Long‐term seizure outcome in 211 patients with focal cortical dysplasia
Summary Objective Focal cortical dysplasia (FCD) is currently recognized as the most common cause of neocortical pharmacoresistant epilepsy. Epilepsy surgery has become an increasingly successful treatment option. Herein, the largest patient cohort reported to date is analyzed regarding long‐term ou...
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| Veröffentlicht in: | Epilepsia (Copenhagen) 2015-01, Vol.56 (1), p.66-76 |
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| creator | Fauser, Susanne Essang, Charles Altenmüller, Dirk‐Matthias Staack, Anke Maren Steinhoff, Bernhard J. Strobl, Karl Bast, Thomas Schubert‐Bast, Susanne Stephani, Ulrich Wiegand, Gert Prinz, Marco Brandt, Armin Zentner, Josef Schulze‐Bonhage, Andreas |
| description | Summary
Objective
Focal cortical dysplasia (FCD) is currently recognized as the most common cause of neocortical pharmacoresistant epilepsy. Epilepsy surgery has become an increasingly successful treatment option. Herein, the largest patient cohort reported to date is analyzed regarding long‐term outcome and factors relevant for long‐term seizure control.
Methods
Two hundred eleven children and adults undergoing epilepsy surgery for histologically proven FCD and a follow‐up period of 2–12 years were analyzed regarding the longitudinal course of seizure control, effects of FCD type, localization, magnetic resonance imaging (MRI), timing of surgery, and postoperative antiepileptic treatment.
Results
After 1 year, Engel class I outcome was achieved in 65% of patients and the percentage of seizure‐free patients remained stable over the following (up to 12) years. Complete resection of the assumed epileptogenic area, lower age at surgery, and unilobar localization were positive prognostic indicators of long‐term seizure freedom. Seizure recurrence was 12% after the first year, whereas 8% achieved late seizure freedom either following additional introduction of antiepileptic drugs (AEDs) (4%), a reoperation (2%), or a running down phenomenon (2%). Thirty‐nine percent of patients had a reduction of AED from polytherapy to monotherapy or a complete cessation of AED treatment. Late seizure relapse was seen in nine patients during reduction of AEDs (i.e., in 12% of all patients with AED tapering); in four of them seizures persisted after reestablishment of antiepileptic medication.
Significance
Postoperative long‐term seizure outcome was favorable in patients with FCD and remained stable in 80% of patients after the first postoperative year. Several preoperative factors revealed to be predictive for the postoperative outcome and may help in the preoperative counseling of patients with FCD and in the selection of ideal candidates for epilepsy surgery. |
| doi_str_mv | 10.1111/epi.12876 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1652405232</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1652405232</sourcerecordid><originalsourceid>FETCH-LOGICAL-c4586-70954116ae1d8d6d2218dd1a3bcd026939387cd9673c61e1006ea9707da785d43</originalsourceid><addsrcrecordid>eNp10LtOwzAYBWALgWi5DLwAisQCQ8C_E18yoqpApUowwBwZ2wVXSRzsRFWZeASekSfBkMKAhJffw6ejo4PQEeBziO_CtPYciOBsC42BEpECML6NxhhDlhZU4BHaC2GJMeaMZ7toRGheUC7YGM3mrnn6eHvvjK-TYOxr703i-k652iS2SQhA0srOmqYLycp2z8nCKVklyvnOfn30OrSVDFYeoJ2FrII53Nx99HA1vZ_cpPPb69nkcp6qnAqWclzQPPaTBrTQTBMCQmuQ2aPSmLAiKzLBlS5iUcXAAMbMyIJjriUXVOfZPjodclvvXnoTurK2QZmqko1xfSiBUZJjSjIS6ckfunS9b2K7qHLOC8IYRHU2KOVdCN4sytbbWvp1Cbj82reM-5bf-0Z7vEnsH2ujf-XPoBFcDGBlK7P-P6mc3s2GyE-NUIMF</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1647792661</pqid></control><display><type>article</type><title>Long‐term seizure outcome in 211 patients with focal cortical dysplasia</title><source>Wiley Free Content</source><source>MEDLINE</source><source>Wiley Online Library Journals Frontfile Complete</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><source>Alma/SFX Local Collection</source><creator>Fauser, Susanne ; Essang, Charles ; Altenmüller, Dirk‐Matthias ; Staack, Anke Maren ; Steinhoff, Bernhard J. ; Strobl, Karl ; Bast, Thomas ; Schubert‐Bast, Susanne ; Stephani, Ulrich ; Wiegand, Gert ; Prinz, Marco ; Brandt, Armin ; Zentner, Josef ; Schulze‐Bonhage, Andreas</creator><creatorcontrib>Fauser, Susanne ; Essang, Charles ; Altenmüller, Dirk‐Matthias ; Staack, Anke Maren ; Steinhoff, Bernhard J. ; Strobl, Karl ; Bast, Thomas ; Schubert‐Bast, Susanne ; Stephani, Ulrich ; Wiegand, Gert ; Prinz, Marco ; Brandt, Armin ; Zentner, Josef ; Schulze‐Bonhage, Andreas</creatorcontrib><description>Summary
Objective
Focal cortical dysplasia (FCD) is currently recognized as the most common cause of neocortical pharmacoresistant epilepsy. Epilepsy surgery has become an increasingly successful treatment option. Herein, the largest patient cohort reported to date is analyzed regarding long‐term outcome and factors relevant for long‐term seizure control.
Methods
Two hundred eleven children and adults undergoing epilepsy surgery for histologically proven FCD and a follow‐up period of 2–12 years were analyzed regarding the longitudinal course of seizure control, effects of FCD type, localization, magnetic resonance imaging (MRI), timing of surgery, and postoperative antiepileptic treatment.
Results
After 1 year, Engel class I outcome was achieved in 65% of patients and the percentage of seizure‐free patients remained stable over the following (up to 12) years. Complete resection of the assumed epileptogenic area, lower age at surgery, and unilobar localization were positive prognostic indicators of long‐term seizure freedom. Seizure recurrence was 12% after the first year, whereas 8% achieved late seizure freedom either following additional introduction of antiepileptic drugs (AEDs) (4%), a reoperation (2%), or a running down phenomenon (2%). Thirty‐nine percent of patients had a reduction of AED from polytherapy to monotherapy or a complete cessation of AED treatment. Late seizure relapse was seen in nine patients during reduction of AEDs (i.e., in 12% of all patients with AED tapering); in four of them seizures persisted after reestablishment of antiepileptic medication.
Significance
Postoperative long‐term seizure outcome was favorable in patients with FCD and remained stable in 80% of patients after the first postoperative year. Several preoperative factors revealed to be predictive for the postoperative outcome and may help in the preoperative counseling of patients with FCD and in the selection of ideal candidates for epilepsy surgery.</description><identifier>ISSN: 0013-9580</identifier><identifier>EISSN: 1528-1167</identifier><identifier>DOI: 10.1111/epi.12876</identifier><identifier>PMID: 25495786</identifier><identifier>CODEN: EPILAK</identifier><language>eng</language><publisher>United States: Wiley Subscription Services, Inc</publisher><subject>Adolescent ; Adult ; Anticonvulsants - therapeutic use ; Antiepileptic drug withdrawal ; Cerebral Cortex - pathology ; Cerebral Cortex - surgery ; Child ; Child, Preschool ; Cohort Studies ; Craniofacial Abnormalities ; Electroencephalography ; Epilepsies, Partial - complications ; Epilepsies, Partial - pathology ; Epilepsies, Partial - surgery ; Epilepsy - complications ; Epilepsy - pathology ; Epilepsy - surgery ; Female ; Focal cortical dysplasia ; Humans ; Infant ; Longitudinal Studies ; Long‐term outcome ; Magnetic Resonance Imaging ; Male ; Malformations of Cortical Development - complications ; Malformations of Cortical Development - pathology ; Malformations of Cortical Development - surgery ; Malformations of Cortical Development, Group I - complications ; Malformations of Cortical Development, Group I - pathology ; Malformations of Cortical Development, Group I - surgery ; Middle Aged ; Prognostic factors ; Retrospective Studies ; Seizures - etiology ; Seizures - therapy ; Treatment Outcome ; Young Adult</subject><ispartof>Epilepsia (Copenhagen), 2015-01, Vol.56 (1), p.66-76</ispartof><rights>Wiley Periodicals, Inc. © 2014 International League Against Epilepsy</rights><rights>Wiley Periodicals, Inc. © 2014 International League Against Epilepsy.</rights><rights>Copyright © 2015 International League Against Epilepsy</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4586-70954116ae1d8d6d2218dd1a3bcd026939387cd9673c61e1006ea9707da785d43</citedby><cites>FETCH-LOGICAL-c4586-70954116ae1d8d6d2218dd1a3bcd026939387cd9673c61e1006ea9707da785d43</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Fepi.12876$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Fepi.12876$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,776,780,1411,1427,27901,27902,45550,45551,46384,46808</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25495786$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Fauser, Susanne</creatorcontrib><creatorcontrib>Essang, Charles</creatorcontrib><creatorcontrib>Altenmüller, Dirk‐Matthias</creatorcontrib><creatorcontrib>Staack, Anke Maren</creatorcontrib><creatorcontrib>Steinhoff, Bernhard J.</creatorcontrib><creatorcontrib>Strobl, Karl</creatorcontrib><creatorcontrib>Bast, Thomas</creatorcontrib><creatorcontrib>Schubert‐Bast, Susanne</creatorcontrib><creatorcontrib>Stephani, Ulrich</creatorcontrib><creatorcontrib>Wiegand, Gert</creatorcontrib><creatorcontrib>Prinz, Marco</creatorcontrib><creatorcontrib>Brandt, Armin</creatorcontrib><creatorcontrib>Zentner, Josef</creatorcontrib><creatorcontrib>Schulze‐Bonhage, Andreas</creatorcontrib><title>Long‐term seizure outcome in 211 patients with focal cortical dysplasia</title><title>Epilepsia (Copenhagen)</title><addtitle>Epilepsia</addtitle><description>Summary
Objective
Focal cortical dysplasia (FCD) is currently recognized as the most common cause of neocortical pharmacoresistant epilepsy. Epilepsy surgery has become an increasingly successful treatment option. Herein, the largest patient cohort reported to date is analyzed regarding long‐term outcome and factors relevant for long‐term seizure control.
Methods
Two hundred eleven children and adults undergoing epilepsy surgery for histologically proven FCD and a follow‐up period of 2–12 years were analyzed regarding the longitudinal course of seizure control, effects of FCD type, localization, magnetic resonance imaging (MRI), timing of surgery, and postoperative antiepileptic treatment.
Results
After 1 year, Engel class I outcome was achieved in 65% of patients and the percentage of seizure‐free patients remained stable over the following (up to 12) years. Complete resection of the assumed epileptogenic area, lower age at surgery, and unilobar localization were positive prognostic indicators of long‐term seizure freedom. Seizure recurrence was 12% after the first year, whereas 8% achieved late seizure freedom either following additional introduction of antiepileptic drugs (AEDs) (4%), a reoperation (2%), or a running down phenomenon (2%). Thirty‐nine percent of patients had a reduction of AED from polytherapy to monotherapy or a complete cessation of AED treatment. Late seizure relapse was seen in nine patients during reduction of AEDs (i.e., in 12% of all patients with AED tapering); in four of them seizures persisted after reestablishment of antiepileptic medication.
Significance
Postoperative long‐term seizure outcome was favorable in patients with FCD and remained stable in 80% of patients after the first postoperative year. Several preoperative factors revealed to be predictive for the postoperative outcome and may help in the preoperative counseling of patients with FCD and in the selection of ideal candidates for epilepsy surgery.</description><subject>Adolescent</subject><subject>Adult</subject><subject>Anticonvulsants - therapeutic use</subject><subject>Antiepileptic drug withdrawal</subject><subject>Cerebral Cortex - pathology</subject><subject>Cerebral Cortex - surgery</subject><subject>Child</subject><subject>Child, Preschool</subject><subject>Cohort Studies</subject><subject>Craniofacial Abnormalities</subject><subject>Electroencephalography</subject><subject>Epilepsies, Partial - complications</subject><subject>Epilepsies, Partial - pathology</subject><subject>Epilepsies, Partial - surgery</subject><subject>Epilepsy - complications</subject><subject>Epilepsy - pathology</subject><subject>Epilepsy - surgery</subject><subject>Female</subject><subject>Focal cortical dysplasia</subject><subject>Humans</subject><subject>Infant</subject><subject>Longitudinal Studies</subject><subject>Long‐term outcome</subject><subject>Magnetic Resonance Imaging</subject><subject>Male</subject><subject>Malformations of Cortical Development - complications</subject><subject>Malformations of Cortical Development - pathology</subject><subject>Malformations of Cortical Development - surgery</subject><subject>Malformations of Cortical Development, Group I - complications</subject><subject>Malformations of Cortical Development, Group I - pathology</subject><subject>Malformations of Cortical Development, Group I - surgery</subject><subject>Middle Aged</subject><subject>Prognostic factors</subject><subject>Retrospective Studies</subject><subject>Seizures - etiology</subject><subject>Seizures - therapy</subject><subject>Treatment Outcome</subject><subject>Young Adult</subject><issn>0013-9580</issn><issn>1528-1167</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2015</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp10LtOwzAYBWALgWi5DLwAisQCQ8C_E18yoqpApUowwBwZ2wVXSRzsRFWZeASekSfBkMKAhJffw6ejo4PQEeBziO_CtPYciOBsC42BEpECML6NxhhDlhZU4BHaC2GJMeaMZ7toRGheUC7YGM3mrnn6eHvvjK-TYOxr703i-k652iS2SQhA0srOmqYLycp2z8nCKVklyvnOfn30OrSVDFYeoJ2FrII53Nx99HA1vZ_cpPPb69nkcp6qnAqWclzQPPaTBrTQTBMCQmuQ2aPSmLAiKzLBlS5iUcXAAMbMyIJjriUXVOfZPjodclvvXnoTurK2QZmqko1xfSiBUZJjSjIS6ckfunS9b2K7qHLOC8IYRHU2KOVdCN4sytbbWvp1Cbj82reM-5bf-0Z7vEnsH2ujf-XPoBFcDGBlK7P-P6mc3s2GyE-NUIMF</recordid><startdate>201501</startdate><enddate>201501</enddate><creator>Fauser, Susanne</creator><creator>Essang, Charles</creator><creator>Altenmüller, Dirk‐Matthias</creator><creator>Staack, Anke Maren</creator><creator>Steinhoff, Bernhard J.</creator><creator>Strobl, Karl</creator><creator>Bast, Thomas</creator><creator>Schubert‐Bast, Susanne</creator><creator>Stephani, Ulrich</creator><creator>Wiegand, Gert</creator><creator>Prinz, Marco</creator><creator>Brandt, Armin</creator><creator>Zentner, Josef</creator><creator>Schulze‐Bonhage, Andreas</creator><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7TK</scope><scope>7X8</scope></search><sort><creationdate>201501</creationdate><title>Long‐term seizure outcome in 211 patients with focal cortical dysplasia</title><author>Fauser, Susanne ; Essang, Charles ; Altenmüller, Dirk‐Matthias ; Staack, Anke Maren ; Steinhoff, Bernhard J. ; Strobl, Karl ; Bast, Thomas ; Schubert‐Bast, Susanne ; Stephani, Ulrich ; Wiegand, Gert ; Prinz, Marco ; Brandt, Armin ; Zentner, Josef ; Schulze‐Bonhage, Andreas</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4586-70954116ae1d8d6d2218dd1a3bcd026939387cd9673c61e1006ea9707da785d43</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2015</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Anticonvulsants - therapeutic use</topic><topic>Antiepileptic drug withdrawal</topic><topic>Cerebral Cortex - pathology</topic><topic>Cerebral Cortex - surgery</topic><topic>Child</topic><topic>Child, Preschool</topic><topic>Cohort Studies</topic><topic>Craniofacial Abnormalities</topic><topic>Electroencephalography</topic><topic>Epilepsies, Partial - complications</topic><topic>Epilepsies, Partial - pathology</topic><topic>Epilepsies, Partial - surgery</topic><topic>Epilepsy - complications</topic><topic>Epilepsy - pathology</topic><topic>Epilepsy - surgery</topic><topic>Female</topic><topic>Focal cortical dysplasia</topic><topic>Humans</topic><topic>Infant</topic><topic>Longitudinal Studies</topic><topic>Long‐term outcome</topic><topic>Magnetic Resonance Imaging</topic><topic>Male</topic><topic>Malformations of Cortical Development - complications</topic><topic>Malformations of Cortical Development - pathology</topic><topic>Malformations of Cortical Development - surgery</topic><topic>Malformations of Cortical Development, Group I - complications</topic><topic>Malformations of Cortical Development, Group I - pathology</topic><topic>Malformations of Cortical Development, Group I - surgery</topic><topic>Middle Aged</topic><topic>Prognostic factors</topic><topic>Retrospective Studies</topic><topic>Seizures - etiology</topic><topic>Seizures - therapy</topic><topic>Treatment Outcome</topic><topic>Young Adult</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Fauser, Susanne</creatorcontrib><creatorcontrib>Essang, Charles</creatorcontrib><creatorcontrib>Altenmüller, Dirk‐Matthias</creatorcontrib><creatorcontrib>Staack, Anke Maren</creatorcontrib><creatorcontrib>Steinhoff, Bernhard J.</creatorcontrib><creatorcontrib>Strobl, Karl</creatorcontrib><creatorcontrib>Bast, Thomas</creatorcontrib><creatorcontrib>Schubert‐Bast, Susanne</creatorcontrib><creatorcontrib>Stephani, Ulrich</creatorcontrib><creatorcontrib>Wiegand, Gert</creatorcontrib><creatorcontrib>Prinz, Marco</creatorcontrib><creatorcontrib>Brandt, Armin</creatorcontrib><creatorcontrib>Zentner, Josef</creatorcontrib><creatorcontrib>Schulze‐Bonhage, Andreas</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Neurosciences Abstracts</collection><collection>MEDLINE - Academic</collection><jtitle>Epilepsia (Copenhagen)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Fauser, Susanne</au><au>Essang, Charles</au><au>Altenmüller, Dirk‐Matthias</au><au>Staack, Anke Maren</au><au>Steinhoff, Bernhard J.</au><au>Strobl, Karl</au><au>Bast, Thomas</au><au>Schubert‐Bast, Susanne</au><au>Stephani, Ulrich</au><au>Wiegand, Gert</au><au>Prinz, Marco</au><au>Brandt, Armin</au><au>Zentner, Josef</au><au>Schulze‐Bonhage, Andreas</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Long‐term seizure outcome in 211 patients with focal cortical dysplasia</atitle><jtitle>Epilepsia (Copenhagen)</jtitle><addtitle>Epilepsia</addtitle><date>2015-01</date><risdate>2015</risdate><volume>56</volume><issue>1</issue><spage>66</spage><epage>76</epage><pages>66-76</pages><issn>0013-9580</issn><eissn>1528-1167</eissn><coden>EPILAK</coden><abstract>Summary
Objective
Focal cortical dysplasia (FCD) is currently recognized as the most common cause of neocortical pharmacoresistant epilepsy. Epilepsy surgery has become an increasingly successful treatment option. Herein, the largest patient cohort reported to date is analyzed regarding long‐term outcome and factors relevant for long‐term seizure control.
Methods
Two hundred eleven children and adults undergoing epilepsy surgery for histologically proven FCD and a follow‐up period of 2–12 years were analyzed regarding the longitudinal course of seizure control, effects of FCD type, localization, magnetic resonance imaging (MRI), timing of surgery, and postoperative antiepileptic treatment.
Results
After 1 year, Engel class I outcome was achieved in 65% of patients and the percentage of seizure‐free patients remained stable over the following (up to 12) years. Complete resection of the assumed epileptogenic area, lower age at surgery, and unilobar localization were positive prognostic indicators of long‐term seizure freedom. Seizure recurrence was 12% after the first year, whereas 8% achieved late seizure freedom either following additional introduction of antiepileptic drugs (AEDs) (4%), a reoperation (2%), or a running down phenomenon (2%). Thirty‐nine percent of patients had a reduction of AED from polytherapy to monotherapy or a complete cessation of AED treatment. Late seizure relapse was seen in nine patients during reduction of AEDs (i.e., in 12% of all patients with AED tapering); in four of them seizures persisted after reestablishment of antiepileptic medication.
Significance
Postoperative long‐term seizure outcome was favorable in patients with FCD and remained stable in 80% of patients after the first postoperative year. Several preoperative factors revealed to be predictive for the postoperative outcome and may help in the preoperative counseling of patients with FCD and in the selection of ideal candidates for epilepsy surgery.</abstract><cop>United States</cop><pub>Wiley Subscription Services, Inc</pub><pmid>25495786</pmid><doi>10.1111/epi.12876</doi><tpages>11</tpages><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
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| ispartof | Epilepsia (Copenhagen), 2015-01, Vol.56 (1), p.66-76 |
| issn | 0013-9580 1528-1167 |
| language | eng |
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| source | Wiley Free Content; MEDLINE; Wiley Online Library Journals Frontfile Complete; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; Alma/SFX Local Collection |
| subjects | Adolescent Adult Anticonvulsants - therapeutic use Antiepileptic drug withdrawal Cerebral Cortex - pathology Cerebral Cortex - surgery Child Child, Preschool Cohort Studies Craniofacial Abnormalities Electroencephalography Epilepsies, Partial - complications Epilepsies, Partial - pathology Epilepsies, Partial - surgery Epilepsy - complications Epilepsy - pathology Epilepsy - surgery Female Focal cortical dysplasia Humans Infant Longitudinal Studies Long‐term outcome Magnetic Resonance Imaging Male Malformations of Cortical Development - complications Malformations of Cortical Development - pathology Malformations of Cortical Development - surgery Malformations of Cortical Development, Group I - complications Malformations of Cortical Development, Group I - pathology Malformations of Cortical Development, Group I - surgery Middle Aged Prognostic factors Retrospective Studies Seizures - etiology Seizures - therapy Treatment Outcome Young Adult |
| title | Long‐term seizure outcome in 211 patients with focal cortical dysplasia |
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