Biomedical subjects

C Mottolese

Publications and source records attributed to C Mottolese.

At least 55 records · Page 3Linked to original sources

PubMed1995

Non-metastatic childhood ependymomas.

PURPOSE: Intracranial ependymomas of childhood are relatively infrequent. There are significant disagreements concerning optimal postoperative treatment as well as the patterns of relapse following treatment. The purpose of this retrospective study was the analysis of the recurrence pattern and therefore the implication on the extent of the radiotherapy fields. Data from 37 patients referred within 19 years were used for this study. PATIENTS AND METHODS: From April 1975 to July 1993, 37 children aged 1-14 years were referred for postoperative treatment of an intracranial ependymoma. Twenty-eight children received postoperative radiation therapy and 26 patients received chemotherapy. The median follow-up is 6 years (range 2 months to 19 years). RESULTS: Overall survival and event free survival at 5 and 10 years were 40%. Eighteen children relapsed. Relapses occurred from 1.5 months to 3.6 years post treatment. Relapses were distant in four cases and local in 14. Age, sex, extent of primary resection, chemotherapy and type of radiation therapy did not influence the outcome. Children with poorly differentiated tumors who did not receive postoperative radiation therapy had a higher relapse rate but this difference is not statistically significant. CONCLUSIONS: Despite doses of radiation > or = 50 Gy the majority of recurrences were local. Our results, despite the small number of patients are in accordance to those previously published, suggest that prophylactic craniospinal irradiation is superfluous. Better means of achieved local control are required, such as three-dimensional conformal radiation therapy with dose-escalation study or hyperfractionation regimen.

Adolescent↗

PubMed1995

Multidisciplinary treatment of cerebral arteriovenous malformations.

A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

Preirradiation chemotherapy including "eight drugs in 1 day" regimen and high-dose methotrexate in childhood medulloblastoma: results of the M7 French Cooperative Study.

The aim of this study was to evaluate the feasibility and efficacy of a protocol that includes "sandwich" chemotherapy, that is, chemotherapy alternated with radiotherapy, and reduced doses of supratentorial irradiation in children with medulloblastoma. Between March 1985 and September 1988, 70 successive children with newly diagnosed medulloblastoma from eight centers were treated in this prospective nonrandomized study. Patients were assigned to two risk groups. Group A included patients with macroscopically complete or subtotal excision, no brainstem involvement, no atypical cells in the cerebrospinal fluid, normal myelography, and who were more than 2 years of age. Group B patients encompassed those who did not fit the criteria for Group A. Two children were excluded from analysis after histological review confirmed ependymoma. Thus, a population of 68 children was selected, with 31 in Group A and 37 in Group B. Treatment consisted of two courses of the "eight drugs in 1 day" ("8/1") regimen followed by two courses of high-dose methotrexate (12 g/m2). Radiotherapy was begun during the 7th week after surgery in Group A and during the 5th week in Group B. In patients older than 2 years, the median radiation dose to the posterior fossa, the spinal axis, and the brain was 54 Gy, 36 Gy, and 27 Gy, respectively. Group B patients received postirradiation chemotherapy with four 8/1 courses monthly. The median time from surgery to radiation therapy was 50 days (range 21 to 141 days). One fatality due to chicken pox on Day 102 and one World Health Organization Grade IV infection occurred. The estimated 5- and 7-year disease-free survival (DFS) rates were 62% and 59%, respectively. These were 74% and 62% in Group A and 57% and 57% in Group B. Patient age, extent of resection, and radiation dose to the whole brain had no prognostic value. Patients with metastasis had a nonsignificant trend for a worse prognosis than patients with nonmetastatic disease (7-year DFS 45% vs. 68%, p = 0.11). In Group B, the 7-year DFS rates for children who received more or less than 30 Gy to the brain were 69% and 52% respectively (p = 0.15). There were recurrences in the posterior fossa (37%), spine (20%), and brain (20%). After a review of radiotherapeutic treatments, only one supratentorial failure could be blamed on reduction of the supratentorial radiation dose. This "sandwich" chemotherapy appeared to be feasible and did not show adverse survival data when compared to other series.

Adolescent↗

PubMed1994

Tectal plate gliomas. Part I: Microsurgery of the tectal plate gliomas.

A series of 12 patients with tectal plate gliomas, is presented treated by direct surgery. Mean age was 19 years. All patients presented with signs of raised intracranial pressure and supratentorial hydrocephalus on CT scan. Diplopia was the most common local sign. CT scan and MR imaging showed 4 intrinsic, 6 exophytic, and 2 ventrally infiltrating tectal tumours. The histological diagnosis was low-grade astrocytoma in 7, high-grade astrocytoma in 2, oligodendroglioma in one, oligo-astrocytoma in one, and ependymoma in one case. The suboccipital supra- and transtentorial approach was used in every cases. Tumour resection was generous at the level of the superior colliculi, but on the contrary, resection was limited at the level of inferior colliculi due to the auditory risk. Tumour removal was total (macroscopically) in 9 cases and partial in 3 cases. There were 4 surgical complications and one death related to surgery. Parinaud's syndrome was the most-common postoperative sequelae. Auditory hallucinations and the acoustic neglect syndrome were seen once. In three cases additional radiotherapy and chemotherapy were given once with severe sequelae. The treatment of tectal plate gliomas is controversial. The role of different therapeutic options remains open. We consider the tectal plate as a relatively safer territory for surgery than the ventral part of the midbrain. The brain stem auditory evoked potentials (BAEPs) and middle latency potentials (MLPs) monitoring can help to determine the appropriate limit of surgery.

Adolescent↗

PubMed1994

Tectal plate gliomas. Part II: CT scans and MR imaging of tectal gliomas.

CT scans and MR images were analyzed in 12 patients with histologically proved tectal plate gliomas. In an attempt to identify the nature of these lesions, their radiological characteristics were correlated with the histological results. In four of our patients CT scan failed to show the tumour. MR imaging demonstrated the tectal distortion in all cases. Contrast enhancement, calcification, cystic portions, exophytic nature were observed in both high and low-grade gliomas. We conclude that in the case of intrinsic tectal tumours, the most probable diagnosis is that of low-grade astrocytoma while in the case of exophytic tectal tumours, the differential diagnosis from pineal region tumour is required and a histological verification is necessary.

Adolescent↗

PubMed1994

Prognostic value of the Spetzler's grading system in a series of cerebral AVMs treated by a combined management.

The prognostic value of the Spetzler's grading system is studied in a series of 52 AVMs treated by a combined management, using one or several of the 3 available techniques: surgical resection, endovascular embolization, radiosurgery. The symptoms at the time of treatment were haemorrhage 50%, seizures 31%, headache and deficit 19%. Three grade groups were considered: I and II (31%), III (33%), IV and V (36%). Overall, AVMs were managed as follows: resection alone 25%, embolization plus resection 23%, embolization alone 23%, radiosurgery with various combinations 29%. According to the grade groups, the most frequently used technique was resection alone for grade I-II AVMs (44%), radiosurgery for grade III AVMs (41%) and embolization alone for grade IV-V AVMs (42%). The clinical outcome was evaluated in terms of deterioration due to treatment. The best results were obtained in grade I-II AVMs (81% with no deterioration) then in grade III AVMs (65%) and in grade IV-V (58%). However, when we consider the outcome in terms of favourable results (no or only minor deterioration) we obtained a similar outcome for grade I-II and grade III AVMs (94% each), and only 79% for grade IV-V malformations. The angiographic outcome showed a better eradication rate in grade III AVMs (88% complete eradication), than in grade I-II AVMs (75%) and in grade IV-V (47%). Our conclusion is that the Spetzler's grading system in this series was well correlated with both the clinical and the angiographic outcome. However, we found no real difference between grade I-II and grade III AVMs. So, in terms of prognostic value, the grade I, II, and III AVMs could be considered together as low-grade malformations, with a better prognosis than the high-grade malformations (grade IV and V).

Adult↗

PubMed1994

Tectal plate gliomas. Part III: Apparent lack of auditory consequences of unilateral inferior collicular lesion due to localized glioma surgery.

The authors present one of their cases operated on for intrinsic tectal plate glioma. The complete resection of the right inferior colliculus (I.C.) had no apparent auditory consequences. The pre- and post-operative tonal and vocal auditory tests were normal. The brain-stem auditory evoked potentials (BAEPs) and middle latency potentials (MLPs) were recorded pre-, post- and intraoperatively. At the end of surgery all waves were present with a marked delay of wave V and a slight delay of the Pa component. The dichotic test showed a significant right ear extinction but admittedly much less important than expected. The role of inferior colliculus (I.C.) in hearing is discussed.

Astrocytoma↗

PubMed1994

Long term outcome after treatment of the ruptured intracranial aneurysm: 73 cases admitted from day 0 to day 3 after subarachnoid haemorrhage.

73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in Hunt and Hess grades I to IV after aneurysm rupture, were studied. All admitted patients were operated upon. The timing of surgery was neither systematic early nor systematic late surgery, but modulated surgery. Patients in good grades (I and II) and under 50 years of age were operated on early. Patients in poor grade and over 50 years of age were operated late. Other patients were operated on preferably early if they were young, even in poor grade, or late if they were old even in good grade. The overall immediate outcome was: good and fair--85%, poor--4%, and death--11%. For those patients operated on early after SAH (D0-3) the good and fair outcome rate went up to 90%. The long term outcome was evaluated after 1 year (from 1 to 6 years, average 1 year 8 months). 97% of patients were available for follow-up. The long-term neurological outcome was identical to the immediate outcome. The resumption of activity was the criteria chosen to evaluate the long term outcome. The long term ability to work in 63 followed-up surviving patients was: normal activity--57%, reduced level of activity--16%, no resumption of activity--27%. This rate of activity resumption was not improved in patients operated on early. Among patients with a good long term neurological outcome, only 67% resumed their previous activity at the same level.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗

PubMed1994

The use of Teflon as wrapping material in aneurysm surgery.

Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping is a well-known alternative technique when aneurysm clipping is not feasible, or is not completely satisfactory. We present a technique of wrapping using fibres of Teflon material shaped in strings or in pledgets, arranged on or around the area to be treated and fixed by fibrin glue. This Teflon technique was used during the years 1990 to 1992, in 44 treated aneurysms (33% or all aneurysms treated during the same period), and in 3 situations: 1) to reinforce a residual or additional ectasia next to the clipped aneurysm, usually proximal to the clip (25 cases, i.e., 57%), 2) to treat an arterial ectasia, so called preaneurysmal ectasia, which proved not clippable at surgery (10 cases, 23%) and 3) to protect a nervous or vascular neighbouring structure which was compressed by the clip grip (9 cases, 20%). No complication was noted in relation to this technique. Up to now, no other know wrapping material has received worldwide approval for being completely innocuous and effective. The Teflon material has been widely used in neurosurgical microvascular decompression and in cardiovascular surgery. In these fields, its reliability, safety, and lack of harmful effects have been widely recognized and should also apply in aneurysm surgery. A very long follow-up will be necessary to assess the outcome for this new wrapping technique.

Bandages↗

PubMed1993

Successful treatment for a metastatic supratentorial malignant rhabdoid tumor.

The case of a boy with a familial history of Rendu-Osler disease, who successively developed a cerebellar pilocytic astrocytoma (at 3 years of age) and a metastatic supratentorial malignant rhabdoid tumor (at the age of 12 years) is reported. After a complete surgical removal, the CSF was cleared by 4 courses of chemotherapy, and the child received a craniospinal irradiation. He is currently alive and well 19 months after completion of the treatment. The authors discuss the ethiopathogeny of such intracranial tumors and argue for aggressive treatment.

Astrocytoma↗

PubMed1993

The combined management of cerebral arteriovenous malformations. Experience with 100 cases and review of the literature.

A series of 100 patients treated for a cerebral arteriovenous malformation (AVM) is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated after the availability of radiosurgery (1989-1992). AVM's were classified in five grades according to the Spetzler's Grading System. Three techniques of treatment were used: surgical resection, intravascular embolization (with cyanoacrylate), and radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization, or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the decrease of the "embolization and resection" group, which until then was predominantly used as well for low-grade (I, II, III) as for high-grade AVM's (IV, V). Overall, for the low-grade AVM's, the treatment of choice was surgical resection (79% of cases), with pre-operative embolization in one-half of these cases; the other low-grade AVM's were irradiated, with various combinations. For the high-grade AVM's, the treatment of choice was intravascular embolization (95% of cases), either alone, or followed by resection (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration following treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%), and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patients' age. More favourable results were obtained for low-grade AVM's (93%) than for high-grade AVM's (60%). For the low-grade AVM's the evolution from 1989 on (favourable outcomes increasing from 89% to 96%) occurred with the lowering of the mortality rate. For the high-grade AVM's, the evolution from 1989 onwards (favourable outcome increasing from 46% to 78%) occurred with the decrease of the cases with deficits. The angiographic results were strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards AVM's. The surgical management which was predominantly used at the beginning gave way progressively to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

PubMed1993

Routine use of the CO2 laser technique for resection of cerebral tumours.

The CO2 laser technique has been routinely used from 1988 through 1992 for the resection of 93 cerebral tumours (meningiomas 58%, gliomas 15%, neurinomas 9%, miscellaneous 18%). The CO2 laser technique was found the more effective 1) in tumours of hard consistency, 2) in large or giant tumours, 3) in tumours with scarce vascularization. Meningiomas were the indication of choice (54 cases that is 58% of all tumours treated with CO2 laser, and 64% of all meningiomas operated on during the same period). Among the meningiomas treated with the CO2 laser, 54% were located on the skull base. The CO2 laser beam provides good haemostasis of small vessels during the vaporization process. When attached to the operative microscope, the other advantages of the CO2 laser technique are: the absence of a handle-piece, the absence of manual manipulation of the tumour, the coaxiality of the laser beam with the visual beam. The disadvantages are: the rigidity of the coupled microscope-Laser arm, the smoke produced by the vaporization of hard tumours, the noise of the device.

Brain Neoplasms↗

PubMed1993

[S. aureus neuromeningeal infection in 3 children with ventricular shunts without cytochemical changes in the lumbar cerebrospinal fluid].

The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with normal white blood cell count and normal CSF glucose level in repeated lumbar CSF examination. All three children (2 months, 17 months and 4 years old) have been operated for neonatal hydrocephalus with setting of a ventriculo-peritoneal shunt one to two months before. Infection was suspected because of fever without evocative clinical signs. In two cases plasma C reactive protein level was increased, and in all three cases a leucocytosis was present. The diagnosis was made by bacteriological examination of the ventricular CSF. Both surgical and medical management were required and the bacteriological outcome was favourable. Since neurological sequellae may occur if the treatment is delayed such atypical infection needs to be promptly assessed.

Fever↗

PubMed1993

[Hemodynamic study of acute neurogenic pulmonary edema in children].

Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From bibliographic data and four personal cases documented by and haemodynamical study, the authors analyse the pathophysiological mechanisms and the haemodynamical changes resulting from massive sympathic outflow, the main mechanism of NPE being haemodynamical rather than lesional. This rare complication needs to be recognized in order to undergo an intensive care treatment generally leading to a favourable evolution. This treatment lies on circulatory and ventilatory supports with positive and expiratory pressure in order to maintain an optimal oxygenation and an optimal cerebral perfusion pressure. With this treatment the outcome of NPE is usually favourable with complete recovery within 2 to 5 days.

Acute Disease↗

PubMed1993

[Evaluation of the clinical benefit of decompression hemicraniectomy in intracranial hypertension not controlled by medical treatment].

Through the findings in the literature on the basis of 9 personal cases, we review the indications and value of decompressive hemicraniectomy with plasty of the dura mater in cases of medically uncontrolled and decompensated intracranial hypertension. Seven patients had a pseudo-tumoral brain infarction. Five patients survived and their functional recovery is consistent with an autonomous daily life. Another patient with acute traumatic sub-dural haemorrhage died. The ninth patient had presuppurative encephalitis and recovered with no disability. At the time of surgery, all the patients were comatose with herniation of the mesencephalon (n = 3), uncal transtentorial herniation which was either unilateral (n = 4) or bilateral (n = 2). ICP was between 25 and 60 mmHg before the operation. After flap removal, ICP decreased by 15% and, after opening of the dura, it fell a further 70%. In 6 patients we were able to carry out continued post-operative monitoring of ICP, which stayed below 50% of initial values. Decompressive hemicraniectomy is an effective means of treating ICH caused by carotid cerebrovascular accidents with a high degree of edema, where mortality rises to 70-85% when only medical treatment is administered. No haemorrhagic complications, which can occur during hemispherectomies, were observed during decompression.

Adolescent↗

PubMed1993

[The neurosurgeon's role in the treatment of cerebral arteriovenous malformations. A study of a series of 100 cases and review of the literature].

The Neurosurgeons's place in the management of cerebral A.V.M.'s is discussed in the light of a personal experience and of the review of the neurosurgical literature. A personal series of 100 treated patients is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated afterwards (1989-1992). A.V.M.'s were classified in five grades according to the Spetlzer's Grading System. Three techniques of treatment were used: Surgical Resection, Intravascular Embolization (cyanoacrylate) and Radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the diminution of the "embolization and resection" group, which until then was predominantly used, for the low-grade A.V.M.'s (I.II.III) and for the high grade A.V.M.'s (IV.V) as well. Overall, for the low grade A.V.M.'s, the treatment of choice was the surgical resection (79% of cases), with a preoperative embolization in one half of these cases; the other A.V.M.'s were irradiated, with various combinations. For the high-grade A.V.M.'s, the treatment of choice was the intravascular embolization (95% of cases), either alone, or followed by exeresis (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration due to treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%) and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patient's age. More favourable results were obtained for low grade A.V.M.'s (93%) than for high grade A.V.M.'s (60%). For the low grade A.V.M.S. the evolution form 1989 on (favourable outcome increasing from 89% to 96%) occurred with the suppression of death cases. For the high grade A.V.M.'s, the evolution from 1989 on (favourable outcome increasing from 46% to 78%), occurred with the decreasing of the deficit cases. The angiographic eradication was strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards A.V.M.'s. The surgical management which was predominantly used at the beginning gave progressively way to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗

PubMed1993

[Teflon wrapping in cerebral aneurysm surgery. A technical note].

Wrapping is a well-known alternative technique when clipping the aneurysm is by no means possible or when it seems necessary to complete an imperfect clip. In 22 operated cases of intracranial aneurysm, we recently experienced pledgets of Teflon arranged and then fixed by drops of fibrin sealant. We used this technique in the following operative circumstances: to reinforce the ectatic base of the clipped aneurysm (11 cases); to wrap a pre-aneurysmal ectasia distant from the ruptured aneurysm (5 cases); to minimize the compression due to the clip to an adjacent cranial nerve or artery (6 cases). So far no complication was noted in relation to this technique. We then propose this technique of wrapping or interposing Teflon as an alternative to the other well-known techniques using autogenous tissue, gelatin sponge, cotton or other synthetic coatings or glue. Up to now, no known material received a worldwide approval for its complete innocuity and/or efficiency. Nowadays, in neurosurgical microvascular decompression and in cardiovascular surgery Teflon is widely and satisfactorily used. Its biologic tolerance is known to be good. This may apply in this new indication, and we would like recommend its practical use. However, for reliability and safety, there is an obvious need for a long-term clinical follow-up and an experimental controlled study as well.

Constriction↗

PubMed1992

Surgical management of unruptured intracranial aneurysms. Personal experience with 37 cases and discussion of the indications.

The authors report a series of 37 cases of unruptured aneurysms, admitted and operated upon over a 5 year period (1985-1990), which represents an incidence of 18% of the total number of aneurysm patients operated upon during this period. These unruptured aneurysms were discovered in 4 types of circumstances: 1) Associated with a ruptured aneurysm but treated in a second procedure (9 cases); 2) After a transient ischaemic attack (6 cases); 3) After a cerebral haemorrhage of a different origin (3 cases), 4) After the onset of various neurological symptoms other than SAH (19 cases). Giant aneurysms (over 2.5 cm in diameter) are excluded from this series. Overall these 37 patients harboured 52 aneurysms, and 1 patient was operated upon on both sides. 27 aneurysms (52%) were located on the right side, 15 (29%) on the left side, and 10 (19%) on the midline. In the immediate post operative period, 1 patient died (2.6%) and 8 patients (21%) presented various complications. The outcome at 6 months was: death 2.6%, moderately disabled 8%, good recovery 89%. The arguments in favour of, or against, the surgical treatment of unruptured aneurysms are discussed in view of the literature. In favour of prophylactic surgery are: 1) The rather poor overall outcome following aneurysm rupture (including deaths before admission); 2) The rather good outcome of surgery in published series of unruptured aneurysms. The data of the natural history of the unruptured aneurysm are more questionable: in this view, surgery seems to be recommended in young patients with an easily accessible aneurysm and being in a good clinical condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗