{"title":"Three Pairs of Mirror Aneurysms and Then Some: A Case Report","authors":"Mukesh K. Sharma, Kalyan Sajja, V. K. Gorijala","doi":"10.1177/25166085221117972","DOIUrl":"https://doi.org/10.1177/25166085221117972","url":null,"abstract":"Multiple mirror aneurysms have been rarely reported in the literature. To the best of our knowledge, 3 pairs of mirror aneurysms in a single patient have not been reported prior. We present a case of 3 pairs of mirror aneurysms. One pair in the bifurcations of bilateral middle cerebral arteries and 2 pairs in the distal anterior cerebral arteries. The patient also had 2 unpaired aneurysms in the anterior communicating artery and left M1-anterior temporal junction, respectively. We have effectively treated these aneurysms with primary endovascular coiling.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87925712","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Effect of Gait-Specific Weight-Bearing Interventions on Physical Performance Among Subjects with Stroke: A Systematic Review and Meta-analysis","authors":"Hariharasudhan Ravichandran, Kshama Shetty, Balamurugan Janakiraman","doi":"10.1177/25166085221115605","DOIUrl":"https://doi.org/10.1177/25166085221115605","url":null,"abstract":"Background Postural instability, gait dysfunctions, and tendency to fall resulting from asymmetrical weight-bearing restrict balance and mobility functions among stroke survivors. Symmetrical weight-bearing is essential for restoring mobility functions following stroke. Strategies to improve symmetrical weight-bearing remain a challenge in stroke rehabilitation. Objective To explore the evidence regarding the effectiveness of weight-bearing interventions to improve physical performance among subjects with stroke. Methods Five databases, including PubMed, Cumulative Index for Nursing and Allied Health Literature, Physiotherapy Evidence Database (PEDro), Google Scholar, and OpenGrey, were screened for identifying published and unpublished studies from their inception and up to 2022. Studies investigating the effect of symmetrical weight-bearing interventions among stroke subjects using objective or self-reporting of physical function as an outcome tool were included. Ten articles with grade 1b level of evidence demonstrated an average PEDro score of 6.4. The risk of bias was moderate among the articles. Results Ten articles with 276 participants were included in this review. Meta-analysis performed using 9 articles report that gait-specific weight-bearing improved balance and gait velocity with an overall effect size of 1.35 (95% confidence interval: 0.88–1.81) and 0.66 (95% confidence interval: 0.20–1.13). However, the effect size of step length (0.51), cadence (0.26), and fall efficacy scale (0.21) indicates nonsignificant improvement. Conclusions This meta-analysis suggests that gait-specific weight-bearing strategies are effective in improving balance and speed of walking but did not improve other parameters of gait and risk of fall. These strategies could be used to improve the symmetrical weight-bearing of stroke subjects in rehabilitation settings who do not have access to technological assistance in rehabilitation.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80605168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Bilateral Cerebral Infarctions Secondary to Unilateral ICA Stenosis","authors":"Dhananjay Gupta, Karan Sharma, D. Thakkar, Nishchint Jain, Rajsrinivas Parthasarathy, Vipul Gupta","doi":"10.1177/25166085221094667","DOIUrl":"https://doi.org/10.1177/25166085221094667","url":null,"abstract":"A 76-year-old diabetic man presented to us with complaints of sudden-onset right-sided weakness for the last 4 days. On evaluation, he was found to have right hemiparesis (Modified Medical Research Council grade 4-/5) along with left leg weakness (4+/5). Neuroimaging revealed acute infarcts in the right anterior cerebral artery (ACA) territory and left cerebral external watershed territory. Magnetic resonance (MR) angiogram of the brain showed a hypoplastic right A1-ACA with bilateral A2-ACA arising from the left A1-ACA (bi-hemispheric A1-ACA). MR angiogram of the neck revealed significant left internal carotid artery (ICA) origin stenosis. It was concluded that the origin of right A2-ACA from left ACA was the probable because of right ACA infarcts, along with left cerebral watershed infarcts (embolic phenomenon). This represents a very important variation, as in these cases, even a unilateral ICA stenosis can lead to bilateral ACA stroke and thus necessitates urgent revascularization.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86721394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Assessment of Outcomes After Decompressive Craniectomy—An Institutional-Based Study from India","authors":"Madhavi Karri, Balakrishnan Ramasamy, A. Varghese","doi":"10.1177/25166085221104914","DOIUrl":"https://doi.org/10.1177/25166085221104914","url":null,"abstract":"Background: Decompressive craniectomy (DC) is a life-saving treatment modality for acute malignant strokes. We aimed to identify the risk factors and assess the long-term functional outcome in patients with malignant stroke undergoing DC. Methods: We conducted an ambispective study on patients (>18 years) undergoing DC between January 2016 and January 2019. Demographic data, stroke risk factors, clinical characteristics, and serial imaging findings were collected. We measured the functional outcomes using the National Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), modified Ranking Scale (mRS), and Barthel index (BI) at 3, 6, and 12 months postoperatively. We did univariate and multivariate regression analyses for the independent variables and outcomes. Results: On admission, the 93 patients (70 males) had a mean GCS of 11.77 (standard deviation [SD]: 2.90) and a mean NIHSS score of 13.65 (SD: 4.41). Diabetes (odds ratio [OR]: 1.76; 0.67-4.46, 95% confidence interval [CI]) and ischemic heart disease (OR: 4.50; 1.44-14.07, 95% CI) showed a positive correlation with the outcome. Forty patients underwent surgery within 48 h of stroke onset, while 53 patients were operated on after 48 h. Twenty-two (23.66%) patients died during the study period, and 55 patients (59.14%) had an mRS score <2 one year after the stroke. Conclusions: DC can produce favorable outcomes in patients with malignant strokes, and early aggressive intervention helps improve the prognosis and quality of life. Only a few studies were reported on the results of DC in stroke, much less from developing countries like India.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91219968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pachipala Sudheer, S. Gomathy, Ayush Agarwal, V. Vishnu, A. Pandit, Vibha Deepti, R. Bhatia, P. Srivastava
{"title":"Effect of Decompression Craniectomy on Survival and Functional Outcome in Patients with COVID-19 and Malignant Infarct: A Retrospective Cohort Study and Review of Literature","authors":"Pachipala Sudheer, S. Gomathy, Ayush Agarwal, V. Vishnu, A. Pandit, Vibha Deepti, R. Bhatia, P. Srivastava","doi":"10.1177/25166085221098914","DOIUrl":"https://doi.org/10.1177/25166085221098914","url":null,"abstract":"Background and objective Amongst the varied neurological manifestations of COVID-19 infection, stroke is one of the common complications. A large portion of patients had large vessel occlusion (LVO) which increases the risk of malignant cerebral infarction requiring decompressive craniectomy. The impact of COVID-19, however, on decompressive craniectomy is not well described. Through this study, we aim to study the impact of decompressive craniectomy in COVID-19 patients presented to our tertiary care hospital. Material and methods Data of all acute ischemic stroke patients who tested COVID positive during the study period was collected. From among them, patients requiring decompressive craniectomy were included. The demographic, clinico-radiological parameters related to stroke, treatment received, outcome and complications were noted. In addition, data from all case reports and case series published on patients with COVID-19, who had developed ischemic stroke and underwent decompression craniectomy was collected and systematically reviewed. Results Twenty-seven stroke patients tested positive for COVID-19 infection, out of whom five patients underwent decompression hemicraniectomy in view of neurologic deterioration. The review of literature yielded 453 abstracts. After reading the full text of 69 articles, 12 studies on 15 patients finally met our inclusion criteria and were included in the systematic review. The mortality rate was 40% among stroke patients requiring decompressive craniectomy in COVID-19 patients. The mortality rate and functional outcomes of this cohort are comparable to the pre-pandemic period. Conclusion Decompressive craniectomy is a life-saving procedure in COVID-19 patients with malignant infarctions similar to patients in the pre-COVID-19 era.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88593080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Tenecteplase for Thrombolysis in Acute Ischemic Stroke and Its Outcome—An Indian Experience","authors":"Madhavi Karri, Balakrishnan Ramasamy","doi":"10.1177/25166085221098905","DOIUrl":"https://doi.org/10.1177/25166085221098905","url":null,"abstract":"Background: Stroke has been a growing concern with increasing morbidity and mortality worldwide. Tenecteplase has been approved in India as a newer thrombolytic, in acute ischemic stroke, since 2016. Very few studies have been reported to know the efficacy of Tenecteplase in AIS compared to alteplase. Aim: This study was done to understand the efficacy and related complications of Tenecteplase in AIS. Methods: In this prospective study, we took 112 people with AIS who received Tenecteplase, admitted between August 2018 and August 2020. After obtaining ethical approval, we tabulated patients’ data and did the statistical analysis using an unpaired t test, Analysis of Variance, and chi-square test. A P value of <.05 using a 2-tailed test was considered significant for all statistical analyses. Results: Out of 112 patients, 67.9% were male and 32.1% were female, with a mean age of 60.7 years. We classified stroke by using the TOAST classification. About 62.5% are classified as large atherosclerotic type, 14.3% cardioembolic, and 17.0% lacunar strokes. A total of 82.1% had a middle cerebral artery region stroke. The mean door to needle time was 76.7 min with a standard deviation of 33.3. The primary outcome was met in 47.3%, and the secondary result was achieved in 59.8%. Intracerebral hematoma was the most commonly observed complication. Mortality accounted for 9.8% of the total population. Conclusions: Tenecteplase is the newer thrombolytic agent with good efficacy. More studies are needed globally to understand regional differences and effectiveness.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84293782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Himani Khatter, J. Pandian, M. Kate, S. Sarma, P. Sylaja, D. Khurana, P. Vijaya, B. Ray, V. Nambiar, S. Aaron, T. George, Gaurav Mittal, I. Sebastian, N. Sundarachary, A. Pai, S. Gorthi, K. Somasundaram, Meenakshi Sharma, R. Dhaliwal, Y. Reddy, S. Narayan, NC Borah, Rupjyoti Das, G. Kulkarni, V. Huded, T. Mathew, P. Srivastava, R. Bhatia, Pawan K. Ojha, J. Roy, Sherly Abraham, Jemin Webster, A. Vaishnav, Arvind K Sharma, S. Jabeen, A. Pathak, S. Bhoi, Sudheer Sharma, S. Sulena, A. Saroja, N. Ramrakhiani, M. Kempegowda, Deepti Arora, S. Verma, R. Huilgol, Aneesh Dasan, V. Renjith
{"title":"Statistical Analysis Plan for the Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA): A Randomized Controlled Trial","authors":"Himani Khatter, J. Pandian, M. Kate, S. Sarma, P. Sylaja, D. Khurana, P. Vijaya, B. Ray, V. Nambiar, S. Aaron, T. George, Gaurav Mittal, I. Sebastian, N. Sundarachary, A. Pai, S. Gorthi, K. Somasundaram, Meenakshi Sharma, R. Dhaliwal, Y. Reddy, S. Narayan, NC Borah, Rupjyoti Das, G. Kulkarni, V. Huded, T. Mathew, P. Srivastava, R. Bhatia, Pawan K. Ojha, J. Roy, Sherly Abraham, Jemin Webster, A. Vaishnav, Arvind K Sharma, S. Jabeen, A. Pathak, S. Bhoi, Sudheer Sharma, S. Sulena, A. Saroja, N. Ramrakhiani, M. Kempegowda, Deepti Arora, S. Verma, R. Huilgol, Aneesh Dasan, V. Renjith","doi":"10.1177/25166085221098928","DOIUrl":"https://doi.org/10.1177/25166085221098928","url":null,"abstract":"Background: Recurrent stroke is one of the major causes of death in stroke patients. Introducing stroke prevention education package to improve the lifestyle behavioral factors could reduce the vascular events. The Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package (SPRINT) study in India aims to assess the role of a stroke prevention education package to reduce recurrent strokes, myocardial infarction, and death in patients with stroke. The objective is to formulate the detailed statistical analysis plan for the SPRINT India prior to trial unblinding. Methods: The plan was developed by trial statisticians with the help of principal investigator and management team of the SPRINT study. The chosen primary and secondary outcome measures and knowledge of critical baseline data were used to construct the statistical analysis plan. All collected data will be thoroughly reviewed. Patient baseline characteristics will be summarized with relevant descriptive statistics. The findings are planned and explained for the most appropriate statistical comparison between the groups. Results: The final statistical analysis plan corresponds to established criteria and will allow for transparent and efficient reporting. Conclusions: The SPRINT trial statistical analysis plan is developed in order to avoid analysis bias arising from prior knowledge of findings and to explicitly summarize prespecified analyses.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75039746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Geethanjali Sundaram, R. Balasubramanian, Navya Christopher, S. Varadharajan, Seetharaman Cannane
{"title":"Reperfusion Injury in the Cord—Rare Case of Pediatric White Cord Syndrome","authors":"Geethanjali Sundaram, R. Balasubramanian, Navya Christopher, S. Varadharajan, Seetharaman Cannane","doi":"10.1177/25166085221096509","DOIUrl":"https://doi.org/10.1177/25166085221096509","url":null,"abstract":"Background: Postoperative neurological deficits following spinal decompression are often caused due to an expanding hematoma or other iatrogenic injuries. When a definitive etiology could not be identified, it may rarely be related to a reperfusion injury. Such unexplained neurological deficits are often associated with the presence of cord signal changes on imaging. It is assumed to result from ischemia-reperfusion injury and is often designated as “white cord syndrome” due to its imaging appearance. Such a diagnosis is made after excluding other differentials. Outcomes are variable based on the current literature. We report a patient with possible white cord syndrome following decompression and excision of cervicodorsal osteochondroma. Case Description: In this case report, we present a young patient who was admitted with slowly progressive paraplegia, and initial imaging showed C7-D1 pedunculated osteochondroma. He underwent an uneventful spinal laminectomy accompanied by tumor excision. In the immediate postoperative period, the patient became paraplegic and a follow-up magnetic resonance imaging was taken. It showed re-expansion of cord in the region of compression by the mass lesion at C7-D1 level with interval abnormal T2/IR hyper intensity extending from C6 to D1 levels. Conclusion: White cord syndrome is an extremely rare condition. It is postulated to be caused by reperfusion injury to the cord within areas of chronic ischemia due to compressive causes. We describe a child with white cord syndrome following decompression and excision of an osteochondroma.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-05-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82133262","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dhrumil Shah, Rajeswari Rajan, A. Batra, I. Anand, A. Saraf, P. Sethi
{"title":"Evaluation of Neutrophil-to-Lymphocyte Ratio Among Ischemic Stroke Subtypes and Stroke Severity","authors":"Dhrumil Shah, Rajeswari Rajan, A. Batra, I. Anand, A. Saraf, P. Sethi","doi":"10.1177/25166085221095183","DOIUrl":"https://doi.org/10.1177/25166085221095183","url":null,"abstract":"Introduction: Recently, neutrophil-to-lymphocyte ratio (NLR) has been proven to be useful in predicting severity, mortality, and morbidity of stroke. NLR is low cost and yet not used widely as a biomarker to predict prognosis. Aims: We evaluated the association of NLR in severity of stroke and ischemic stroke subtypes. Methodology: A total of 69 subjects with ischemic stroke onset within 24 h were included in the study and categorized according to TOAST classification. National Institutes of Health Stroke Scale was used to determine stroke severity at admission. Samples were obtained within 24 h of stroke onset and NLR measured which was later correlated with severity and subtypes of stroke. Results: NLR and severity of stroke showed statistically significant association (P < .05). Median (interquartile range [IQR]) of NLR was significantly high in severe cases (7.1 [4.03-7.698]), as compared to others. The area under the receiver operating characteristic curve for NLR to predict the stroke severity was 6.07 [area under the curve 0.764; 95% confidence interval: 0.647 to 0.858). When NLR was more than 6.07, there was 90.90% chances of moderate-to-severe stroke and with milder stroke, 93.10% had NLR of less than equal to 6.07. NLR and stroke subtypes also showed statistically significant association (P < .05). Median (IQR) of NLR in embolic stroke was significantly high (4.75 [2.95-8.2]), as compared to other stroke subtypes. Conclusion: NLR, at a cut-off 6, has moderate sensitivity and higher specificity in predicting stroke severity and NLR was high in embolic stroke among other stroke subtypes.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89111010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pachipala Sudheer, Ayush Agarwal, V. Vishnu, A. Pandit, D. Vibha, R. Bhatia, M. Srivastava
{"title":"Neuroimaging in COVID-19 Patients on Mechanical Ventilation Receiving Sedation: Insight Beyond Diagnosis: A Case Series","authors":"Pachipala Sudheer, Ayush Agarwal, V. Vishnu, A. Pandit, D. Vibha, R. Bhatia, M. Srivastava","doi":"10.1177/25166085221085780","DOIUrl":"https://doi.org/10.1177/25166085221085780","url":null,"abstract":"Patients with severe COVID-19 are at risk of thrombotic complications such as deep vein thrombosis, pulmonary thromboembolism, myocardial infarction, and stroke. The incidence of strokes following COVID-19 is reported to be around 1.2%. There has been increased incidence with COVID-19 of large vessel strokes, especially in young patients without any known vascular risk factors. We reported four patients with severe COVID-19-associated acute respiratory distress syndrome where stroke was diagnosed following neuroimaging. All the patients were on ventilatory assistance and supportive treatment when stroke was diagnosed. They had received sedation and paralytics during mechanical ventilation. Poor response to stimulation and nonresponsiveness after wearing off sedation prompted neuroimaging in these patients, which revealed stroke. Incidentally, all these patients had hypernatremia when stroke was diagnosed. This case series suggests that stroke should be considered a possible cause in all COVID-19 patients presenting with abnormal or altered sensorium.","PeriodicalId":93323,"journal":{"name":"Journal of stroke medicine","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81763314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
求助内容：
应助结果提醒方式：
京公网安备 11010802042870号
