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Study Leave semester 2 year 1 > Week 8 > Flashcards

Week 8 Flashcards

1
Q

Give me the exact definition of stroke

A

Blocked or ruptured blood vessel in the brain causing a failure of neuronal function, leading to some deficit in brain function

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2
Q

4 causes of stroke

A

Blockage with thrombus or coke
Disease of vessel walk
Disturbance of normal properties of blood
Rupture of vessel wall (haemorrhage)

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3
Q

What are the two types of strokes?

A

Infarction
Haemorrhage

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4
Q

What’s haemorrhage vs ischaemic stroke?

A

Haemorrhage/blood leaks into brain tissue

Clot blocks blood supply to an area of the brian

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5
Q

3 diseases that can block blood vessels?

A

Small artery diease
Large artery disease
Clot coming from the heart

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6
Q

Areas of bifurcation eg carotid vessels tend to be areas of what , and therefore what

A

Shear force, lots of turbulence, so atheroma’s develop

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7
Q

What could happen after an atheroma develops

A

Clot forms on top and then the clot breaks eg and can go up internal carotid

Eh area of plaque around bifurcation

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8
Q

An example of large vessel disease causing stroke?

A

Carotid diseas

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9
Q

Cardioembolic stroke is due to what

A

A large vessel occlusion.

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10
Q

Commonest cause being cardioembolic stroke

A

Atrial fibrillation eg clot forms in atrial appendage, clot to cerebral vessels

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11
Q

Penumbra is what

A

Reversible injured brain tissue around ischemic core
Just not getting enough oxygen and glucose to function, that’s all

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12
Q

How soon after penumbra forms does the tissue die

A

24-36 hours after the stroke

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13
Q

Commonest cause of small vessel disease?

A

Lacunar stroke

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14
Q

Which vessel blocked in lacunar stroke?

A

Well.. it’s the large vessels, they have little tiny branches going off deep into the brain tissue, and it’s these that are blocked. Just affects small part of brain therefore

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15
Q

What are lacunar strokes associated with?

A

Hypertension
Thickening of the wall of tiny vessels, making the lumen smaller

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16
Q

Rarer cause of large vessel stroke is carotid dissection, explain

A

Where the lining of the blood vessel tears and a thrombus forms

Could be due to trauma, or be idiopathic

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17
Q

What does carotid dissection look like on an angiogram?

A

Lumen kinda tapers, just kinda looks thin

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18
Q

Aortic arch plaque could lead to what

A

Brain infarctkon

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19
Q

Valve disease could lead to what

A

Brain imfarction

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20
Q

Left ventricle thrombi

A

Stroke

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21
Q

Intracranial stenosis could lead to what

A

Stroke

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22
Q

3 big risk factors for stroke?

A

Hypertension
Smoking
Waist to hip

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23
Q

Is diet a risk for stroke

A

Yah

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24
Q

Is physical activity a risk for stroke

A

Yah

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25
Q

Is: alcohol, stress/depression, diabetes, cardiac causes, risk for stroke?

A

Yah

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26
Q

Smoking is a risk factor for stroke

A

Yah

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27
Q

Ratio of ApoB to ApoA is responsible for risk for stroke?

A

Yah

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28
Q

Rough percentage of large vessel cause of stroke

A

About 20%

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29
Q

How many strokes are cryptogenic/no cause found?

A

30%

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30
Q

Haemorrhage mostly happens within big or small vessels

A

Small

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31
Q

Haemorrhage is often due to what (2)

A

Hypertension mostly!!!
Or amyloid

But also excess alcohol? Hypo cholesterolaemia, haemorrhagic transformation

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32
Q

What’s amyloid when referring to blood vessels, when referring to stroke

A

Where the vessels become glass-like, fracture easily, haemorrhage occurs easily

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33
Q

Is high cholesterol is associated with haemorrhage of blood vessels

A

No bro
It’s actually LOW cholesterol that’s associated with haemorrhage

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34
Q

Primary haemorrhage vs what in strokes

A

Occurring in tissue already damaged by an ischaemic event

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35
Q

Penumbra is getting blood supply (to not die)

A

Yes from collateral flow

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36
Q

Why is it important to know if penumbra?

A

Treatment is either: protect penumbra, or restore blood supply

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37
Q

Transient ischemic attack?

A

Transient ischaemia,
Ischaemia results from the failure of cerebral blood flow to part of the brain

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38
Q

Ischaemia results in varying degrees of what (2)

A

Hypoxia
Hypoglycaemia

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39
Q

In Ischaemia, there are two parts:

A

Ischemic core
Ischemic penumbra

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40
Q

Lack of oxygen: cells can die, or…

A

Use anaerobic metabolism for a while

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41
Q

Hypoxia = penumbra
Anoxia = ?

A

Infarction, leading to necrosis

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42
Q

Is stoke just penumbra or can you have ahayqwwb

A

A completed strike is infarction from anoxia

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43
Q

Once completed stroke, where does further damage come from?

A

Oedema, damage from swelling, water bursts from cells

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44
Q

Oedema does what to the brain

A

Kinda like squashes it

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45
Q

Surgical procedures if oedema in the brain?

A

Ask the surgeons to consider removing a flap of skull to allow brain to swell out the way- prevents mortality (but doesn’t restore function obvs)

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46
Q

When cells in penumbra switch to anaerobic metabolism, what’s released

A

Lactic acid

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47
Q

What could release of lactic acid in the brain do

A

Potential to destroy cells by disrupting the normal acid base balance

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48
Q

What happens when ATP reliant ion transport pumps fail

A

Membrane becomes depolarises
Influx of calcium and efflux potassium

So intracellular calcium high= excitatory amino acid glutamate = stimulates something = even more calcium

Excess calcium entry = Ischaemic cascade, excitotoxicity

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49
Q

After excititoxicity, (ischaemic cascade) what happens? (3)

A

Cell membrane broken down by phospholipases

More permeable so More Ions and harmful chemicals enter cell

Mitochondria break down, realising apoptotic factors into cell
Cells undergo apoptosis

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50
Q

What happens after ischaemic cascade, and then apoptosis, and therefore necrosis, =

A

It releases glutamate and toxins,
Toxins poison nearby neurons and glutamate overexcites them

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51
Q

Why does release of toxins after necrosis, resulting in loss of vascular structural integrity due to neurons being poisoned, lead to cerebral oedema?

A

Due to breakdown of protective blood brain barrier

So secondary progression of bleeding

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52
Q

How quickly does the excititoxicity occur?

A

Within minutes

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53
Q

Oxidative stress occurs how quickly?

A

Just over an hour ish

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54
Q

Post ischaemic inflammation and oedema following necrosis in a stroke, occurs over what time frame

A

Over two weeks

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55
Q

Disruption of blood supply can be caused by: (4)

A

Thrombus formation or embolus eg with atrial fibrillation
Atherosclerosis
Shock
Vasculitis

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56
Q

TIA is basically what

A

Neurological dysfunction secondary to ischaemia without infarction

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57
Q

What’s a crescendo TIA?

A

Two or more TIAs within a week

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58
Q

Presentation of a stroke: (sudden) (4)

A

Weakness of limbs
Fascial weakness
Speech disturbance
Visual or sensory loss

FAST
Face, arm, speech, time

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59
Q

Is the combined contraceptive pill a risk factor for stroke?

A

Yes

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60
Q

Angina, myo infarct and peripheral vascular disease is a risk factor for stroke

A

Yah

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61
Q

What’s the ROSIER tool for recognition of stroke in the emergency room

A

Based on clinical features and duration

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62
Q

For ROSIER tool, stroke is likely if the patient scores anything above what

A

0

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63
Q

NICe management of stroke: (4)

A

Admit patient to a specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain scan to exclude primary intracerebral haemorrhage
Aspirin 300mg stat (after the CT) and continued for 2 weeks

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64
Q

What can be used after the CT brain scan has excluded intracranial haemorrhage

A

Thrombolysis with alteplase

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65
Q

What’s alteplase

A

A tissue plasminogen activator, that rapidly breaks down clots

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66
Q

Treatment of hypertension is what acronym

A

ABCD

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67
Q

Explain treatment of hypertension acronym

A

ABCD

Angiotensin receptor blocker/ Angiotensin converting enzyme - end in sartan

Beta blockers - end in lol

Calcium channel blockers - end in dipine

Diuretics - end in pril

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68
Q

When might a thrombectomy be offered?

A

If an occlusion is confirmed on imaging, depending on time and location

Not used after 24 hrs since onset of symptoms

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69
Q

Why should blood pressure not be lowered during a stroke

A

Cuz this risks reducing perfusion to the brajb

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70
Q

Management of TIA

A

Start aspirin 300mg daily
And secondary prevention measures for cardiovascular disease

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71
Q

What specialist imaging for strokes?

A

Diffusion-weighted MRI/ CT is alternative
Carotid ultrasound for carotid stenosis

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72
Q

If carotid stenosis is suspected

A

Do carotid stenting

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73
Q

Endarterectomy is for what

A

Removing plaques

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74
Q

(4) secondary prevention of stroke? L

A

1) clopidrogrel 75mg once daily

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75
Q

Ace inhibitors do what

A

Well remember that angiotensin 2 constricts blood vessejs

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76
Q

What do we see in basilar artery strokes?

A

People can be very very sleepy, and find it difficult to keep awake

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77
Q

Effects post basilar artery stroke?

A

Heart beat and breathing affected

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78
Q

Coordination maintained by what part of the brain?

A

Cerebellum

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79
Q

What does the carotid system supply?

A

Most of the hemispheres, and cortical deep white matter

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80
Q

The vertebro-basilar system supplies the what

A

Brain stem, cerebellum and occipital loves

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81
Q

What’s the sensory sign of stroke?

A

Loss of feeling

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82
Q

What’s gaze palsy a sign of?

A

Stoke

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83
Q

Hemianopia is a sign of what

A

Stroke

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84
Q

In stroke most symptoms are what

A

Loss of something

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85
Q

Sudden loss of feeling with stroke is different to migraine how?

A

Migraine is mainly just pins and needles

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86
Q

What happens if the anterior cerebral artery is occluded? (3)

A

Paralysis of contra lateral foot and leg

Sensory loss over contra-lateral toes, foot and leg

Impairment of gait and stance

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87
Q

Why could a small lacunae stroke have a big affect?

A

Major deficit of all fibres tightly packed together like flowers in a vase

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88
Q

Posterior circulation of the brain is with with artery

A

Basilar

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89
Q

Nausea, vomiting, are common in a posterior circulation stroke

A

Yah

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90
Q

Pons is what

A

Motor

91
Q

Carotid bruits is associated with stroke

A

True

92
Q

Angina is associated with not only heart attacks, but what:

A

Stroke

93
Q

Previous TIA is a risk factor for what

A

Stroke

94
Q

Aortic aneurysm is a risk factor what what

A

Stroke

95
Q

Cocaine and alcohol abuse is a risk factor for what vascular thingy

A

Stroje

96
Q

Lots of haemorrhages are associated with what

A

Poor blood pressure r control

97
Q

Stroke incidence increases dramatically when blood pressure rises above what

A

160

98
Q

Hypertension is particularly associated with what type of stroke

A

Small vessel/ lacunar stroke

99
Q

Does diabetes increase incidence of stroke?

A

Yes
3 fold

100
Q

Smokers have a two fold increased risk of ischaemic stroke

A

True

101
Q

A high LDL can result in excessive amounts of what within the arterial wall

A

Cholesterol

102
Q

Is high LDL a risk of actor for stroke?

A

Not in itself, but in conjunction with hypertension, cigarette smoking, bad

103
Q

Small amounts of alcohol decrease risk of stroke

A

True

104
Q

Heavy drinking increases risk of stroke

A

True

105
Q

Obesity is a risk factor not only for vascular disease, but also

A

Stroke

106
Q

AF is risk factor for stroke

A

Yah

107
Q

Guess three purposes of treatment of stroke

A

Protect damaged brain before ischaemia becomes cell death

Get rid of the clot

Prevent the clot happening in the first place

108
Q

Benefit of thrombolysis is time dependant?

A

Yes
Within 90 minutes please

109
Q

At what time would harm increase over benefit for thrombolysis? (We don’t actually treat)

A

Past 4 and a half hours

110
Q

Why not thrombolyse a patient if too longer after eg after 4 1/2 hours?

A

High risk that they’d bleed into tissue

111
Q

Do you get a headache with stroke?

A

Not generally

112
Q

Get patients, admitted with ischaemic stroke, thrombolysised within what time frame?

A

30 mins of arrival

113
Q

What imaging in emergency department for stroke?

A

CT scan

114
Q

Why would perfusion CT be helpful if stroke in emergency department?

A

See if any tissue is viable

115
Q

Why are MRIs good in stroke treatment?

A

Can see good levels of infarcts

116
Q

What’s alteplase

A

Thrombolytic agent

117
Q

Glasgow Coma Scale asses what

A

Impairment of conscious level in response to defined stimuli

118
Q

Highest possible score in Glasgow coma scale?

A

15
= fully conscious

119
Q

Lowest possible score in the Glasgow Coma Scale?

A

3
(Coma or dead)

120
Q

What score is dead on Glasgow coma scale?

A

3

121
Q

What does the Glasgow coma scale rate on?

A

Motor responsiveness, verbal performance, and eye opening

122
Q

Could you literally put the thrombolysis in the artery eg basilar artery which has high mortality

A

Yah
Intra-arterial procedure
Put line in through groin, up into the basilar artery

123
Q

Where’s the sinotubular junction?

A

Defining point for where the aortic ‘root’ finishes

124
Q

Where does the ‘ascending aorta’ end?

A

At the brachiocephalic artery

125
Q

The aortic arch is what

A

The bit with the three arteries: starts at Brachiocephalic, the left carotid, and ends just after the left subclavian

126
Q

How many sinuses in the sinus of valsalva?

A

3

127
Q

Where do the coronary arteries come from?

A

Sinus if valsalva of aorta

128
Q

How many coronary sinuses are there out of the three sinuses of valsalva of the aorta?

A

2
There is one non-coronary artery

129
Q

What’s the junction between the sinus of valsalva and the ascending aorta called?

A

Sinotubular junction

130
Q

We measure the aortic root at three levels. What are they?

A

Sinotubular junction diameter

Sinus of valsalva diameter

Annulus diameter

131
Q

What’s the sinus of valsalva?

A

Abnormal dilatation of the aortic root

132
Q

What’s the annulus?

A

Where the aortic valve leaflets hinge/ gets attached to the myocardium

133
Q

The three leaflets/cusps of the aortic valance corresponds to a different sinus of valsalva

A

Yes
Eg right coronary cusp > right sinus of valsalva (and for left)
And. Eg
Non coronary cusp to non coronary sinus

134
Q

Basic histology of aorta:

A

Tunica intima
Tunica media
Tunica adventitia

135
Q

What is the tunica Adventitia?

A

Thin connective tissue layer

136
Q

What does the collagen in the tunica Adventitia do?

A

Prevents elastic arteries from stretching beyond their physiological limits during systole

137
Q

5 big risk factors for atherosclerosis?

A

Hypertension
Hypercholesteroleamia
Smoking
Diabetes
Genetics

138
Q

Atherosclerosis timeline?

A

Takes decades

139
Q

4 things that atherosclerosis can lead to

A

Myo infarct
Stroke
Peripheral vascular disease
Aneurysm

140
Q

What’s an aneurysm

A

Localised enlargement of an artery
Caused by weakening of a vessel walk

141
Q

What are the 3 types of anywrysms ?

A

True
False
Diseecting

142
Q

Two sub types of true aneurysm?

A

Saccular (1 side)
Fusiform (both sides)

143
Q

False aneurysm

A

Rupture of walk of aorta- contained by adventitia or surrounding soft tissue

144
Q

What type of aneurysm could occur in inflammation eg endocarditis?

A

False

145
Q

Marfans is collagen abnormality, lead to what aneurysm?

A

Trie

146
Q

What infections could lead to an aneurysm?

A

Mycotic/ syphillis

147
Q

Bicuspid aortic valve could lead to what

A

True aneurysm

148
Q

Why has a pseudo aneurysm have a high chance of rupture

A

Cuz walls are thinner

149
Q

5 signs and symptoms of aortic aneurysms

A

Breathlessness
Pulsating mass
Back pain
Dysphagia and hoarseness swallowing problems
Symptoms of dissection (sharp chest pain radiating to back)

150
Q

Why dysphagia and hoarseness in thoracic aneurysms?

A

Cuz compressing

151
Q

Two tests of choice for investigating thoracic aneurysms

A

Ct angiogram aorta to diagnose
MRI aorta to diagnose and follow up

152
Q

Why MRI aorta follow up test for aneurysms?

A

Because….. no radiation

153
Q

What’s aortic dissection?

A

Tear in the inner wall of the aorta
Blood forces the walls apart

154
Q

Are aortic dissections usually chronic or acute?

A

Acute usually
But also could be chronic

155
Q

5 risk factors for dissection

A

Hypertension
Atherosclerosis
Marfan’s syndrome
Bicuspid aortic valve
Trauma

156
Q

How could dissection = myo infarct

A

Because could involve coronary arteries

157
Q

How would dissection = stroke

A

If carotid arteiee

158
Q

What is cardiac tamponade??????????????

A

Pressure on heart when blood or fluid builds up in space between heart muscle and pericardium

159
Q

Aortic regurgitation could be caused by dilation of what part of the aorta

A

Ascending

160
Q

Type A (Stanford) is any aortic dissection that what

A

Involves ascending aorta, regardless of the site of origin

161
Q

Stanford , what’s type B dissection.

A

Doesn’t involve ascending aorta

162
Q

DeBakey classification of aortic dissection… type 3 is not involving ascending aorta…
What’s type 1 vs type 2?

A

Type 1= originates in ascending aorta, and is more
Type 2= ONLY ascending aorta

163
Q

How might an aortic dissection. Present?

A

Collapse maybe due to tamponade
Sharp pain, radiating to the back
Stroke if carotid arteries are involved

164
Q

Examination of carotid arteries

A

Reduced or absent peripheral pulses
Hypertension/hypotension
BP mismatch
Diastolic murmur -aortic regurgitation
Pulmonary oedema

165
Q

What scan confirms diagnosis of aortic dissection?

A

CT angiogram aorta

166
Q

ECG of aortic dissection might show what

A

ST elevation
Ischaemia indicating coronary involvement

167
Q

What might CXR show in aortic dissection?

A

Widened mediastinum

168
Q

What is the test of choice for diagnosing aortic dissection?

A

CT angiogram aorta

169
Q

How high is the mortality for aortic dissection?

A

About 50% pre hospital

170
Q

What does treatment of aortic dissection depend on?

A

Whether the dissection is type A or type B

171
Q

Both Type A and Type B aortic dissection involve blood pressure control with beta blockers, calcium channel blockers, IV nitrate etc.

But additional surgery is different how?

A

Type A = emergency surgery
Type b = per ur Amelia (Endo vascular) intervention

172
Q

Would you ever use IV nitrate for treatment of aortic dissection?

A

Yah

173
Q

Syphyllis predisposes patients to what

A

Thoracic aortic disease such as stenosis, aneurysm, thrombosis

174
Q

What’s takayusu arteritis

A

Granulomatous vasculitis

Can result in stenosis, aneurysm
Also thrombosis

Just weird stuff basically

175
Q

Because takayusu arteritis is basically inflammation, what does it involve treatment-wise

A

Steroids and immunosuppressive therapy

176
Q

What’s syphilis

A

As STD (that has cardiac manifestations)

177
Q

What will treatment of antibiotics prevent in syphilis

A

Late stage complications

178
Q

2 examples of cardiac manifestations of syphilis??????????

A

Syphilitic aortitis - aneurysm
Aortic regurgitation

179
Q

3 examples of congenital aortic aneurysm?????????????????????????

A

Bicuspid aortic valve
Coarctation
Marfans syndrome

180
Q

Why in bicuspid aortic valve,(congenital) are you prone to aneurysm and dissection

A

Reduced tensile strength bro

You can develop stenosis or regurgitation

MONITOR THE SITUATION BRO

181
Q

Coarctation is aortic narrowing WHERE

A

Close to where the the ductus arteriosus (pre birth) inserts/ where the ligamentum arteriosum is now

182
Q

What was the ductus arteriosus

A

It went between the primary artery and the aorta

183
Q

There are three types of coarctation, what are they and which one is worst

A

Pre-ductal
Ductal
Post-ductal

Pre ductal is worse OBVS YOU NINCOMPOOP

184
Q

Why cold legs in coarctation?

A

Reduced blood supply and reduced blood pressure in the legs

Therefore also poor leg pulses

185
Q

What’s the radial radial delay thingy with coarctation

A

Well bro

If before left subclavian artery = radial-radial delay, and RIGHT radial-femoral delay

But if after left subclavian artery = no radial-radial delay, and a right and left radio-femoral delay

186
Q

For coarctation, difference in radial radial thingy for before and after left subclavian artery????

A

If before left subclavian artery = radial-radial delay, and RIGHT radial-femoral delay

But if after left subclavian artery = no radial-radial delay, and a right and left radio-femoral delay

187
Q

Presentation of coarctation??? Severe vs less severe please

A

If severe, in infancy, = heart failure and failure to thrive

If less severe, = can present later in life with hypertension

188
Q

Diagnosis of coarctation with what imaging

A

CT
MRI

189
Q

What could you see on X-ray for coarctation?

A

Notching of the ribs

190
Q

What’s ‘notching of the ribs’

A

Image looks like that due to enlargement of intercostal arteries

191
Q

Marfans is caused by a mutation in which gene

A

Fibrillin 1

192
Q

What is Marfans

A

A connective tissues disease
Multi-system

193
Q

2 cardiac manifestations of Marfans???????

A

Aortic/mitral valve prolapse leading to regurgitation
Aortic aneurysm and dissection

194
Q

Connection between Marfans pregnancy and cardiac stuff

A

Pregnant marfaners = risk for aortic thoracic aneurysm and dissection is increased

195
Q

The most commonly affected area for aneurysm?

A

Ascending aorta

196
Q

The first time a Patient May become aware of an aneurysm is when

A

When it ruptures
Causing life threatening bleeding into mediastinum cavity
Very high mortality

197
Q

When do false aneurysms typically occur

A

After trauma, such as a road traffic accident or after surgery

198
Q

Which gender more commonly affected for aneurysms

A

Male

199
Q

Is Marfans a risk factor for aneurysms

A

Yah

200
Q

Why symptoms in aneurysms?

A

Due to taking up space in mediastibum

201
Q

Presentation symptom of aneurysm relating to chest

A

Pain

202
Q

Presentation symptom of aneurysm relating to trachea or left bronchus compression

A

Cough sob and Stridor

203
Q

Presentation symptom of aneurysm relating to phrenic nerve compression

A

Hiccups

204
Q

Presentation symptom of aneurysm relating to compression of oesophagus

A

Dysphagia (can’t swallow)

205
Q

Presentation symptom of aneurysm relating to compression of recurrent laryngeal nerve

A

Hoarse voice

206
Q

2 main investigations for aneurysm diagnosis?

A

Echocardiogram
CT or MRI angiogram

207
Q

Management for aortic aneurysm

A

Stop smoking
Healthy diet and exercise
Optimising management of hypertension, diabetes. And hyperlipidaemia

208
Q

3 modifying management options of aneurysms

A

Surveillance with regular imaging

TEVAR: thoracic endovascular aortic repair (with catheter inserted via femoral artery, for stent graft)

Open surgery: to remove section of the aorta with the defect in the wall and replace it with a synthetic graft

209
Q

3 complications of aortic aneurysm

A

Aortic dissection
Ruptured aneurysm
Aortic regurgitation

210
Q

If a ruptured aneurysm bleeds into the oesophagus, what happens

A

Haematesis (vomit blood)

211
Q

Ruptured aortic aneurysm bleeding into airways could lead to what

A

Haemoptysis

212
Q

Ruptured aneurysm which bleeding into the pericardial cavity = what

A

Cardiac tamponade (compression the the heart)

213
Q

Ruptured thoracic aneurysm often leads to what (as well as death) (3)

A

Severe chest pain or back pain
Haemodynamic instability (hypertension and tachycardia)
Collapse therefore

214
Q

Emergency open surgery is required for ruptured aortic aneurysm, explain

A

Replacement of affected section of the aorta with a synthetic graft

215
Q

What’s cardiac tamponade

A

Where the pericardial effusion is large enough to raise the intrapericardial pressure, squeeze heart

216
Q

Cardiac tamponade affects diastole and systole how

A

Reduced heart filling during diastole
Decreasing cardiac output during systole

217
Q

What’s pericarditis

A

Inflammation of the pericardium

218
Q

Cause of pericarditis

A

Idiopathic
Or
Viral

219
Q

What’s pericarditis treated with

A

NSAIDS

220
Q

How does pericarditis present

A

With chest pain and fever

221
Q

Could the Epstein Barr virus (like HIV, TB) cause pericarditis?

A

Yah

222
Q

Autoimmune conditions such as lupus and arthritis can causes pericarditis

A

Yah

223
Q

Open heart surgery and trauma could cause pericarditis

A

Yah

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