normal. 42 is very severe stroke. It includes parameters that assess the level of consciousness, the motor function, including the limbs and the face and the eyes coordination functions as well as speech. The other long term clinical or functional outcome is the modified ranking score. Uh And this assesses the disability or the uh independence of the patient. Uh zero is normal, six is dead, anything in between or various degrees of disability or independence. These are the uh references and the take home message is time, time is brain. Um hospitals and healthcare system needs to uh deal with this type of patient's very, very rapidly A I as we mentioned, can save time. Um If, if we have more intervention, neural George's, we can offer more around the clock uh from victims service. So training more people will also save more people. Um It's an underutilized procedure. It's a great value procedure. As we mentioned, the number need to treat is can be as good as three. Uh Actually, it's part of the NHS long term 10 year plan to implement uh this treatment more widely. Um There are lots of institution and personal preference. Francis regarding the imaging modalities as well as regard vices. Uh and personally speaking, it's, it's a very rewarding procedure, both the patient and the doctor with instant uh reward. Thank you very much and we'll open for questions. Thank you so much, Doctor Sheehan. That was really interesting, really useful. Um I think we'll open up question. So if, if anyone has any questions, please put them in the chat. Um I had one question I know you said about aspiration versus um sort of stent retrieval being institutionally and personal preference. Is there any evidence which suggests which one is better to use first? Or are they both equivocal in terms of which one you try for? They are, it has been investigated and they are equivocal. Okay. Uh There are some research that it's a bit recent research uh that mentions that if, if the clot is in line uh with the the castor uh from back to me device, sorry, an aspiration castor might be better. But if the clot is uh in a bend bended or around an angle, a a sensitive advice might be better because the suction uh in in this case can be directed to the vessel wall rather than to the clot. So this this example is a good example where a sensitive will be good when you, when you have an angle and angled vessel. But yeah, it's, it's, it's it's all soft evidence. The strong evidence is that they are equivalent. Thank you. So let people put their questions in the chat. I think Gazans also joined from the committee. Hello. Hi, Doctor and thank you for that talk. Uh um So, I mean, this important opinion question, I think there's a big debate going on at the moment about developing some of it around the clock service like you said to offer this. Um, yeah, and there's a bit of a debate about whether you should be training other sort of interventional radiologists, interventional cardiologists. Um This speaker is to hear what your thoughts are. Do you think that's sort of something that you envisage will happen in the future? Do you think it's a wise thing to do? Uh But yeah, a big debate around going around at the moment, isn't there? So from, from a technical point of view, I think with, with some training, definitely body I ours and card your intervention controls uh might be able to participate in, in uh from back to me this, but this is theoretically and technically, practically speaking ir is stretched very thin and interventional cultures are stretched thin as well. So I can see how would this happen? So uh every, every interventional specialty that can help are already stretched. So we need to train more people. That's, that's the uh the bottom line. Thank you. My pleasure. So, any more questions, anything related to A I uh what were the pictures of the cases clear enough? Any anyone wants us to go through any one of uh the cases again. Um Just another quick question. Um you solve at the center sort of up here in salt would, um, they use all this, uh Baltimore? It's cold. It's like this thing that comes on your Apple watch. I mean, I was just wondering, do you guys use that as well where you can still see the scans and things? Uh It's not related but I'm just wondering if I think it's pretty cool. Yeah, so uh I'm personally not yet on the official Trump wrote, obviously, uh I'm still ST three. Uh but consultants should have access for this 24 7 around the clock at home. Uh And basically this is the screen that, that you get, you get an aspect score here and as we said, anything uh seven and above it's favorable. Uh you get the pictures, uh you get the anatomy, you get the, you know, the included vesalius. So it's um it's, it's very cool. Does someone still have to report that that scan then or do you, do you use it based on what AI has said? So obviously you as a clinician who received a notification, um you look and, and make sure that what, what's right, what's the reported by the application is in keeping with what's on the imaging? Um But for medical legal purposes, I think you, you obviously you are a qualified radiologist doing the procedure. So you wouldn't, you wouldn't need the, the registrar to give you a report. But I think they get reported. Anyway, did this answer your question? Um And in terms of obviously one cessation does have so hopefully, fingers crossed, mechanical thrombectomy, it's successful of the follow up. Um, sort of thing. Do you, do you follow them up or will they go back onto the neurologists of who? Yeah. So they get an unstable. We do an unstable convened city uh to make sure that there is no immediate massive bleed on tables and we do a 24 hour city and obviously, we can do a CT whenever grease, clinical deterioration. So this is the bare minimum. So zero hour on Table City just at, at the conclusion of the from Malcolm procedure and another one at 24 hours plus or minus uh further cities uh as required uh regarding the clinical care of the patient, it's not under neurology, it's under a dedicated stroke team. Uh And they, they take over the uh the management afterwards, but obviously, we uh we should participate in the neurovascular MBTs. And uh it's very good to have ownership for, for the patient management and share in the world rounds as well. So we have two questions from the messages. Um uh We'll start with the first one um from Irene. Uh So do patient's always have thrombolysis first and if that fails, they have mechanical thrombectomy. So if there is no contra indication for from policies, the patient should always get from policies as you mentally, the management if there's no contradiction of thrombosis, if the patient has no bleed. Uh And regarding the other uh general contributions from policies, then thromboses must be given. Uh And then if there is large vessel occlusion, a true victim, we should be offered. If there is no large vessel occlusion, then uh from policy should be enough. Is this clear Irene? Yep. Um And then Allen is A M S K trainee. Um It gets people applying to radiology asking about I N R as a lifestyle. So what insights we have um in terms of of going through it as a career you guys will recommend. Um So as a trainee and what life is like and so the training pathway, that's a bit more. Yeah, so definitely it's uh it's a very demanding uh procedure at, at a consultant level. Uh You're one of the few consultants who would be on site after midnight. Um because obviously this is an advanced procedure, lots of uh high stakes procedure as well. And uh this means that you, you would have to be as a consultant on site for every procedure. Uh comparing this with a musculoskeletal radiologist or a nuclear Joe's or breast regulars. Obviously, there is a stark difference in lifestyle. So this definitely needs to be taken into consideration when you decide uh to get into this path. Uh Probably it will be busier than a surgeon at night, I'd say uh is this, has this answered the question? I hope? I mean, so as obviously, you're at the ST three stages of what were the typical week involve as a training? Um uh As a new intern trainee would be able to solve, talk through that. But if that's OK. So, neurointerventional training uh is six years program. You have three years of court radiology training, uh which doesn't include new intervention. And then the second three years of the training S T 456 uh is the eye in our training. It's combination of diagnostic as well as interventional neuro uh radiology. A typical week is probably uh combination uh every day. You, you would be expected to participate in the uh interventions happen, maybe one or two cases happen every day at least. And then for the rest of the day you report CT heads or MRI heads. Uh Basically, that's, that's your uh daily activity. So Andrew Sweet Plus reporting when there is nothing interesting happening in the Andrew Sweet as a trainee, you get you to do the uh diagnostic angiograms in the beginning and then bit by bit, you uh you move towards independence uh near the end of your train uh regarding the participation in the on call ROTA. Currently at Queen Elizabeth Hospital Birmingham, uh We don't have a dedicated on call ROTA for the interventional uh neuroradiology, registrars. Uh because again, it's a consultant led uh service but this might change in near future. Super, I think there's one more question from Diogo. Um How many Trebek to me is, does your consultant uh do per week? So, um I'd say we have about definitely more than 202 100 from victims per year. So, uh this is for, for the positives. I think it's more than 200. So I'd say uh maybe one every night or one every other night or day. Yeah. So if, if a consultant is on call for a week, they can do maybe four or five strokes in this week. It's, and it's, it's increasing because, you know, the referral is, is getting better and better and we've recently had the 24 7 service. So cases are increasing. That's why I can't really come accurately compare with the past years because it would be very different from this year. Thank you. No problem. Any more questions. So I can't see them on, on my monitor for some reason. Uh That's why I'm relying on you. Um I think most people have asked you want to do, sorry. There's actually one more, um I guess from Diogo. Um Do you have any sort of middle grade HPS um slash PAS removing training opportunities from stds? Um And if you can answer that or not, but it is program inside. Uh No, no, definitely, no, not, not in Europe. It's uh obviously it's a very technical procedure and uh a lot is at stake. So I, I wouldn't, I wouldn't see this happening anytime soon if ever. And speaking with that, by the way, in the, in the body, I our world because I come from a body ir background, background overseas, uh, in the body. I our world. Uh, there is slow, uh, creep of, uh, pas, uh, physician assistants and photographers, uh, to do the minor procedures like climbs and drains and, uh those types of procedures. And I think uh they will definitely have a major role in, in the minor procedures in the, in the near and intermediate switch, but I, I wouldn't see this happening in, in Europe. Thank you. Hopefully, I think that should answer the question yet. We have most welcome. My pleasure. Anything else do you go and again, apologies. Uh I forgot to lock the door before I started the took and we, we had an interruption. So apologies for that. It was, it was a really great talk. Thank you very much doctor for your, for your time. Thank you very much, Keegan. Thank you. I think if we don't have any, any further questions and we'll let you go and enjoy the rest of your evening. But, but thank you again, Doctor Gyn for your time and we really appreciate it. My pleasure. Thank you very much. Have a good night. Thank you, Doctor Hashem. Most welcome. Bye bye.