Campbell, B. C.V. et al. (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.ABSTRACT Background: CT-perfusion (CTP) and MRI may assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of ischaemic core and penumbra volumes were associated with functional outcomes and treatment effect.

Campbell, B. C. V. et al. (2018) Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurology, 17(1), pp. 47-53. (doi:10.1016/S1474-4422(17)30407-6) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/149670/ variables. An alternative approach using propensity-score stratification was also used. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models. Bias was assessed using the Cochrane tool.Findings: Of 1764 patients in 7 trials, 871 were allocated to endovascular thrombectomy. After exclusion of 74 patients (72 who did not undergo the procedure and 2 with missing data on anaesthetic strategy), 236/797 (30%) of endovascular patients were treated under GA. At baseline, GA patients were younger and had shorter time to randomisation but similar pre-treatment clinical severity compared to non-GA. Endovascular thrombectomy improved functional outcome at 3 months versus standard care in both GA (adjusted common odds ratio (cOR) 1·52, 95%CI 1·09-2·11, p=0·014) and non-GA (adjusted cOR 2·33, 95%CI 1·75-3·10, p<0·001) patients. However, outcomes were significantly better for those treated under non-GA versus GA (covariate-adjusted cOR 1·53, 95%CI 1·14-2·04, p=0·004; propensitystratified cOR 1·44 95%CI 1·08-1·92, p=0·012). The risk of bias and variability among studies was assessed to be low.Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding:The HERMES collaboration was funded by an unrestricted grant from Medtronic to the University of Calgary. Research in contextEvidence before this study between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of general anaesthesia versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of general anaesthesia. Added value of this studyThese data from contemporary, high quality randomised trials form the largest study to date of the association between general anesthesia and the benefit of endovascular thrombectomy versus standard care. We used two different approaches to adjust for baseline imbalances (multivariable logistic regression and propensity-score stratification). We found that GA for endovascular thrombectomy, as practiced in contemporary clinical care across a wide range of expert centres during the rand...

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Failure of TFA in the endovascular treatment of AIS is uncommon but leads to unacceptable delays in reperfusion and poor outcomes. Standardization of benchmarks for access switch could serve as a guide for neurointerventionalists. TRA is a valid approach for the endovascular treatment of AIS.

The mechanisms and phenotype of ischemic stroke associated with coronavirus disease 2019 (COVID-19) remain uncertain. A retrospective study was conducted in patients with COVID-19 presenting with ischemic stroke from March 1 to May 25, 2020, and cases with large-vessel occlusion were identified. To provide baseline institutional stroke data within and outside the COVID-19 pandemic, all consecutive ischemic stroke and TIA admissions (COVID and non-COVID) to the hospital during a 10-week period from March 1 to May 10, 2020, were collected and compared with data from the same time period in 2019. Among 20 patients with COVID-19 and acute ischemic stroke, 15 (75%) had large-vessel occlusion. These patients were young (mean age, 46.5 years), male (93%), without major burden of traditional cardiovascular risk factors, and had a severe stroke presentation. Largevessel occlusions were observed in multiple vessels (40%), uncommonly affected vessels, and atypical locations with a large thrombus burden. Systemic thrombosis separate from large-vessel occlusion was not uncommon (26%). At short-term follow-up, stroke etiology remained undetermined in 46% of patients and functional outcome was poor. The above findings raise the possibility of stroke related to mechanisms induced by the COVID-19 infection itself, including a hypercoagulable state and/or endothelial damage. In addition, they document the severe presentation and poor outcomes of large-vessel occlusion in COVID-19 ischemic stroke. ABBREVIATIONS: CCA ¼ common carotid artery; COVID-19 ¼ coronavirus disease 2019; LVO ¼ large-vessel occlusion; SARS CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus-2 C oronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by infection with the Severe Acute Respiratory Syndrome coronavirus-2 (SARS CoV-2). 1,2 There are now multiple reports of COVID-19 affecting the central nervous system, ranging from meningitis/encephalitis to stroke. [3][4][5] In a single-center study of 214 hospitalized patients with COVID-19 from Wuhan, China, where the infection first occurred, up to 36.4% of patients had neurologic manifestation, including acute cerebrovascular disease with severe and nonsevere infection in 5.7% and 0.8% of these patients, respectively. 3 In addition, there are also reports of ischemic stroke being caused by large-vessel occlusion (LVO) in patients with COVID-19 without significant pre-existing cardiovascular risk factors. 6 While the reasons for ischemic stroke in COVID-19 are unclear, hypotheses of an inflammatory cytokine storm-triggered hypercoagulable state, endothelial damage, and arrythmias have been postulated. 7,8 However, as it stands, the mechanisms, phenotype, and optimal management of ischemic stroke associated with COVID-19 still remain uncertain.There is an urgent need to identify associations and predictors of severity, morbidity, and mortality in patients with ischemic stroke and COVID-19, especially in the LVO subgroup, given that it is most disabling.

In this challenging group of advanced retinoblastomas refractory to aggressive multimodal therapy, virtually 100% of eyes are generally enucleated. In contrast, the authors' protocol of infusing melphalan directly into the ophthalmic artery led to a dramatic decrease in the enucleation rate to 23.5%. While it is now the treatment of choice for refractory retinoblastoma at their center, its role in less advanced disease remains to be elucidated.

Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

Minimally invasive and interbody and instrumented fusion techniques are increasingly being used for the treatment of adult degenerative disc disease, stenosis, and deformity of the lumbar spine. Advocates of minimal access spinal approaches list certain advantages over open procedures, including decreased postoperative pain and narcotic requirements, shorter hospital stays, less blood loss, and smaller incisions. The minimally invasive anterolateral approach allows access to the lumbar spine through the retroperitoneal space. We report on the short-term clinical and radiographic outcomes in four patients with mid to high lumbar coronal deformities treated at our institution with the anterolateral transpsoas minimally invasive approach. The primary presentation of these patients was back and leg pain. All patients showed improvement in their preoperative symptoms and solid arthrodesis at 6 months. Independent nonbiased patient pain analysis was also performed. Mean follow-up was 10 months (standard deviation, 1.4 mo), and mean hospital stay was 3.5 days (standard deviation, 1.9 d). One patient had additional posterior segmental instrumentation placed. Mean Cobb angles in the coronal plane were 28.5 degrees preoperatively and 18.3 degrees postoperatively (P < 0.05). We also present a historical perspective on retroperitoneal spine surgery, a regional anatomic description of the lumbosacral plexus and surrounding structures, and a description of the surgical technique as related to treatment of lumbar deformity.