Transcript Cerebrovascular Disease William R. Rooney, MD VP & Medical Director Generali USA Life Reassurance Welcome & Webinar Guidelines • Thanks for attending!! • Phones will be locked.

Cerebrovascular
Disease
William R. Rooney, MD
VP & Medical Director
Generali USA Life Reassurance
Welcome & Webinar Guidelines
• Thanks for attending!!
• Phones will be locked during the presentation
• Please submit questions by using the
question “?” function in the lower right corner
to type in your question
• Question & Answers will be discussed at the
end (time permitting)
• Your comments are important; please
complete the survey at the end of the webinar
2
Introduction: William Rooney, M.D. FAAFP, EMBA
• Joined Generali USA in April,
2012
• 20 year history of direct patient
care.
• Eight years of insurance
industry experience.
• Board certified in Family
Medicine
3
Overview
•
•
•
•
•
•
•
•
•
Stroke Facts
Mortality numbers
Definitions
Anatomy review
Types of strokes
Diagnosis
Primary and secondary treatment
Another look at Mortality numbers
CIMT, Carotid US, and Silent strokes
4
CASE
•
2 cases arrive for underwriter review. Which has the worst mortality risk
based upon the following limited information provided?
– Case 1:
• 66 y/o female with hx. of a “TIA-like” event 4 years ago with no subsequent
symptoms. Hx. of hypertension and hyperlipidemia. BMI 30
• MRI of the brain WNL.
• US of the carotids WNL.
• ECG WNL.
• CIMT abnormal at 90th percentile for age.
– Case 2:
• 65 y/o female with no known neurological complaints—past or present
• Hx. of hypertension and hyperlipidemia. BMI 30
• MRI of the brain shows 2 small lacunar infarcts—age unknown
• US of the carotids WNL
• ECG WNL
• CIMT normal
5
Stroke Facts
1. 795,000 Americans suffer strokes each year
2. 134,000 deaths each year
3. 6,400,000 stroke survivors
4. 34% of people hospitalized for stroke in 2009 were under 65 years of
age.
6
Prevalence of stroke by age and sex
Rosamond W et al. Circulation 2007;115:e69-e171
Copyright © American Heart Association
7
Stroke Facts
1. Women are twice as likely to die from stroke than breast cancer annually.
2. African Americans have almost twice the risk of first ever stroke compared to
whites. Hispanic Americans’ risk falls between those of whites and African
Americans.
3. A leading cause of death in the United States
4. 1998-2008:
– Annual stroke death rate fell 35%.
– Actual number of deaths fell 19%.
8
Temporal trends in age-adjusted death rates for the top 10 causes of death in the
United States from 1931 to 2008.
2nd most common cause of death world wide
In 2008 CVA dropped from the 3rd most common cause of
death in the US to the 4th.
Towfighi A , and Saver J L Stroke 2011;42:2351-2355
Copyright © American Heart Association
9
Mortality rate from Stroke
10
Similar downward trend noted in the European Union.
Point #1
The stroke mortality rate in the Western countries is
declining.
• Decreased incidence
• Decreased case-fatality rate
Point #2
The projected total number of US deaths from
strokes is not expected to decline through 2030
however because of the aging population
Kunst A E et al. Stroke 2011;42:2126-2130
Copyright © American Heart Association
Definitions
1.
TIA
• Classic Definition: Rapidly developing clinical signs of focal or global
disturbance of cerebral function lasting fewer than 24 hours, with no apparent
non-vascular cause.
• June 2009 AHA/ASA scientific statement definition: A transient episode of
neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia,
without acute infarction
2.
CVA
• An infarction of the central nervous system tissue
Definition and Evaluation of Transient Ischemic Attack. A Scientific Statement for Healthcare Professionals From the American Heart
Association/American Stroke Association Stroke Council; Easton, Donald J et al.
Stroke. 2009:40:2276-2293
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Consequences of the definition change
1.
Anticipate a drop in annual incidence of TIA’s by 33%
2.
Increase in diagnosis of CVA’s by 7%.
3.
There has been a change in the enrollment of members into studies
•
Potential change in treatment guidelines in the future
•
Mortality statistics impact
4.
Comparison of old statistics to newer and future statistics won’t be apples to apples
5.
Potential improvement in CVA morbidity and mortality results from earlier treatment.
Decreased “wait and see” approach.
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Consequences of definition change---Consider 3 diagnosis outcomes
TIA
– No longer is this the poor prognostic event that it was
– 90 day risk of stroke with residual symptoms is <1%
Image-positive transient event
– 90 day risk of stroke with residual symptoms is ~14%
– ~15 x the chance of having a stroke with residual symptoms in the next 7 days as
compared to those with a stroke that already have residual neurological
symptoms
Ischemic stroke with residual neurological symptoms
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Brain cells have different functions in different locations
Parietal Lobe
Hand
Language
Sensation
Telling right from left
Temporal Lobe
Speech
Memory
Hearing
Hip
Language
Arm
Fingers
Vision
Occipital Lobe
Speech
Hearing
Vision
Cerebellum
Balance
Fine motor control
Coordination
Brain Stem
Breathing
Swallowing
Blood Pressure
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Balance
Coordination
Smell
Frontal
Lobe
Personality
Memory
Reasoning
Anatomy of the cerebrovascular system
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The size of the emboli impacts the size of the infarction
The vascular “tree”
16
Strokes from atrial fibrillation are typically associated with more brain tissue
involved when compared to carotid artery disease-induced strokes.
Presumably due to larger emboli.
Two Major Types of Stroke
•
Ischemia
– Thrombosis (local obstruction of an artery)
– Embolism (Debris or blood clot traveling from elsewhere and lodging in an artery
causing obstruction)
– Systemic hypo-perfusion (general medical condition with lack of blood supply
reaching the brain
•
Hemorrhage
– Subarachnoid hemorrhage (bleeding into the CSF within the subarachnoid space
around the brain)
– Intra-cerebral hemorrhage (bleeding directly into the brain tissue)
•
•
80% of strokes are secondary to ischemic cerebral infarction
20% of strokes due to hemorrhage
17
18
http://www.stroke.org/site/PageServer?pagename=brochures
CVA’s are caused by anything that can cause vascular compromise
•
Heart
–
–
•
Large Blood Vessels
–
–
–
•
Atrial fibrillation/rhythm disturbances
VSD/PFO/Endocarditis
Thrombus
• Atherosclerosis
• Takayasu arteritis
• Giant cell arteritis
• Fibromuscular dysplasia
Emboli
Dissection
• Marfan’s syndrome and other similar conditions
Intracranial Blood Vessels
–
–
–
–
Thrombus
• Same as large blood vessels but also includes Moya-Moya
Emboli
Dissection
Rupture of the Blood vessel and bleeding
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Vascular Compromise
•
Blood itself
– Bleeding Tendencies
• Complication of anticoagulation medications
• Hemophilia
– Clotting Tendencies
• Protein C or S deficiency
• Prothrombin gene mutation
• Factor V Leiden
• Antithrombin III deficiency
• Hyperhomocysteinemia
• Antiphospholipid syndrome
• Essential thrombocytosis
• Sickle cell anemia
• Polycythemia Vera
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TIA—Making the diagnosis
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TIA—Making the diagnosis
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The important point here is
that there are several
potential etiologies for
transient neurological events
If vascular compromise is of
concern there ideally will be
results of a typical
diagnostic work-up for
underwriter review to assess
mortality risk
CVA—Making the diagnosis
•
•
Brain imaging with CT or MRI is indicated in all patients with a suspected
TIA or minor non-disabling stroke as soon as possible.
The 2013 AHA/ASA guidelines suggest:
•
•
•
•
•
•
•
Imaging within 24 hours of symptom onset
MRI and specifically Diffusion-weighted Imaging MRI as the preferred
modality
Noninvasive imaging (MRA, CTA) of the cervico-cephalic vessels to be part
of the evaluation of suspected TIA’s or non-disabling strokes
Imaging techniques and quality of the exams has evolved
To some extent the type of imaging performed is based upon the availability
of testing devices and expertise of staff
Many feel that the Diffusion Weighted Imaging (DWI) MRI is more sensitive
than CT for the early detection of acute ischemia.
CT’s are frequently more accessible and are frequently used—especially
first tests. CT’s are also especially good at detecting the presence of
hemorrhage.
http://stroke.ahajournals.org/
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CVA—Making the diagnosis
•
Cardiac evaluation is important when TIA or CVA is suspected. Testing
frequently performed include:
– ECG
– Echocardiogram
– Cardiac monitoring
•
Other tests are performed as needed
–
–
–
–
Blood cultures
Sed rate
CBC
PT/PTT
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JOKE TIME!!
Diagnostic dilemma
25
What could it
be?
What is wrong
with me?????
So far I have
removed a banana
from your right ear
and a carrot from
your nose. Now I
find part of an apple
in your left ear.
You are not
eating
properly!!!!
Making the diagnosis of a CVA
http://www.medscape.com/viewarticle/452843
26
DWI
Cerebellum
region
Thalamocapsular
region
T2 weighted
FLAIR
27
Dissection
http://uvahealth.com/services/vascularcenter/treatment/arterial-dissections
28
http://www.ajnr.org/content/24/10/2052/F1.expansion.html
Primary treatment of an acute ischemic CVA or TIA
Acute Ischemic strokes:
–
Thrombolytic therapy with intravenous alteplase (tPA—recombinant
tissue-type plasminogen activator)
• Early treatment important
• Many exclusions
• Unfortunately, in the US only about 8% of all ischemic stroke
victims present to the ER within 3 hours and also meet the eligibility
criteria for tPA.
Vertebral artery or Carotid artery dissecting aneurysms
–
–
Thrombolytic therapy is not contraindicated and the effectiveness and
safety is comparable to ischemic strokes from other causes
Extension of the aortic dissection is a potential complication of the
thrombolysis however.
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Primary treatment of an acute bleed
Subarachnoid hemorrhage
–
Aneurysmal (~80%)
• Surgical management usually needed
Surgical clipping
Endovascular therapy with coil system
–
Non-aneurysmal (~20%)
• AVM
Surgical clipping
Endovascular therapy
•
Intracranial artery dissection
Surgical clipping
Endovascular therapy
•
Perimesencephalic non-aneurysmal subarachnoid hemorrhage
Subtype identified in 1985
Findings of localized blood on CT, normal angiography, and a relatively benign
course
Long term mortality is significantly better than aneurysmal SAH approaching
normal controls.
Intra-cerebral bleeding
–
–
–
–
Reversal of anticoagulation
Monitoring of intracranial pressure
Seizure prophylaxis
Surgery for cerebellar decompression and possibly supratentorial ICH (controversial)
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Secondary Treatment of the acute ischemic CVA or TIA
•
Smoking cessation
•
Heavy ETOH consumption should be avoided but light to moderate consumption (no more than 2 per day
for men and 1 drink per day for women) is reasonable
•
Physical exercise—30 min of moderate-intensity for 30 min or more 1-3 times per week
•
Antithrombotic therapy initiation within 48 hours of stroke
•
BP management—Goal of therapy is BP of <120/80 mm Hg.
•
Lipid lowering therapy (Statins) for those with elevated LDL >100 mg/dl with goal LDL-C of <70 mg/dL.
•
Prophylaxis for DVT and PE important for those at risk
•
DM management (Diabetics have twice the typical risk for CVA). Unfortunately studies have not provided
conclusive evidence that tight control decreases macro-vascular disease similar to the benefit in microvascular disease. The AHA/ASA still supports good control of blood sugars however.
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare
Professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:227-276
31
Secondary Treatment of the acute ischemic CVA or TIA—Slide 2
Atrial Fibrillation (paroxysmal or permanent):
• Anticoagulation with a vitamin K antagonist
preferred
• ASA alone for those who can’t tolerate a vitamin
K antagonist
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Prosthetic heart valves
• Oral anticoagulation with an INR of 2.5-3.5
• ASA is recommended to be added to the oral
anticoagulation for those with an ischemic event while
on anticoagulation
Cardiomyopathy with EF <35%:
• Warfarin, ASA, Clopidogrel, or the combo of ASA
and dipyridamole may be considered
Non-cardioembolic ischemic strokes or TIA’s
• Antiplatelet therapy
Acute MI and left ventricular thrombus
• Oral anticoagulation recommended for at least 3
months
PFO (Patent Foramen Ovale)
• Antiplatelet therapy is reasonable
• Insufficient data to make a recommendation for
surgical closure in those with PFO who have had a
stroke
Arterial Dissection
• Antithrombotic treatment for 3-6 months
• Endovascular stenting should be considered for recurrent ischemic
events despite medical treatment
• Surgical treatment should be considered for those failing stenting.
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare
Professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:227-276
Secondary Treatment of the acute ischemic CVA or TIA
•
Symptomatic extracranial carotid disease:
–
–
–
–
–
•
Extracranial vertebrobasilar disease:
–
–
•
70-99% stenosis of ipsilateral side: Carotid endarterectomy recommended
• When morbidity and mortality risk is <6%
50-69% stenosis: Carotid endarterectomy to be considered
• When morbidity and mortality risk is <6% and
• Dependent on pt specific factors (age, sex, comorbid conditions)
<50% stenosis
• No indication for endarterectomy or stenting
Carotid angioplasty and stenting is an alternative in some settings
• > 70% stenosis by noninvasive testing
– Especially those difficult to assess surgically such as radiation induced stenosis or restenosis after endarterectomy
• > 50% stenosis by angiography
Optimal medical therapy including antiplatelet therapy, statins, etc.
Optimal medical therapy
Consider surgery when medical therapy has failed.
Intracranial atherosclerosis
–
50-99% stenosis:
• ASA recommended (in preference to warfarin)
• Angioplasty and/or stent placement usefulness is unknown and considered E/I
• Bypass surgery is not recommended
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare
Professionals from the American Heart Association/American Stroke Association. Furie, Karen et al. Stroke. 2011; 42:227-276
33
Mortality implications of TIA’s and CVA’s
34
TIA
•
•
TIA without images being positive
Transient event that is image positive
90 day stroke risk <1%
90 day stroke risk 14%
CVA
CVA’s have a high peri-stroke period mortality rate
Complications clearly are determined by
•
•
Location of the stroke
How much brain tissue is involved
•
•
•
95% of patients have at least one medical complication1
24% of patients have at least one serious, life threatening complication1
Direct effects of the stroke cause death in the first few days. Medical
complications account for the mortality thereafter
In the first year the most common cause of death is2:
•
First week:
2-4 weeks:
2-3 months:
>3 months
1Randomized
Cerebrovascular disease
PE
Pneumonia
Cardiac disease
trial of Tirilizad Mesylate in Acute Stroke (RANTTAS)
of myocardial infarction and vascular disease after transient ischemic stroke and ischemic stroke: a systematic review and meta-analysis. Touze
E et al.
Stroke. 2005:36 (12):2748
2Risk
Cardiac complications of a stroke
•
Cardiac complications are not just the association of atherosclerosis
– Stroke is a coronary artery disease risk equivalent
• Those with a stroke with no known coronary disease have a similar risk of MI
as those with established coronary disease
•
Takotsubo cardiomyopathy is one condition that can occur
– Extreme catecholamine release is postulated to cause this
– Causes an acute cardiomyopathy
– Interestingly it typically involves the apical and mid sections of the heart
•
ECG abnormalities present in 92% of patients with an acute stroke
– Classic large and upright T waves can occur
– Prolonged QT intervals are common
– Cardiac arrhythmias
35
Included those
with hx. of heart
disease
Did not include
those with hx. of
heart disease
36
4 QUESTIONS
1. What percentage of stroke victims die within 1 month of their first stroke?
2. What percentage of stroke victims die within 5, 10 and 15 years?
3. Does age matter?
4. Does type of stroke matter?
37
Proportion of patients dead 1 year after first stroke.
38
>64 y/o
45-64 y/o
Go A S et al. Circulation 2013;127:e6-e245
Copyright © American Heart Association
Proportion of patients dead within 5 years after first stroke.
39
>64 y/o
45-64 y/o
Compared to the general population nonfatal stroke is associated with a:
5 fold increase for death between 1 month and 1 year.
2 fold increase for death at 5 years
Writing Group Members et al. Circulation 2012;125:e2-e220
Copyright © American Heart Association
Figure 1. Short-term survival probability for patients aged 65 years at first nonfatal stroke by
subtype (Cox regression).
40
Estimated cumulative risk for death:
28 days
28%
1 year
41%
5 years
60%
However, risk of death did vary based upon
type of stroke
Brønnum-Hansen H et al. Stroke 2001;32:2131-2136
Copyright © American Heart Association
IDS
Ill Defined Stroke
CI
Cerebral Infarct
SAH
Subarachnoid Hemorrhage
PICH
1o Intracerebral Bleed
Figure 2. Long-term survival probability for patients aged 65 years at first nonfatal stroke by
subtype (Cox regression).
41
Estimated cumulative risk for death:
5 years
60%
10 years
76%
15 years
86%
SAH
Subarachnoid Hemorrhage
http://www.theuniversityhospital.c
om/stroke/stats.htm
SAH
CI
PICH
IDS
Brønnum-Hansen H et al. Stroke 2001;32:2131-2136
Copyright © American Heart Association
Subarachnoid Hemorrhage
Cerebral Infarct
1o Intracerebral Bleed
Ill Defined Stroke
42
Imaging results frequently encountered by the underwriting staff
•
3 tests, frequently seen, that I want to discuss in more depth are:
–CIMT testing
–Carotid Duplex Ultrasound testing
–MRI or CT scan which shows the presence of a previous infarct—
incidental finding
43
Carotid artery intima-media thickness (CIMT)
•
44
•
CIMT measures the
thickness of 2 layers
(intima and media) of the
carotid artery walls
Carotid artery methods
are being refined so it is
important to know
exactly where the artery
is being measured
(Carotid bulb, common
carotid, or internal
carotid), near or far
walls or both.
http://www.diabetesresearchclinicalpractice.com/article
/S0168-8227(05)00410-9/abstract
http://www.sonosite.com/apps-n-softwares/sonocalc-imt
•
http://www.prweb.com/releases/2011/5/prweb8502142.htm
Thought by
some to be an
even earlier
indicator of
atherosclerosis
than Coronary
artery calcium
measurements
since thickening
precedes a
plaque
http://www.preventionhealthscreenings.com/services_imt.html
Carotid artery intima-media thickness (CIMT)
Abnormal (“high risk”) frequently defined as media thickness above the 75th percentile.
•Conflicting evidence whether this test has independent predictive power as compared to usual CV
risk factors
•American Heart Association Position Statement (dated 3/7/12) even suggested this test not be
mandated by health insurers as the predictive power hasn’t been established. (Of note however is
that they also did not support EBCT measurements whereas there is some evidence this test is
helpful, at least in intermediate risk individuals, independently of other tests).
•In the Multi-Ethnic Study of Atherosclerosis (MESA) which had 6698 subjects aged 45-89 years CIMT
was a modestly better predictor of stroke than EBCT but was not as good as EBCT for CV disease
prediction
Meta-analysis has shown that serial measurements are not useful for predicting progression.
45
US and MRA
46
Evaluation of the Carotid arteries
•
Carotid duplex ultrasound frequently performed:
–
–
–
–
–
•
81-98% sensitive
82-89% specific
Less precise for stenosis of <50%
Less precise for stenosis of 100%
Frequently used with MRA or CTA for confirmation of stenosis of >50% or for
100% stenosis.
Complete Obstruction: No surgical treatment has been proven to be of
benefit.
– Combo of US and MRA very good at detecting this
– CTA is also extremely good at detecting this
– Gold standard is angiography
47
Asymptomatic extracranial carotid artery disease
The 2011 AHA/ASA Guidelines
• Medical therapy and lifestyle changes should be instituted
• Population screening for asymptomatic carotid artery stenosis is not
recommended
• Benefit in women is very controversial
• Prophylactic CEA performed with <3% morbidity and mortality should be
considered when:
–
–
Minimum of 60% occlusion by angiography or
>/= 70% occlusion on doppler
• >80% occlusion on CTA or MRA for those with US showing 50% to 69% stenosis
– The number to treat (NTT) to prevent 1 stroke over 3 years is 33
•
Carotid artery stenting can be considered but the advantage over medical
therapy is not well established
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare
Professionals from the American Heart Association/American Stroke Association. Furie, Karen et al. Stroke. 2011; 42:227-276
48
Silent Strokes
A not so uncommon incidental finding
Evaluated in the
Cardiovascular Health Study1
• Published in 2002
• 5888 people >/= 65 y/o
with normal MRI
followed by repeat MRI
in 5 years.
• 17.7% had 1 or more
infarct
• Only 11% had
experienced a
documented TIA or
CVA .
• Those with + MRI
scans showed >
decline in Mini-Mental
exam test results
Not such good outcomes when found 49
Evaluated in the Rotterdam Scan
study2
• Published in 2003
• 1077 elderly people
followed for over 4 years.
• Silent brain infarcts
increased the chance of a
subsequent major CVA by
5 times.
• Those with >1 silent
infarct were at the highest
risk for a subsequent
major CVA.
• The presence of silent
infarcts significantly
increased the risk of
dementia
1. Incidence, manifestations, and predictors of brain infarcts defined by serial cranial magnetic resonance imaging in the elderly:
The Cardiovascular Health Study. Longstreth WT et al Stroke. 2002;33(10):2376.
2. Silent brain infarcts and white matter lesions increase stroke risk in the general population: the Rotterdam Scan Study.
Vermeer SE, et al, Rotterdam Scan Study Stroke. 2003;34(5):1126
http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2012/June/could-a-silent-stroke-erode-your-memory
More examples of silent CVA’s
50
Axial T2-weighted
Axial T1-weighted
Zhu Y et al. Stroke 2011;42:1140-1145
Copyright © American Heart Association
FLAIR
Axial Proton Density
Summary
•
CVA rates in the US are declining. However, based upon population demographics the
total number/year is anticipated to continue to rise
•
Definition changes regarding TIA and CVA will impact mortality numbers
•
There are several types of strokes and multiple etiologies. Regardless of the type
there are significant adverse long term mortality concerns
•
Diagnosis of TIA’s and CVA’s can be accomplished with several types of imaging. A
diffusion weighted MRI probably is one of the best methods. Quick evaluation is
important
•
Primary and secondary treatment depends on the etiology of the stroke but does
impact mortality
•
CIMT testing might demonstrate future potential value in underwriting but as an
independent cardiac or cerebrovascular disease indicator there are currently conflicting
results
•
Carotid US results and the presence of CVA’s found incidentally do help with
underwriting
51
CASE
•
2 cases arrive for underwriter review. Which has the worst mortality risk
based upon the following limited information you are provided?
– Case 1:
• 66 y/o female with hx. of a “TIA-like” event 4 years ago with no subsequent
symptoms. Hx. of hypertension and hyperlipidemia. BMI 30
• MRI of the brain WNL.
• US of the carotids WNL.
• ECG WNL.
• CIMT abnormal at >75th percentile for age—no plaque.
– Case 2:
• 65 y/o female with no known neurological complaints—past or present
• Hx. of hypertension and hyperlipidemia. BMI 30
• Recent MRI of the brain shows 2 small lacunar infarcts—age unknown
• US of the carotids WNL
• ECG WNL
• CIMT normal
52
JOKE TIME AGAIN!!
Medical Record Documentation---sometimes words just come out …well, wrong
The patient has been depressed ever since she began seeing me in 1983.
The patient was to have a bowel resection.
However he took a job as a stockbroker instead.
The patient has no past history of suicides.
The patient left the hospital feeling much better,
except for her original complaints.
http://freefunnyjokes.blogspot.com/2007/04/medical-records-joke.html
53
Questions?
54
Questions?
Please use the ? function on
your screen to type in a
question.
E-mail or call me if you think of questions later
[email protected]
(913) 901-4619
Copies of the presentation will be available:
• On the Website: http://www.generaliusalifere.com/Publications/Pages/Housecalls.aspx
or
• By contacting [email protected]
A recording of the webinar should be available in few days:
• On the Website: http://www.generaliusalifere.com/IndividualLife/Services/Pages/HousecallsWebinars.aspx
Thank You For Attending
Housecalls: Webinar #8
Cerebrovascular
Disease
Presented by:
William R. Rooney, M.D., VP & Medical Director
July 24, 2013