Cervical Artery Dissection: Implications for the Physical Therapist A Case Report from a Direct Access Environment


You receive a call from your friend and fellow DPT classmate to evaluate her neck… the patient herself is a physical therapist by occupation. A healthy and fit 29 year old female, 5’0″, 115lbs. She reports she is having some cervical musculoskeletal issues going on. She has an achy pain in the bilateral upper traps., levator scapula, and peri-cervical muscles. She is limited by pain with the following cervical motions: right side-bend, right rotation and extension. No signs of central or peripheral neurological issues.

You are an experienced PT and have completed many cervical manipulations on a patient like this and it’s the end of your day. So you are going to do a quick favor for a friend and manipulate her neck, complete some STM, and maybe some PROM/SNAGs/isometrics/METs or whatever your favorite manual therapy technique is. What could go wrong? She’s a therapist herself so she wouldn’t miss anything serious. Being that you are friends you want to do some “magic” giving her some relief of symptoms. So… snap, crackle, manip. You move into some PROM and she reports severe vertigo, nausea, double vision, and you notice hemi-facial asymmetries as she talks about her onset of symptoms. Now what?  Your table, your hands, your patient.

Okay, maybe that’s not how this case study ended… however everything up to performing the manipulation is accurate. If it wasn’t for a diligent physical therapist she very well could have ruined the friendship and in this case killed her, which would be biologically plausible.


The 29 year-old patient returns from an Alaskan vacation in June, 2011. This patient began to experience a dull ache behind her right eye which mimicked a typical headache that she has experienced prior. 4 weeks later, in July, she continued to have the pain but it was getting progressively worse, and now she experiences hemi-facial pain which corresponds with the intensity of her headache. As the headache increased, facial pain increased. She treated herself with Advil and various OTC medications.

Throughout the month of August, 2011 she checked herself into the ER due to a 9/10 pain in the right cervical region. The results for her four ER visits are as follows: 1) Brain CT Scan (-), 2) Brain MRI (-), 3) Brain MRV (-), 4) Brain MRA (-)… 4 times cleared by the emergency department and told it’s progressive migraines, please manage them with medications. The patient returns home very frustrated, exhausted due to lack of sleep from pain and now in what is a more consistent pain varying 5/10 to 9/10. The patient made an appointment with an Ophthalmologist due to the continued ache behind her right eye. Ophthalmologist’s diagnosis is a bad case of “twisted eye muscles” … huh? Yeah I’m serious. No joke. Patient continues to move along the health system (which is failing her) and is fed up. It’s now September 26th, 2011 and she now has sore traps and levator, peri-cervical and peri-scapular muscular pain, and she really would like some quick pain relief. Doesn’t matter if it’s short-term effects, she just needs some effect.

So.. who else will give her pain relief but that good friend and fellow physical therapist? The patient calls her friend and asks to be seen by her, even requesting manual therapy work to her cervical spine.

At this point the reader should take off his or her shoes and put on the shoes of the patient’s friend. Your friend was cleared by the ER 4 times with 4 negative image reports, was cleared by an ophthalmologist, and is a physical therapist herself. What could go wrong?

Patient walks into the clinic and the evaluation begins, as it should no matter who it is:

  • Direct Access Physical Therapy Visit
  • Demographics
    • 29 y/o, female, 5’0”, 115lbs
  • Chief Complaint
    • Hemi-Facial Pain
    • Right cervical and shoulder pain
    • R sided Headache
    • Right Orbital Pain
  •  Palpation
    • Tender to Nuchal Ligament, R Upper Trapezius, R Temple Region, R Cervical Extensors
  •  MMT
    • 5/5 Myotome UE, C-Spine not tested due to pain
  • Reflexes
    • 2+ bilaterally and Equal biceps, triceps, brachioradialis
    • Hoffman Test: Negative
  • Cervical ROM
    • R rotation, R SideBend, and Extension 75% limited
    • Shoulder ROM: WNL Bilaterally
  •  Sensation
    • Intact to light touch, Sharp/Dull, and Hot/Cold on Face and Upper Extremity
  • Cranial Nerve Test
    • All Normal

Due to the repetitive diagnosis of migraines the PT even tested with perfume, and light which had no change on her current pain. Subjectively that wasn’t an issue outside of the clinic anyway.

At this point it seems very straight-forward. However, regardless of the patient having been “cleared” by many medical professionals, her 3 months of progressively worse pain and hemi-facial pain is a concern for the PT. 

Next is the most important and concerning data from the evaluation and is also one of the most overlooked part of an outpatient physical therapy evaluation: Vitals…

  • Blood pressure: 265/138 mmHg
  • HR: 98 BPM

That’s not good.

The PT questioned the patient on her BP reading. The patient had been monitoring her blood pressure herself over the past month which had been high, but not that high. The patient noted a progressive increase in blood pressure since onset of symptoms and had been monitored each time by the ED.

At this point- Red Flag.. not treating. Constant pain, very high BP. The physical therapist gave her a name of a good neurologist to go see. Finally on 10/31/2011 the patient made it into the office of the neurologist. Upon exam the neurologist found blood located behind the right retina. His next question was

Do you feel or hear a thump in your head with your symptoms?

She responded with “yes, I feel a thump in my head with my symptoms.” After that he decided to order an MRA… wait… she already had an MRA, right? The previous MRA was only of the brain. What she needed was an MRA from Subclavian to the brain. The following images are the real images of this patient.

Left Vertebral Artery

Left Vertebral Artery

Right Vertebral Artery

Right Vertebral Artery

Vertebral Artery Dissection C5-Brainstem

Vertebral Artery Dissection C5-Brainstem

Axial View of Right VAD

Axial View of Right VAD

After consult with surgeons the risk of surgical correction was too high due to the proximity of the vertebral artery dissection to the brainstem. The patient was medically managed with Neurontin, HCTZ, and Aspirin.

So.. The what’s the take away from this case in bullet format… 

  • CAD will often manifest as musculoskeletal pain and dysfunction, which tends to lead them to conservative treatment first by chiropractors and physical therapists.(3)
  • The evidence is not clear on a cause-effect relationship of CAD secondary to manipulation, or if patients with pre-existing CAD are seeking treatment.(6-8)
  • However, recent publications support cervical manipulations are a potential cause of CAD, stroke, and death.(1-7)
  • A recent report(3) demonstrated 2 participants with unknown CAD died following chiropractic cervical manipulation.
  • Physical therapists need to be aware there is a population, albeit small, that possess underlying CAD that put the patient at risk for a vascular accident.
  • If Cervical Manipulative Therapy is a treatment of choice, patients should be screened for Ehlers-Danlos Syndrome, cardiovascular risk factors, previous traumas, previous CMT, and neurological/cranial nerve testing.(7)
  • Mobilization techniques provide similar results as cervical manipulation(9), and presumably with less stress to the vasculature structures, perhaps therapists should consider cervical mobilization as the intervention of choice.(5)

Closing Note:  As physical therapists it is our duty to decide how to treat our patients. No one in their right mind purposefully attempts to injure their patient or tries to lengthen treatment by means of withholding treatment. It is our job to decipher a collection of information like past experiences (clinicals, work, school), current literature, personal comfort level/confidence all while maintaining an awareness of potential bias and then putting together the best plan of care for our patient.

I hope this case study can increase the awareness of potential underlying issues that may contraindicate treatment and motivate readers to perform a good evaluation.

~Stephen Henry


1.Leon-Sanchez A, Cuetter A, Ferrer G. Cervical Spine Manipulation: An Alternative Medical Procedure with Potentially Fatal Complications. Southern Medical Journal [serial online]. February 2007;100(2):201-203. Available from: Academic Search Complete, Ipswich, MA. Accessed July 12, 2015.

2.Giossi A, Ritelli M, Pezzini A, et al. Connective tissue anomalies in patients with spontaneous cervical artery dissection.Neurology [serial online]. November 25, 2014;83(22):2032-2037. Available from: CINAHL, Ipswich, MA. Accessed July 12, 2015.

3.Thomas L, Rivett D, Attia J, Levi C. Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. July 2015;45(7):503-511. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed August 9, 2015.

4.Paciaroni M, Bogousslavsky J, Cerebrovascular Complications of Neck Manipulation. Eur Neurol 2009;61:112-118. Accessed August 9, 2015

5.Gross A, Hoving J, Bronfort G, et al. A Cochrane Review of manipulation and mobilization for mechanical neck disorders. Spine (03622436) [serial online]. July 15, 2004;29(14):1541-1548. Available from: CINAHL, Ipswich, MA. Accessed September 7, 2015.

6.Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. The Lancet. Neurology [serial online]. July 2009;8(7):668-678. Available from: MEDLINE, Ipswich, MA. Accessed September 7, 2015.

7.Thomas L, Rivett D, Attia J, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Manual Therapy [serial online]. August 2011;16(4):351-356. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed September 7, 2015.

8.Ernst E. Vascular accidents after neck manipulation: cause or coincidence?. International Journal Of Clinical Practice [serial online]. May 2010;64(6):673-677. Available from: CINAHL, Ipswich, MA. Accessed September 7, 2015.

9.Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manipulation or Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004249. DOI: 10.1002/14651858.CD004249.pub3.

16 thoughts on “Cervical Artery Dissection: Implications for the Physical Therapist A Case Report from a Direct Access Environment

  1. This is a great case report guys, wish I would have been able to discuss it at recent VPTA conference! Great work and should help add to the literature on importance of vitals (vascular system) with our examination.

    From my experience and metacognition over the years, these are my take-aways from this case:
    1. Never, ever trust what diagnostics some other healthcare provider has done, even with plain x-rays. I learned this the hard way and took a lesson from it.
    2. PT’s ability to evaluate is just as good or better than our colleagues. Definitely respect our healthcare buds but this case shows that resting BP, which you would think should be a part of the other examinations, would fly high a red flag.
    3. Based on #2, sometimes symptoms & examination findings may not have been present in the past even though symptoms were present. This is not an always or never statement. Her BP may not have been THAT high at ER, but would be interesting to know what vitals actually were during previous visits.
    4. Cervical manipulation always seems to jump up as an adverse event and relays the question, “would you manipulate this individual?”. I would argue that cervical mobilization and even PROM is just as bad as a set up for manipulation for clinical reasoning. This is biological plausible too with blood flow studies. Even wrong to do soft tissue mobs or trigger point work as the examination findings (BP) should lead you away from moving to any further examination and treatment approaches.
    5. Final thought, would you do a vertebral artery test here? 🙂


    Liked by 1 person

    • Great reflection. Patients BP was not that high in ER. It had been steadily rising though with each visit and with time. Yes, previous case I came across doing this case was on a patient suffering a stroke immediately following deep tissue massage to the c-spine from a massage therapist. Causation.. not determined and most likely a significant issue prior to treatment. The vertebral artery test should NOT be done in this case. If you already suspect vascular involvement refer out. No need to verify that.


  2. This is so important– thank you for sharing this case! I think we all tend to jump to treatment for friends/colleagues without doing a complete assessment and forget how important it is to truly be comprehensive and thorough. Love your blog also btw! Keep up the great posts!

    Liked by 1 person

  3. Great article- really beneficial to see how important clinical vital signs can be.
    I am interested to understand the patient management of such a case. For instance do you think the diagnostic criteria set are still valid when one of the vital signs are not abnormal, perhaps when the patient presents to the practice earlier in the development of CAD when Blood pressure is lower (as could have easily been the situation in this case example)? Is there then sufficient research evidence to suggest not using CMT with a presentation of constant headaches and raised HR? Thanks


    • Fantastic question mark, I did come across an article describing the importance of screening every patient (even undiagnosed CAD) prior to CMT for Cardiovascular risk factors.. I dont remember them mentioning exactly what to screen but my “go-to” would be ACSM cardiovascular risk factors (FMHX, exercise, smoking, etc.). However I saw nothing saying don’t use CMT with early stage CAD patients. But of course atherosclerosis or chronic HTN places more risk. Perhaps attempt to solve their pain/dysfunction with the lower level and more neutral treatment such as Jerry’s method below.


  4. Stephen,
    Thank you for taking the time to do the case. Very important. I had a recent case of upper cervical instability, who remarkably after reporting to be feeling like a bobble-head after a kiddie ride at a circus, was given cervical traction as ordered! UGH! I certainly agree with you regarding the stance of no need to test when signs and symptoms are clear. There is a general consensus that the VA testing is very limited. for those occasions when upper cervical joint treatment is appropriately, I choose to treat close to neutral with a very gentle approach. There is some good info on upper cervical testing at the IFOMPT web site. Thank you again for sharing this important case. Please consider submission for publication. Best Regards, Jerry Hesch, MHS, PT, DPT Hesch Institue


    • Thanks for reading and commenting Jerry, truly appreciate it. I have thought about submitting to JOSPT on this case, and will being to look into it. A very scary thought to receive a script for traction with cervical instability. Close to neutral treatment with low level isometrics and monitoring any symptoms seems to be the way to go… or another opinion from another doc?


      • Hi Stephen glad to hear re submission.
        I think it might have a wider read in JOSPT and facilitate change more so than manual therapy journals where perhaps the majority of readers are already familiar with the topic. I will dig deeper later into your references, and see what is in the literature re vascular studies. I do think you bring light to the value of vascular work up which perhaps is under-appreciated as opposed to the concept of instability.
        This is a client who has seen 70 clinicians over the course of 3 years, not one truly listened. People are desperate, she also saw more than one practitioner who treated her with cervical manipulation. I told her no more. So I armed her with a letter suggesting referral to a neurosurgeon who specializes in the upper cervical spine, perhaps prior to that obtaining a flexion/extension CT scan as x-rays won’t capture C1. So, latest news she did get a referral but requires an imaging test first demonstrating pathology, and the CT was obtained…but w/o flexion/extension! So, she is still on the merry go round, and I suggested that maybe concurrent vascular work up appropriate. I shared your case and the references, she is very bright. Noteworthy is that she is completely intolerant of flexion.


  5. Hi Stephen,

    Congratulations again on your poster presentation on this case at the VPTA conference. I wish that I could have stayed for the remainder of the conference to see the poster in person and have a face to face conversation. We discussed this case on on twitter in the past, but that is a poor forum for discussions regarding clinical reasoning. Thank you for posting your poster presentation on your blog for everyone to read and learn. There are several points in this case that I would like to discuss and I will separate the areas over several comments.

    This is a great case demonstrating the need of a clinician to perform a thorough examination and have a clinical diagnosis to base their treatment. Vertebral artery dissection is an extremely rare event occurring and has been estimated to be 0.97 cases per 100,000 individuals (Lee et al 206), but the true incidence is unknown because most cases are asymptomatic. I will f/u in another comment about CAD screening.

    Your case first grabbed my attention due to your tweet.

    “@SHenry_DPT: Cervical manipulation, risk vs. benefit… Not worth your license #vptaconference #PTBT #EBP http://t.co/ZmTo2SnTSa”.

    This statement regarding cervical manipulation is a very common clinical reasoning error and inappropriate conclusion regarding cervical HVLAT. However, I have heard many instructors at CEU courses, tweets, blogs & fellow clinicians echo this opinion.

    The most obvious rebuttal to this statement is the inappropriate amount of weight applied to case studies or case series in light of more robust studies. Case studies are very important in EBP, but they should be used to spur more vigorous research on a topic or used by a clinician to gain insight on a topic with little or no higher quality evidence. In this example, Cassidy 2008 has performed the most robust study to date with a case controlled study of 818 VBA CVAs. This study was preceded by Smith et al 2003 & Rothwell et al 2001 that both found correlations of VBA CVA and CS SMT. However, the Smith & Rothwell studies did not use a case control which significantly weakens the findings regarding CVA & SMT. I was hoping that you would include the studies by Cassidy, Rothwell, & Smith in your blog, but they were not included and case studies were used as a poor substitute. Cassidy found a correlation (not causation) with SMT, but also found very similar correlation of VBA CVA with PCP visits (PCP did not charge a manual therapy code & study assumed PCP did not manipulate the CVA pt). This indicates that VBA dissection was most likely already in progress and all clinicians missed the diagnosis and the patients went on to suffer from a VBA CVA. At this point, this is where clinician and researcher logical fallacies come into play as mentioned by an earlier post on your blog (https://ptbraintrust.wordpress.com/2015/10/05/five-days-of-fallacies-day-1-post-hoc/). The clinician or researcher attributes an outcome to an earlier event when no causal relationship actually exists, but a correlational relationship exists (ex. polio viral infections increased in the summer & ice cream sales increased in the summer. Polio infections & ice cream sales are correlated, but there is no causation). The example of rain dances as a post hoc logical fallacy is at play. So, in one patient a VBA CVA occurred, pt was manipulated in the past therefore the manipulation caused the stroke. In another patient a VBA CVA occurred, pt was not manipulated and saw PCP therefore the Dx was just missed and unfortunate. There are several well performed studies that demonstrate that SMT and VBA CVA are not correlated (Murphy et al 2010, Chung et al 2014 and a systematic review by Carlesso et al 2008). Also, many clinical guidelines have found a high benefit for CS SMT (UK BEAM trial as an example). Therefore, the risk vs. benefit is completely unknown for VBA CVA & SMT and strong statements to cease CS SMT should be avoided.

    Many clinicians state that mobilizations are much safer than manipulation and I perform upper CS mobilizations for safety reasons. This is a complete assumption and many biomechanical studies (Herzog 2012, Wuest 2012, Symons 2002, are showing that end range of motion or mobilization place much greater strain on the VBA compared to SMT. So, clinicians performing MDT repeated end range rotation with or without overpressure, SNAG with rotation with or without overpressure, vertebral artery testing, physiological ROM testing with and without overpressure, grades 3-4 mobilizations are placing the VBA system under a much greater strain. However, no clinician has looked at VBA CVA and these procedures. The correlation maybe much higher with these procedures than SMT and may or may not be worth your license.

    So, back the case study in your post. This patient was not safe for ANY treatment; vertebral artery testing, ligamentous testing, PAIVMs, ROM testing or possibly even UBE. I know that you would agree that she was not safe for any treatment and this brings up the question why clinicians only mention SMT in regards to CAD dysfunction? The focus should be on better screening and assessment for CAD in order to refer them to appropriate provider and not which treatment could possibly finish them off.

    Kind regards,



    • Hi Eric,

      Thank you for reading and demonstrating a compassionate enthusiasm for our profession as too many are uninterested in reading and bettering themselves.

      I have to agree with the comment that the incidence of VAD is unknown as searching through the literature the numbers are very diverse and not consistent.

      As far as my tweet: “@SHenry_DPT: Cervical manipulation, risk vs. benefit… Not worth your license #vptaconference #PTBT #EBP http://t.co/ZmTo2SnTSa”.

      Perhaps I was feeling alittle pumped up post-poster presentation and should have said “Not worth my license”.

      I say this not being stubborn, but in my eyes quite the opposite.
      I have spent 4 years pre-DPT school in a clinic that focuses with use of spinal manipulation techniques and dry needling with combination of exercise and various manual therapy techniques. Coming into school 100% biased for all my previous experiences I was educated to think more critically about all things/all treatment in DPT school with an emphasis on EBP. Not necessarily told not to get into SMT but to simply supply the minimal dosage of treatment needed. With the current understanding that VAD can be elusive I choose to be conservative with CMT.
      Hopefully Maitland will still take my money for my COMT, regardless of feeling more comfortable using other cervical techniques than manipulation at this time but still wanting the skill set for a wide variety of mobs/manips.

      I agree as mentioned in my blog cervical manipulation has no causation of CAD. Evaluation is extremely important for the therapist to justify use of SMT. However, as you said “incidence is unknown because most cases are asymptomatic” in my mind it only takes 1 asymptomatic case to put you at risk for an unfortunate case study. Now this goes back to individual comfort level… so perhaps again my previous tweet was a bit offensive because your comfort level is not mine.

      As far as the biomechanical studies, thank you for bringing attention to them as I have yet to come across those specific studies and I will read through them. However I am well aware end ROM causes stress to the VAD along with previous cases of CAD occurring while looking in the blind spot while driving a car, or a swimmer suffering a non-traumatic VAD. And pure observation from my own search for body of evidence on the matter; it seems most chiropractic journals will support lack of evidence just as neurology journals would support correlation.

      Regardless this post was not intended to take a stab at those who utilize CMT. It is to stress the importance of evaluation and never assume. While increasing awareness that cervical dissections can mimic musculoskeletal pain.

      Appreciate your passion,


  6. Stephen,
    First off, I do want to say that this is a very good piece on the importance of differential diagnosis, particularly for such a serious condition as VBI/CAD. However, I think that your reference to spinal manipulation having any correlation in this case is fear-mongering at worst, and unnecessarily inflammatory at best. (Words have power, don’t they–“snap, crackle, pop”)?

    This case has very little to do with spinal manipulation and everything to do with the skill of differential diagnosis. As Eric pointed out above, ANY treatment for this patient would be ill-advised. For those of us who are well-trained in spinal manipulation, especially in the cervical spine, safety is highly emphasized. I understand that in this example, the “patient” is a colleague that the clinician is doing a favor for, and likely would not have taken extensive history as with a regular customer. The point being, perhaps we should not be so cavalier with, again, any treatment, because even mobilizations carry inherent risk, even arguably more risk due to sustained pressure on potentially sensitive structures. Manipulation, when performed properly, has the added component of speed, not force, when compared to mobilizations.

    Furthermore, in looking at stress to the vertebral artery, according to Symons et al in 2002, (for one), spinal manipulation provides 1/10 of the force required for VA failure at C0/1 and 1/30 the amount strain in the mid-cervical spine. 53% strain on the VA can result in tissue failure, however, HVLAT techniques produce strain levels only at 6.2%, and supine cervical rotation ROM also puts more strain on the VA than SMT. Albeit, these are levels on “healthy” subjects however, it should still be eye-opening to people who have habitually practiced fear-avoidance with cervical manipulation.

    That being said, as mentioned in the beginning, the main take away from your post is that a thorough history and examination should be the standard of care for all musculoskeletal conditions, especially those that have the potential to masquerade as benign occurrence, regardless of one’s treatment bias.



  7. Hey Stephen,

    Thanks for the compliment on my passion. I enjoyed your post on CAD in regards to clinical screening & clinical assessment in a direct access environment. I believe that your post goes a little off track when one type of treatment is singled out. We have already discussed this point, but any treatment (cardiovascular, mobilizations, AROM/PROM or HVLAT) could have ended in disaster. It would still be your treatment table and your hands that were correlated with the VBA CVA without a proper assessment. Your clinical screening, assessment & reasoning ensured that the patient had a good outcome & not which treatment was or was not performed.

    Great job in catching the patient’s high blood pressure & high resting HR during your evaluation. Many clinicians would have missed that finding in an otherwise healthy 29 y/o female with a BMI of 22.5 presenting with cervical pain and headache. Looking at CAD, did you perform auscultation of the internal carotids (https://youtu.be/DW45TzycYOI) during your assessment? The internal carotids are much more likely to be a source of CVA in the general population and patients seeking care in PT. The referral pattern for ICA dysfunction is very similar to VBA dysfunction. A dysfunction of the ICA that is missed during evaluation can lead to disaster as well. However, many clinicians trained in MDT (McKenzie method) would have performed cervical retraction/extension with or without over-pressure to expose cervical dysfunction (tight tissue) or reduce a cervical derangement using directional preference procedures. Many MDT clinicians would stay away from HVLAT and perform this treatment citing the lower risk:benefit ratio with repeated movement treatments. This assessment and possible treatment places a large strain on the ICA and could have worsened a dissection or loosened a plaque. Auscultation of the VBA is not reliable due to its relationship with the spine and only real time ultrasound imaging or MRA would have been helpful in that situation (which you nicely referred to a physician). So, was auscultation a part of your examination or a part of your normal examination when you are suspicious of an arterial dysfunction?

    Kind regards,



  8. Hey Stephen,

    Looking at your MRA of the right VBA. It appears that the VBA dissection is located in zone 1 which is a similar finding in Puentadura et al 2012 adverse event study which found most dissections in zones 1 & 2. Zone 1 is before the vertebral artery enters the transverse foramen of C6. It would be interesting see how this would change many clinician’s point of view of cervical manual therapy safety.


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