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Could CHF, ASD And Bicuspid Aortic Valve With Moderate Aortic Stenosis Lead To SVD?
Question: Hi Dr. Olsi,
I asked you a question a few weeks ago regarding MS. I also asked a neuroradiologist and was told that the white hyperintensities on my brain are not in the more common areas where MS is found (and I don't have any lesions on my spine - thoracic or cervical) so while MS remains possible, it's not as likely (I know you had said the same thing).
Instead, they suspect that the lesions are either from a prior infection/injury, from migraines, from nothing (they said they can be seen in healthy people), or from small vessel disease.
I'd like to get your insight into the latter - small vessel disease. In my gut, I feel as though these lesions are vascular. I don't have the typical causes of small vessel disease - I'm not hypertensive and I don't have clogged arteries. However, I have a very extensive cardiac history and I'm wondering if that could be the cause.
My history is as follows:
Congestive heart failure at one week old
Severe co-arctation of the aorta repaired at 8 days old and again at five years old (I now have a small aneurysm at the repair site)
Atrial Septal Defect with both left to right and right to left shunting (unrepaired)
Bicuspid aortic valve (unrepaired) with moderate aortic stenosis
Occluded IVC
Subaortic membrane
Mitral valve regurgitation and torn chordae
I also had the beginning stages of pulmonary hypertension at my last heart XXXXXXX (eight years back)
Besides that, I am healthy and I remain fairly free of symptoms. I have leg swelling, heart palpitations, and I struggle at altitude, but I feel pretty good. I do not have any factors of typical heart disease - I am thin, I don't smoke, I work out regularly, and my blood pressur is low. But I do have it in my family.
I am followed very closely and have essentially been told that my heart works much better than it should and until it starts to not work as well, they'll monitor me yearly. They have talked about repairing the ASD but I'm still on a wait and see protocol.
So, with all of that, I'm curious if these lesions could indeed be vascular. They were not viewable on a 2014 MRI, but that MRI was done in the ER and read by the ER doctor and not a neuroradiologist so I'm assuming they could have been missed. It was also a very short MRI so I don't know how many images were taken.
I am most concerned about my risk of stroke. I am already at a high risk because of my cardiovascular issues and I'm curious if these hyperintensities place me at a higher risk. However, the lesions have not worsened in two years.
Where I live there is a neurovascular clinic that specializes in neuro issues related to vascularity. I'm curious if you think it would be worth getting a consult from them.
Thank you again.
I asked you a question a few weeks ago regarding MS. I also asked a neuroradiologist and was told that the white hyperintensities on my brain are not in the more common areas where MS is found (and I don't have any lesions on my spine - thoracic or cervical) so while MS remains possible, it's not as likely (I know you had said the same thing).
Instead, they suspect that the lesions are either from a prior infection/injury, from migraines, from nothing (they said they can be seen in healthy people), or from small vessel disease.
I'd like to get your insight into the latter - small vessel disease. In my gut, I feel as though these lesions are vascular. I don't have the typical causes of small vessel disease - I'm not hypertensive and I don't have clogged arteries. However, I have a very extensive cardiac history and I'm wondering if that could be the cause.
My history is as follows:
Congestive heart failure at one week old
Severe co-arctation of the aorta repaired at 8 days old and again at five years old (I now have a small aneurysm at the repair site)
Atrial Septal Defect with both left to right and right to left shunting (unrepaired)
Bicuspid aortic valve (unrepaired) with moderate aortic stenosis
Occluded IVC
Subaortic membrane
Mitral valve regurgitation and torn chordae
I also had the beginning stages of pulmonary hypertension at my last heart XXXXXXX (eight years back)
Besides that, I am healthy and I remain fairly free of symptoms. I have leg swelling, heart palpitations, and I struggle at altitude, but I feel pretty good. I do not have any factors of typical heart disease - I am thin, I don't smoke, I work out regularly, and my blood pressur is low. But I do have it in my family.
I am followed very closely and have essentially been told that my heart works much better than it should and until it starts to not work as well, they'll monitor me yearly. They have talked about repairing the ASD but I'm still on a wait and see protocol.
So, with all of that, I'm curious if these lesions could indeed be vascular. They were not viewable on a 2014 MRI, but that MRI was done in the ER and read by the ER doctor and not a neuroradiologist so I'm assuming they could have been missed. It was also a very short MRI so I don't know how many images were taken.
I am most concerned about my risk of stroke. I am already at a high risk because of my cardiovascular issues and I'm curious if these hyperintensities place me at a higher risk. However, the lesions have not worsened in two years.
Where I live there is a neurovascular clinic that specializes in neuro issues related to vascularity. I'm curious if you think it would be worth getting a consult from them.
Thank you again.
Brief Answer:
Doesn't look vascular.
Detailed Answer:
Hello again, thanks for coming back to HealthcareMagic.
Given the issues you've had with your heart and aorta your worry is understandable. However I do not think it is small vessel disease, or at least it is unlikely. Small vessel disease can be found in the setting of many different conditions, but not those you mention. It is true that heart issues like abnormal rhythm or dilatation may create blood clots which can cause strokes. However stroke from a heart origin do not involve small vessels, they usually involve big and middle size arteries with cortical lesions. So they are not related to small vessel disease.
Furthermore the fact they weren't noticed in 2014 is another argument against it, small vessel disease is more gradual and progressive in nature doesn't happen abruptly to then stop suddenly. I understand that it was an ER MRI and not all sequences may have been done, but still I am sure it has included at least the FLAIR sequences in it, part of every MRI, which are more than enough to evidence such lesions like in small vessel disease, it's not something which can be missed.
So I don't think the findings are vascular in nature and I wouldn't recommend to necessarily go to a clinic specialized in vascular neurology.
I hope to have been of help.
Doesn't look vascular.
Detailed Answer:
Hello again, thanks for coming back to HealthcareMagic.
Given the issues you've had with your heart and aorta your worry is understandable. However I do not think it is small vessel disease, or at least it is unlikely. Small vessel disease can be found in the setting of many different conditions, but not those you mention. It is true that heart issues like abnormal rhythm or dilatation may create blood clots which can cause strokes. However stroke from a heart origin do not involve small vessels, they usually involve big and middle size arteries with cortical lesions. So they are not related to small vessel disease.
Furthermore the fact they weren't noticed in 2014 is another argument against it, small vessel disease is more gradual and progressive in nature doesn't happen abruptly to then stop suddenly. I understand that it was an ER MRI and not all sequences may have been done, but still I am sure it has included at least the FLAIR sequences in it, part of every MRI, which are more than enough to evidence such lesions like in small vessel disease, it's not something which can be missed.
So I don't think the findings are vascular in nature and I wouldn't recommend to necessarily go to a clinic specialized in vascular neurology.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. I was told that my underlying heart condition is the result of a connective tissue disorder that puts me at higher risk for aneurysms (brain and aortic) and makes all the vessels in my body more "elastic" than they should be. Could that be a cause?
Seeing how it hasn't changed in two years, would you recommend continued surveillance at all? I have a history of migraines as well so I always wonder if that's the cause.
I also had a minor head injury in the year after the 2014 MRI and before the 2015 one. I know trauma can cause these but I'm curious how bad the trauma needs to be. My injury was mild - I slipped on ice and fell straight back onto my head onto a driveway. I wasn't knocked out but I was disoriented for a moment and had a headache for a few days.
Seeing how it hasn't changed in two years, would you recommend continued surveillance at all? I have a history of migraines as well so I always wonder if that's the cause.
I also had a minor head injury in the year after the 2014 MRI and before the 2015 one. I know trauma can cause these but I'm curious how bad the trauma needs to be. My injury was mild - I slipped on ice and fell straight back onto my head onto a driveway. I wasn't knocked out but I was disoriented for a moment and had a headache for a few days.
Brief Answer:
Connective tissue conditions increase risk of stroke, unlikely in your case
Detailed Answer:
Sorry for answering so late, it has been a hectic day.
Thank you for the additional information! It might have been useful to know the specific condition you were diagnosed with (if there was a specific diagnosis - there are connective tissue conditions which remain undetermined), might be more specific in speaking about possible vascular complications.
Connective tissue disorders are often associated with an increased stroke risk, so you are an individual in which vascular complications should be considered anytime there is a new neurological symptom. As I said it might be easier if there was a more specific diagnosis, but from what you describe it seems that in your case it is the bigger size vessels which are included. Small vessel walls are differently composed, have different characteristics. So in connective tissue conditions affecting big vessels usually stroke happens due to aneurysms as you've been mentioned or due to greater likelihood of dissections (tears in blood vessel walls leading to clot formation and narrowing). That is why I doubt that is your case, it's not the mechanism behind your lesions. So together with the previously mentioned fact that lesions appeared all from one year to the other to then stop, makes it unlikely that the lesions are due to the vascular damage from the connective tissue condition present since birth.
As for surveillance, as I said if there is a new symptom it should be taken seriously, the threshold for clinical suspicion requiring MRI imaging should be lower in your case, MRI imaging with vessel evaluation would be necessary. If on the other hand there are no new symptoms then would still repeat imaging but in progressively longer intervals, I would say in 2 years.
Regarding the head injury you mention, there is not a precise answer, there are many factors apart from the intensity of impact such as the angle of the impact and genetic susceptibility, there are no precise rules. However from clinical everyday experience I would say that it is unlikely that that kind of trauma alone caused all those findings.
Let me know if I can further assist you.
Connective tissue conditions increase risk of stroke, unlikely in your case
Detailed Answer:
Sorry for answering so late, it has been a hectic day.
Thank you for the additional information! It might have been useful to know the specific condition you were diagnosed with (if there was a specific diagnosis - there are connective tissue conditions which remain undetermined), might be more specific in speaking about possible vascular complications.
Connective tissue disorders are often associated with an increased stroke risk, so you are an individual in which vascular complications should be considered anytime there is a new neurological symptom. As I said it might be easier if there was a more specific diagnosis, but from what you describe it seems that in your case it is the bigger size vessels which are included. Small vessel walls are differently composed, have different characteristics. So in connective tissue conditions affecting big vessels usually stroke happens due to aneurysms as you've been mentioned or due to greater likelihood of dissections (tears in blood vessel walls leading to clot formation and narrowing). That is why I doubt that is your case, it's not the mechanism behind your lesions. So together with the previously mentioned fact that lesions appeared all from one year to the other to then stop, makes it unlikely that the lesions are due to the vascular damage from the connective tissue condition present since birth.
As for surveillance, as I said if there is a new symptom it should be taken seriously, the threshold for clinical suspicion requiring MRI imaging should be lower in your case, MRI imaging with vessel evaluation would be necessary. If on the other hand there are no new symptoms then would still repeat imaging but in progressively longer intervals, I would say in 2 years.
Regarding the head injury you mention, there is not a precise answer, there are many factors apart from the intensity of impact such as the angle of the impact and genetic susceptibility, there are no precise rules. However from clinical everyday experience I would say that it is unlikely that that kind of trauma alone caused all those findings.
Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr. Olsi - I have one more question regarding this. So, as I mentioned I had an MRI in 2014 that came back normal. But I actually had two MRIs, one in March and then one in the very beginning of April. The reason was the ER MRI didn't use contrast and my doctor wanted contrast used (and she wanted to do an MRA as well).
Anyway, I was able to get the ER MRI images and I do not see any of they hyperintensities on there. However, the MRI/MRA I had two weeks later - I got that disc as well. On it, I can see the hyperintensities as plain as day. I'm sure they were there for the ER MRI too (I can't imagine that they developed over a two week span), but they didn't show for whatever reason.
So, on the 2014 MRI/MRA all the hyperintensities reported on the MRI in 2015 and onward show up. But the radiologist report was normal. I'm wondering if there is a reason why they wouldn't mention these? Are they viewed as incidental findings? The second MRI took place through my cardiologist and was read by radiologists who work with cardio patients. I don't know if they expect to see hyperintensities in the cardiology population and so they don't mention them or what. But they were definitely there. So I'm just curious is hyperintensities are always mentioned. The only thing the radiology report said was one of my cerebral arteries was smaller on the right than the left and that it was likely a normal variant.
Thank you again.
Anyway, I was able to get the ER MRI images and I do not see any of they hyperintensities on there. However, the MRI/MRA I had two weeks later - I got that disc as well. On it, I can see the hyperintensities as plain as day. I'm sure they were there for the ER MRI too (I can't imagine that they developed over a two week span), but they didn't show for whatever reason.
So, on the 2014 MRI/MRA all the hyperintensities reported on the MRI in 2015 and onward show up. But the radiologist report was normal. I'm wondering if there is a reason why they wouldn't mention these? Are they viewed as incidental findings? The second MRI took place through my cardiologist and was read by radiologists who work with cardio patients. I don't know if they expect to see hyperintensities in the cardiology population and so they don't mention them or what. But they were definitely there. So I'm just curious is hyperintensities are always mentioned. The only thing the radiology report said was one of my cerebral arteries was smaller on the right than the left and that it was likely a normal variant.
Thank you again.
Brief Answer:
If present should be mentioned.
Detailed Answer:
Hello again!
If the hyperintensities were visible they should be mentioned in the report, even if they are considered by the radiologist to be incidental he still should mention them, it is his duty to describe, as it is the duty of the doctor ordering the MRI to have the final say if they are relevant or not. In your case being only 39 years old it is even more imperative to mention them, can't be brushed aside as chronic changes in a 90 years old patient (should be mentioned in that case as well mind you).
Since you seem to have the MRI discs at your disposal, if you want me to I could have a look. Best way to do that preserving image quality is to open in your file explorer zip the folder with the images in a single file (or the whole disc content if unsure) and upload the file to a file sharing service (say google drive or dropbox) and provide the link for me to download and view. If you want me to that is, you still have a free follow up question remaining, can upload all the MRIs. You may upload the reports as well as photos in the reports section.
If present should be mentioned.
Detailed Answer:
Hello again!
If the hyperintensities were visible they should be mentioned in the report, even if they are considered by the radiologist to be incidental he still should mention them, it is his duty to describe, as it is the duty of the doctor ordering the MRI to have the final say if they are relevant or not. In your case being only 39 years old it is even more imperative to mention them, can't be brushed aside as chronic changes in a 90 years old patient (should be mentioned in that case as well mind you).
Since you seem to have the MRI discs at your disposal, if you want me to I could have a look. Best way to do that preserving image quality is to open in your file explorer zip the folder with the images in a single file (or the whole disc content if unsure) and upload the file to a file sharing service (say google drive or dropbox) and provide the link for me to download and view. If you want me to that is, you still have a free follow up question remaining, can upload all the MRIs. You may upload the reports as well as photos in the reports section.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I have put few of the images here: https://app.box.com/s/5yz7tds27dhnvtxuoj93odcecjgbjodc
It has the axial T1 images first which don't show anything but the diffuse and flair images show the hyperintensity. The T2 shows it too but I didn't upload them.
There were a few smaller hyperintensities but this one is the most obvious and I'm surprised they didn't mention it. Like I said, this MRI was from 2014 and it came back as normal except for one right artery being smaller and that it was likely a natural variant (maybe they were referring to this hyperintensity?).
They did not say anything else. The most recent MRI I had was 3 years after these images and the hyperintensities did not change. They look exactly the same as they did. I think the big one is possibly smaller than it was.
So, basically, I'm not sure why they didn't mention this or if they did think it was an incidental finding.
I have been told by cardiologists a few things that might be worth noting. One is that white matter hyperintensities are very common in congenital heart disease patients, especially those who had cyanotic events (which I did in infancy). So I guess it's possible that they've been there forever and the radiologist expected to see them and didn't mention it because of that. I had no MRIs in childhood.
I was also told that the cells that make up the aorta and the brain are the same (neural stem cells?) and that because my aorta has something wrong with it, it's more likely that the arteries in my brain will be weakened too. Which is why they screen me for aneurysms.
The report said
There is asymmetry in size of the A1 segment of bilateral anterior cerebral arteries, smaller on the right, likely a normal variant.
-- IMPRESSION --
Normal MRI of the brain with and without contrast
It has the axial T1 images first which don't show anything but the diffuse and flair images show the hyperintensity. The T2 shows it too but I didn't upload them.
There were a few smaller hyperintensities but this one is the most obvious and I'm surprised they didn't mention it. Like I said, this MRI was from 2014 and it came back as normal except for one right artery being smaller and that it was likely a natural variant (maybe they were referring to this hyperintensity?).
They did not say anything else. The most recent MRI I had was 3 years after these images and the hyperintensities did not change. They look exactly the same as they did. I think the big one is possibly smaller than it was.
So, basically, I'm not sure why they didn't mention this or if they did think it was an incidental finding.
I have been told by cardiologists a few things that might be worth noting. One is that white matter hyperintensities are very common in congenital heart disease patients, especially those who had cyanotic events (which I did in infancy). So I guess it's possible that they've been there forever and the radiologist expected to see them and didn't mention it because of that. I had no MRIs in childhood.
I was also told that the cells that make up the aorta and the brain are the same (neural stem cells?) and that because my aorta has something wrong with it, it's more likely that the arteries in my brain will be weakened too. Which is why they screen me for aneurysms.
The report said
There is asymmetry in size of the A1 segment of bilateral anterior cerebral arteries, smaller on the right, likely a normal variant.
-- IMPRESSION --
Normal MRI of the brain with and without contrast
Brief Answer:
Visible, should've been mentioned. Anyway same thoughts as before.
Detailed Answer:
Thank you for the images. I wish you could've uploaded the full exam but it's ok. By the way you say you haven't, but you do have uploaded the T2 images. I am afraid the diffusion images are not the best ones (there are two sets of images in the DWI series, it's the other set which shows acute lesions). Anyway don't fret too much about it.
In those available images on FLAIR and T2 one can see one of the lesions, the one in the right temporal lobe mentioned in the 2015 MRI report as well. It may well be due to the hypoxia in infancy as you've been told, but still the radiologist should report that, as I said it's not for him to judge that. He may give his opinion on the nature naturally, but not leave it out of the report.
As for the asymmetry in A1 size such variations in size are very common, nothing to worry about that as you've been told.
Judging from that lesion alone I do not think it likely to be due to classic small vessel disease, meaning not likely to be an evolving progressive process.
As for the comment on the cells in the aorta being the same as those in the brain, I do not think they meant the brain nerve cells themselves but the cells in the walls of the blood vessels supplying the brain with blood. It is in these blood vessels that aneurysms develop as you were told. As I said it is a process involving major big or medium size vessels, not the tiny ones involved in small vessel disease.
So more or less my opinions remain the same as in previous answers. Wishing you good health.
Visible, should've been mentioned. Anyway same thoughts as before.
Detailed Answer:
Thank you for the images. I wish you could've uploaded the full exam but it's ok. By the way you say you haven't, but you do have uploaded the T2 images. I am afraid the diffusion images are not the best ones (there are two sets of images in the DWI series, it's the other set which shows acute lesions). Anyway don't fret too much about it.
In those available images on FLAIR and T2 one can see one of the lesions, the one in the right temporal lobe mentioned in the 2015 MRI report as well. It may well be due to the hypoxia in infancy as you've been told, but still the radiologist should report that, as I said it's not for him to judge that. He may give his opinion on the nature naturally, but not leave it out of the report.
As for the asymmetry in A1 size such variations in size are very common, nothing to worry about that as you've been told.
Judging from that lesion alone I do not think it likely to be due to classic small vessel disease, meaning not likely to be an evolving progressive process.
As for the comment on the cells in the aorta being the same as those in the brain, I do not think they meant the brain nerve cells themselves but the cells in the walls of the blood vessels supplying the brain with blood. It is in these blood vessels that aneurysms develop as you were told. As I said it is a process involving major big or medium size vessels, not the tiny ones involved in small vessel disease.
So more or less my opinions remain the same as in previous answers. Wishing you good health.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you again. I'm going to upload the entire MRI I had in the ER. The one that I uploaded above was a few weeks later and it's on a disc with a whole bunch of files and it won't let me upload just the one study.
But, I'd rather have you look at this one. I was told that this MRI was totally normal and I do not see the hyperintenisty (not the big one) even though it's clearly there a few weeks later.
I went to the ER in 2014 because I thought I was having a stroke. They diagnosed me with an ocular migraine (but I only had it in one eye - my left, which is why I thought it was a stroke). The whole experience was strange and I felt as though they blew me off because of my age (I was 36 at the time). But, I'm wondering if you can look at this MRI and let me know if you see any signs of stroke.
It is uploaded here:https://appYYYY.com/XXXX
But, I'd rather have you look at this one. I was told that this MRI was totally normal and I do not see the hyperintenisty (not the big one) even though it's clearly there a few weeks later.
I went to the ER in 2014 because I thought I was having a stroke. They diagnosed me with an ocular migraine (but I only had it in one eye - my left, which is why I thought it was a stroke). The whole experience was strange and I felt as though they blew me off because of my age (I was 36 at the time). But, I'm wondering if you can look at this MRI and let me know if you see any signs of stroke.
It is uploaded here:https://appYYYY.com/XXXX
Brief Answer:
No sign of stroke.
Detailed Answer:
I reviewed the MRI images you sent. I can confirm that there is no stroke in it.
It's something which can be stated pretty confidently, the necessary sequences to detect stroke are done and there is no changes neither on DWI nor on FLAIR sequences, the two most sensitive sequences for ischemic stroke, nor is there any sign of hemorrhage in GRE sequences which detect hemorrhage. So they were perfectly correct in excluding stroke.
The lack of the lesions on this previous MRI would also exclude them being due to cyanotic events in infancy as well, would have been visible.
No sign of stroke.
Detailed Answer:
I reviewed the MRI images you sent. I can confirm that there is no stroke in it.
It's something which can be stated pretty confidently, the necessary sequences to detect stroke are done and there is no changes neither on DWI nor on FLAIR sequences, the two most sensitive sequences for ischemic stroke, nor is there any sign of hemorrhage in GRE sequences which detect hemorrhage. So they were perfectly correct in excluding stroke.
The lack of the lesions on this previous MRI would also exclude them being due to cyanotic events in infancy as well, would have been visible.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
So they weren't there but then they were three weeks later. That seems like a small window for them to appear. Is it possible for an MRI to miss a stroke or to have a stroke and not know it?
I'm curious about the ADC images - series 9, specifically. There is a darker area on images 12 and 13 where the bigger lesion appears three weeks later. Does that mean anything? I think it might just be CSF fluid.
I'm curious about the ADC images - series 9, specifically. There is a darker area on images 12 and 13 where the bigger lesion appears three weeks later. Does that mean anything? I think it might just be CSF fluid.
Brief Answer:
MRI would detect stroke.
Detailed Answer:
The answer is no, it is not possible to have missed a stroke. It could be missed on a CT scan, but not on MRI. MRI is the best exam to detect a stroke and the MRI you uploaded was of an adequate quality, there weren't moving artifacts or lack of proper sequences which would be possible causes for missing it. That is why I stressed in my previous answer that I was pretty confident about it.
As for the images you refer to, it is true there are some hypointense areas, not only in the temporal lobe but also the right pons. However ADC images are not interpreted alone, together with DWI they are part of the so called diffusion sequences and are interpreted together with DWI images. In ischemic lesions appear as hyperintense (bright) on DWI and hypointense (dark) in ADC as early as minutes after the onset of stroke (that is why they are vital in stroke, far from the best in image quality and resolution, but positive right away). After about 6 hours they appear on FLAIR and later on other sequences as well. So if there were DWI changes with those ADC changes it would show a stroke, but the lack of corresponding changes in those areas in the DWI means they are not significant in my opinion.
MRI would detect stroke.
Detailed Answer:
The answer is no, it is not possible to have missed a stroke. It could be missed on a CT scan, but not on MRI. MRI is the best exam to detect a stroke and the MRI you uploaded was of an adequate quality, there weren't moving artifacts or lack of proper sequences which would be possible causes for missing it. That is why I stressed in my previous answer that I was pretty confident about it.
As for the images you refer to, it is true there are some hypointense areas, not only in the temporal lobe but also the right pons. However ADC images are not interpreted alone, together with DWI they are part of the so called diffusion sequences and are interpreted together with DWI images. In ischemic lesions appear as hyperintense (bright) on DWI and hypointense (dark) in ADC as early as minutes after the onset of stroke (that is why they are vital in stroke, far from the best in image quality and resolution, but positive right away). After about 6 hours they appear on FLAIR and later on other sequences as well. So if there were DWI changes with those ADC changes it would show a stroke, but the lack of corresponding changes in those areas in the DWI means they are not significant in my opinion.
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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