Intra-arterial chemotherapy in refractory and advanced intraocular retinoblastoma

Purpose: To evaluate the efficacy of secondary and salvage intra?arterial chemotherapy (IAC) as a globe salvage treatment modality in advanced and refractory intraocular retinoblastoma. Methods: A retrospective chart review of advanced intraocular retinoblastoma (groups D and E International Classification of Retinoblastoma [ICRB] classification) patients refractory to intravenous chemotherapy (IVC) and undergoing IAC as the secondary and salvage treatment modality between December 2018 and June 2021 was carried out. All patients underwent the IAC procedure by super?selective ophthalmic artery catheterization and with triple?drug chemotherapeutic agents of melphalan, topotecan, and carboplatin. Data were collected about tumor regression, eye salvage, metastasis, and survival outcome at follow?up. Results: Out of 13 patients, 12 patients received secondary IAC after being primarily treated with IVC and focal therapies and one patient received rescue IAC after recurrence following primary IAC. Mean number of IAC cycles administered was 2. Overall, globe salvage rate was 53.84%, with a mean follow?up of 17.53 months (range 6–37 months), three patients had enucleation for residual tumor or tumor recurrence. One patient developed metastasis post enucleation and two patients who were lost to follow?up after enucleation advice for residual tumor developed orbital tumor extension and eventually died of metastasis. Conclusion: Secondary triple?drug IAC following failure of IVC, along with other adjunct treatment modalities might a be a cost?effective option for eye salvage in advanced intraocular retinoblastoma patients who refuse enucleation, with a globe salvage rate of 53.84%. It can also be an effective approach to improve treatment compliance and can help in addressing the barrier of treatment refusal when enucleation is advised.

Research progress on intra-arterial thrombolysis for the treatment of central retinal artery occlusion / 国际眼科杂志(Guoji Yanke Zazhi)

Central retinal artery occlusion(CRAO), also known as eye stroke, always results in acute and painless visual loss. At present, conservative treatments, such as eye massage, lowering intraocular pressure and vasodilators have little effect on reducing visual loss. Intra-arterial thrombolysis(IAT)has significantly improved prognosis in patients with acute ischemic stroke, thus IAT has been gradually applied in the treatment of CRAO. IAT injects fibrinolytic drugs directly into the ophthalmic artery by a microcatheter, and dissolves the emboli that block the central retinal artery to restore the blood flow of the retina. Theoretically, IAT may be effective for CRAO as what has been found for stroke, but existing clinical studies exhibited inconsistent results. This paper summarizes the feasibility, efficacy, and safety of IAT treatment in CRAO. It will also analyze related factors that affect the prognosis, putting forward potential development directions and providing insights for the further clinical application of IAT.

Efficacy and safety of intra-arterial thrombolysis for retinal artery occlusion based on the green channel for eye stroke / 中华眼底病杂志

Objective:To explore the short-term efficacy and safety of intra-arterial thrombolysis (IAT) in the treatment of retinal artery occlusion (RAO) with the assistance of the rescue green channel in the eye stroke center.Methods:A prospective, interventional, single-center study. Thirty-eight eyes from 38 RAO patients who received IAT treatment in Guangdong Provincial People’s Hospital were enrolled. All the patients were rescued via the green channel in our eye stroke center. Data from comprehensive ocular examinations including best-corrected visual acuity (BCVA) and optical coherence tomography angiography (OCTA) were collected. BCVA was measured with Snellen chart and converted to the logarithmic minimum angle of resolution (logMAR) unit for statistical analysis. RTVue XR OCTA was used to measure vascular densities (VD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and radial peripapillary capillary (RPC), and central retinal thickness (CRT). All RAO eyes attempted IAT treatment and 34 eyes were successful. Four eyes failed to complete IAT because of the occlusion of internal or common carotid arteries on the same side with the RAO eyes. Ocular examinations in post-operative 1-3 days were performed with the same devices and methods as those before surgery. Parameters measured before and after surgery include BCVA, VD of SCP, DCP, RPC, and CRT. Data of the green channel collected include the time intervals from onset of RAO to first presentation in local hospitals, and from onset of RAO to our eye stroke center. Comparisons of VD and CRT between the RAO eyes and contralateral healthy eyes were performed with independent samples Mann-Whitney U test; comparisons of VD and CRT in RAO eyes before and after IAT surgery were performed with paired samples Wilcoxon Rank Sum test. Results:Among the 34 RAO patients who had successful IAT surgery, 18 (52.9%, 18/34) were males and 16 (47.1%, 16/34) were females; the mean age was (51.0±12.9) years old. There were 30 and 4 eyes diagnosed as central RAO and branch RAO respectively. The logMAR BCVA before and after IAT surgery was 2.52±0.61 and 2.18±0.85 respectively, and the difference was statistically significant ( Z=-3.453, P=0.002). Before surgery, VD of SCP, DCP and RPC were significantly decreased and CRT was significantly increased in the affected eye compared with the contralateral healthy eyes, with the statistical significance ( P<0.001). Compared with those before surgery, the VD of SCP and DCP were significantly improved after surgery ( Z=-2.523, -2.427; P=0.010, 0.014), while there was no difference in VD of RPC and CRT ( Z=-1.448, -1.454; P=0.150, 0.159). The time interval between onset of RAO and first visit to the hospital was (6.56±6.73) hours; the time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early postoperative period and no cerebrocardiovascular events were observed later. he time interval between onset of RAO and the arrival at our hospital was (24.11±19.90) hours. No cerebral stroke was observed in the early postoperative period and no cerebrocardiovascular events were observed later. Conclusions:The short-term efficacy and safety of IAT in the treatment of RAO were satisfactory. The rescue time window might be prolonged.

A single-center retrospective clinical study on comprehensive treatment for 157 patients with retinoblastoma / 中华眼底病杂志

Objective:To evaluate the efficacy and safety of comprehensive treatment for retinoblastoma (RB).Methods:A retrospective clinical study. From January to December in 2019, 157 cases (203 eyes) of RB who were diagnosed by the Department of Ophthalmology of Xinhua Hospital and received comprehensive treatment were included in this study. Of cases, 76 were male, and 81 were female; 111 were unilateral, and 46 were bilateral. The medium of age at diagnosis was 20.1 months. All patients received treatment for the first time. Patients with intraocular tumors were divided into A-E stages, extraocular stage and distant metastasis according to international intraocular RB classification standard. The median follow-up time was 37.4 months. Clinical features, treatment, prognosis and ocular complications of all cases were recorded.Results:Among 157 cases (203 eyes), 137 cases (180 eyes) were in intraocular stage; 6, 14, 10, 98, and 52 of eyes were in A-E stages, respectively. Twelve cases (12 eyes) were in extraocular stage; 8 cases (11 eyes) were in distant metastasis stag; 8 cases died due to distant metastasis; 149 cases (94.9%, 149/157) survived; 48 eyes were enucleated, 34 of which underwent initial enucleation, and 14 eyes underwent enucleation after eye-preserving treatment. The overall global salvage rate was 155 eyes (76.4%,155/203), and that after eye-preserving treatment was 91.7% (155/169). Severer eye for bilateral cases was taken into account for statistic; 120 cases (120 eyes) received initial eye-preserving treatment. Among them, 36 and 84 eyes underwent initial intravenous chemotherapy (IVC) and initial intra-arterial chemotherapy (IAC), respectively. The enucleation of the two groups was 7(19.4%, 7/36), 7(8.3%, 7/84); 33 (91.7%, 33/36) and 33 (39.3%, 33/84) eyes received the second treatment, respectively. There was no significant difference in the rate of enucleation between the two treatments ( χ2=2.037, P=0.154). There was significant difference in the percentage of secondary treatment ( χ2=27.937, P<0.001). Fifty-four eyes (45.0%, 54/120) stabilized after initial treatment, and 66 eyes (55.0%, 66/120) underwent secondary treatments due to poor response or tumor recurrence. For 66 eyes receiving secondary treatments, enucleation, IAC, intravitreous chemotherapy (IVitC), IAC combined with IVitC, and laser and/or cryotherapy was performed in 6, 18, 12, 13, and 17 eyes, respectively. The number of eyes of enucleation among the IAC, IVitC, and IAC combined with IVitC group was 5 (27.8%, 5/18), 1 (9.3%, 1/12), and 2 (15.4%, 2/13) eyes, which was no significantly different ( χ2=2.001, P=0.368). Until the last follow-up, visual acuity outcomes were acquired in 148 eyes (72.9%, 148/203). Among them, 41, 53, 16 and 38 eyes had no light perception, light perception to finger counting, 20/400, and ≥20/200, respectively. In total, among 203 eyes, 121 eyes received IAC, of which 2, 4, and 1 eyes had optic disc atrophy, vitreous hemorrhage, and severe retinal-choroidal atrophy, respectively; 60 eyes received IVitC, of which one and one eye had vitreous hemorrhage and macular hemorrhagic necrosis, respectively. Conclusions:In this study, the overall survival rate was 94.9% after comprehensive treatment and the rate of global salvage after eye-preserving treatment was 91.7%. The comprehensive treatment of retinoblastoma had a relatively high efficacy and safety.

The value of cell division cycle 42 in the efficacy and prognosis evaluation of arterial infusion chemotherapy for pancreatic cancer / 肿瘤研究与临床

Objective:To explore the value of cell division cycle 42 (CDC42) in the efficacy and prognosis evaluation of arterial infusion chemotherapy for pancreatic cancer.Methods:The clinical data of 100 patients with pancreatic cancer who underwent arterial infusion chemotherapy from January 2018 to January 2020 at Second People's Hospital of Wuhu were retrospectively analyzed, and all patients were divided into effective group (the complete remission and partial remission) and ineffective group (the stable disease and the progressive disease) according to the chemotherapy efficacy determined by CT. The clinicopathological characteristics of both groups were compared. The influencing factors of chemotherapy efficacy were determined by using multivariate logistic regression model analysis. The efficacy evaluated by CT examination was treated as the gold standard. The receiver operating characteristic (ROC) curve was used to analyze the value of CDC42 level predicting the efficacy of arterial infusion chemotherapy for pancreatic cancer patients before infusion chemotherapy. Survival analysis was performed by using Kaplan-Meier and log-rank test was also performed.Results:Among 100 patients with pancreatic cancer, there were 13 cases of complete remission, 30 cases of partial remission, 20 cases of stable disease, 37 cases of progressive disease; 43 cases in effective group and 57 cases in ineffective group. The proportions of tumor long diameter > 4 cm, TNM staging Ⅲ-Ⅳ, carcinoembryonic antigen (CA)199 > 37 U/ml, carcino-embryonic antigen (CEA) > 5 ng/ml, neutrophil-to-lymphocyte (NLR) > 2.8, serum total bilirubin > 34.2 μmol/L before infusion, CDC42 ≤ 1.11 μg/L, low differentiation degree and vascular invasion in ineffective group were higher than those in effective group (all P < 0.05). Tumor long diameter > 4 cm, TNM staging Ⅲ-Ⅳ, CA199 > 37 U/ml, CEA > 5 ng/ml before infusion, low differentiation degree, vascular invasion, and CDC42 ≤ 1.11 μg/L were independent risk factors for effectiveness of arterial infusion chemotherapy (all P < 0.05). The area under the ROC curve of CDC42 predicting the ineffectiveness of arterial infusion chemotherapy was 0.810 (95% CI 0.781-0.839, P <0.01), and the optimal cut-off value was 1.11 μg/L, the sensitivity was 96.25%, and the specificity was 63.13%. Survival curve analysis showed that the 2-year overall survival rate of patients with CDC42 > 1.11 μg/L was 58.93% which was greater than that of patients with CDC42 ≤ 1.11 μg/L (22.73%), and the difference was statistically significant ( χ2 = 14.99, P<0.001). Conclusion:CDC42 level is an independent influencing factor for the efficacy of arterial infusion chemotherapy in patients with pancreatic cancer, and it can effectively predict the prognosis of patients.

A rare case of cerebral hemorrhage associated with intra-arterial infusion chemotherapy for advanced sphenoid sinus cancer

Central nervous damage related to intra-arterial infusion chemotherapy (IAC) for head and neck cancer reported to date are cerebral infarction, transient ischemic attack, and neuropathy. There have been no reports of cerebral hemorrhage as an IAC-related complication for head and neck cancer. Authors report a case that underwent intra-arterial infusion chemoradiotherapy for advanced sphenoid sinus cancer which extended to the left cavernous sinus and cranium, subsequently suffered cerebral hemorrhage thought to have been caused by IAC. Treatment should be performed with greater caution when the head and neck cancer involves the cavernous sinus or cranium, as in the present case

Development of stage and clinical treatment for adenoid cystic carcinoma of lacrimal gland / 国际眼科杂志(Guoji Yanke Zazhi)

@#Adenoid cystic carcinoma of lacrimal gland is the most common malignant epithelial tumor of the lacrimal gland, and surgical treatment alone shows unsatisfactory result. In recent years, as the application of radiotherapy and chemotherapy, changes have happened in the treatment modality for adenoid cystic carcinoma of lacrimal gland. On one hand, clinical staging is gradually refined, which promote the application of standardized comprehensive treatment. On the other hand, neoadjuvant therapies, such as proton radiotherapy, neutron radiotherapy and intra-arterial cytoreductive chemotherapy, can further improve the application of eye-sparing surgery, decrease the rate of local recurrence and metastasis, and prolong the disease-free survival. In this review, we attempt to arrive at some general insights regarding the progress of treatment in adenoid cystic carcinoma of lacrimal gland, in order to provide new reference basis.

Outcomes of neonatal retinoblastoma in pre-chemotherapy and chemotherapy eras

Purpose: To quantify outcomes for neonatal retinoblastoma patients treated during the pre-chemotherapy (1980�1994) and chemotherapy (1995�2018) eras. Methods: Retrospective review of retinoblastoma patients diagnosed within the first 28 days of life between 1/1/1980 and 11/30/2018. Student's t-test, Chi-square, and Fisher's exact test were performed to compare treatments and outcomes by era. Results: There were 68 patients with neonatal retinoblastoma (12% unilateral and 88% bilateral). According to era (pre-chemotherapy vs. chemotherapy), the number of treated patients was 26 (38%) vs. 42 (62%). Primary treatment was external beam radiotherapy (50% vs. 1%,P < 0.001), plaque radiotherapy (17% vs. 0%,P < 0.001), focal treatment (transpupillary thermotherapy or cryotherapy) only (21% vs. 14%,P= 0.33), intravenous chemotherapy (0% vs. 81%,P < 0.001), enucleation (10% vs. 4%,P= 0.26), or exenteration (2% vs. 0%,P= 0.37). Outcomes included tumor control (79% vs. 94%,P= 0.02), globe salvage (75% vs. 91%,P= 0.02), final gross visual acuity for salvaged eyes 20/200 or better (66% vs. 89%,P < 0.01), and death (19% vs. 0%,P < 0.01). Conclusion: Chemotherapy advancements for neonatal retinoblastoma have improved tumor control, globe salvage, visual acuity, and patient survival.

Intra-arterial chemotherapy in retinoblastoma – A paradigm change

Intra-arterial chemotherapy (IAC), also known as superselective ophthalmic artery chemotherapy or chemosurgery, is currently widely accepted as one of the primary treatment modalities for intraocular retinoblastoma worldwide. Following the introduction of the technique in 1998, IAC has evolved over the past decades to be safer and more effective. Accumulated evidence shows that IAC is more effective in providing eye salvage in group D and E retinoblastoma as compared to conventional systemic intravenous chemotherapy (IVC). In contrast to IVC, IAC has the added benefits of reduced overall treatment duration and minimal systemic toxicity. This review provides a comprehensive update on the history, technique, indications, contraindications, and outcome of IAC. We have also identified the strengths, weaknesses, opportunities and threats (SWOT analysis) of the technique in this review.

In-utero ultrasonography detection of fetal retinoblastoma and neonatal selective ophthalmic artery chemotherapy

We report a case of non-familial, sporadic fetal retinoblastoma (RB) that was accidently detected at 39 weeks of gestation on pre-natal ultrasonography in left eye (OS). Post-natal examination revealed Group A and, Group D RB in right eye (OD) and OS, respectively. At 35 days, selective ophthalmic artery intra-arterial chemotherapy (IAC) was performed in OS and laser for OD. Pre-natal ultrasound and its application in RB are limited to those cases with a strong genetic predisposition. Our case was accidently detected at late gestation with no familial or genetic predisposition. In addition, this was the youngest reported case that received IAC on literature review.

Consenso sobre accidente cerebrovascular isquémico agudo / Consensus on acute ischemic stroke

El accidente cerebrovascular es la tercera causa de muerte y la primera de discapacidad en la Argentina. Los eventos isquémicos constituyen el 80% de los casos. Los accidentes vasculares cerebrales requieren la implementación de protocolos sistematizados que permitan reducir los tiempos en la atención, la morbilidad y mortalidad. En el consenso participaron especialistas de nueve sociedades médicas relacionadas con la atención de pacientes con enfermedad cerebrovascular. Se consensuó un temario separado en capítulos y para la redacción de los mismos se conformaron grupos de trabajo con miembros de diferentes especialidades médicas. Se discutió y acordó para cada tema el nivel de recomendación en base a la mejor evidencia clínica disponible para cada tópico. Se realizó una adaptación al ámbito local de las recomendaciones cuando se consideró necesario. El sistema de la American Heart Association se utilizó para redactar las recomendaciones y su grado de evidencia. La corrección y edición fue realizada por cinco revisores externos, que no participaron en la redacción y con amplia experiencia en enfermedad vascular. Finalizado el documento preliminar, se organizó una reunión general con todos los integrantes de los grupos de trabajo y los revisores para redactar las recomendaciones definitivas. El consenso abarca la atención del paciente con accidente cerebrovascular isquémico en la fase pre-hospitalaria, evaluación inicial en la central de emergencias, terapias de recanalización (trombolisis y/o trombectomía mecánica), craniectomía descompresiva, neuroimágenes y cuidados clínicos en la internación.

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

Current Assessment and Management of Retinoblastoma / 임상소아혈액종양

Retinoblastoma is the most common intraocular malignancy in childhood. Diagnosis is currently made by ophthalmologists under general anesthesia as it is the gold standard for intraocular assessment. However, evaluations for extraocular disease are also necessary. Treatment strategies vary according to the disease status. If a single eye is involved, the treatment goal is oriented to the removal of the tumor and prevention of relapse. In bilateral retinoblastoma, the main treatment goal is to save monocular vision and save life. This article will explore the available treatment options for retinoblastoma including enucleation, radiotherapy, local therapy, intravenous chemotherapy, intra-arterial injection and intra-vitreal injections. There were recent advances in our understanding on the genetic pathophysiology of the retinoblastoma protein gene in tumorigenesis, which may help developing future treatment. Early detection of retinoblastoma is important for prolonging survival and improving quality of life.

Anesthesia management of selective ophthalmic intra-arterial chemotherapy for retinoblastoma / 上海交通大学学报（医学版）

Objective: To investigate the safety of treatment with ophthalmic artery cannulation for intra-arterial chemotherapy (IAC) in children with retinoblastoma (RB) during general anesthesia. Methods: A total of 60 children with RB who underwent ocular artery interventional chemotherapy under general anesthesia in Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine from September 2015 to August 2018 were collected. Induction of anesthesia was performed with rapid induction of endotracheal intubation with midazolam, fentanyl, propofol and rocuronium. Sevoflurane and oxygen were administered for maintenance of general anesthesia, with intermittent injection of rocuronium and fentanyl. Intraoperative continuous monitoring of hemodynamic parameters, respiratory parameters (EtCO2, oxygen saturation and inspiratory peak pressure) and sevoflurane minimum alveolar concentration (MAC) was performed, and intraoperative pulmonary compliance, hypoxemia, hypotension and other cardiopulmonary adverse events were observed and recorded. Results: Over a 3-year period, 185 treatment sessions were performed in 60 patients. Thirty-two cardiopulmonary adverse events were observed in 20 patients, and the incidence rate was 17.2%, mainly including severe decrease in lung compliance, hypoxemia and arterial hypotension. All severe decreases in lung compliance occurred within 1 or 2 minutes after catheter insertion in the ophthalmic artery. After active treatment with propofol, phenylephrine and epinephrine, no death and permanent sequelae occured. Conclusion: An appreciable incidence of trigeminocardiac reflex to intra-ophthalmic artery infusion of chemotherapy in patients with RB is found. Both interventionalists and anesthesiologists should be aware of this potential event and be prepared to provide immediate resuscitative measures.

Advances in the research of transcatheter arterial thrombolysis for severe frostbite therapy / 中华烧伤杂志

Severe frostbite (grade Ⅲ to Ⅳ) is a common disease accompanied with high disability rate in cold regions, especially for military training and disaster events in cold regions. The treatment of severe frostbite mainly includes rapid rewarming in the early stage and amputation in the later stage; while the damage of vascular endothelial cells, microvascular thrombosis, and decreased tissue perfusion secondary to severe frostbite are important factors affecting prognosis. Transcatheter arterial thrombolysis is a new technique for the treatment of severe frostbite. It has the advantages of minimally invasive, high safety, and significantly reduced amputation rate. We reviewed the advances in the research of transcatheter arterial thrombolysis for the treatment of severe frostbite.

Selective intra-arterial cold saline infusion combined with intravascular reperfusion for acute ischemic stroke with large artery occlusion: a preliminary safety and feasibility study / 国际脑血管病杂志

Objective To preliminarily investigate the safety and feasibility of intra-arterial cold saline infusion combined with intravascular reperfusion for acute ischemic stroke with large artery occlusion. Methods From March 2016 to March 2018, consecutive acute ischemic stroke patients with large artery occlusion within 8 h after onset admitted to the Department of Neurology, the People's Hospital of Longhua District, Shenzhen and recanalized successfully after endovascular treatment were enrolled. After recanalization, cold saline was infused through the guiding catheter via the ipsilateral guilty vessel (10 ℃, 33 ml/min for 30 min). Results A total of 20 patients were enrolled, including 15 males. Their median age was 67 years (interquartile range, 53-80 years). Fifteen patients were treated with thrombolysis. A median onset-to-needle time was 300 min (interquartile range, 260-360 min). During the infusion of cold saline, the lowest rectal temperature was only decreased 0. 1 ℃, but within 5 min after completion of perfusion, it returned to the temperature before perfusion. Complications associated with intra-arterial hypothermia were not observed. The median National Institutes of Health Stroke Scale score was significantly decreased from 21 (interquartile range 15-55) before needle to 15 (interquartile range 10-16; Z = -4. 549, P < 0. 001) at discharge. Conclusion Selective intra-arterial cold saline infusion combined with intravascular reperfusion for acute ischemic stroke with large artery occlusion is safe and feasible.

The Evolution of the Neurosurgical Treatment of Ischemic Stroke

The neurosurgical approach to the management of ischemic stroke has evolved dramatically over the past century with the bulk of these changes occurring over the past 25 years. With recent advances in technology and continued refinements in neurosurgical techniques there has been significant improvement to the safety and efficacy of our treatment options. The focus of this article will be to review the historical and recent reports in the literature related to revascularization techniques.

Experience in intra-arterial chemotherapy using two protocols for the treatment of OSCC over two decades at the University Hospital Vienna

OBJECTIVES: This retrospective study performed a comprehensive analysis of the usage of intra-arterial chemotherapy (iaCh) for locally recurrent UICC stage IV oral squamous cell carcinoma (OSCC) over two decades at the Department of Cranio-Maxillofacial and Oral Surgery at the University Hospital Vienna to assess the utility of its future use. METHODS: Between 1994 and 2014, iaCh was indicated in 48 OSCC cases. In these, the two most frequent iaCh schemes, cisplatin/5-fluorouracil (Cis/5-FU) and methotrexate/bleomycin (MTX/Bleo), were chosen for further analysis. The effect on survival of two distinct intra-arterial protocols and their covariates were analyzed with the Kaplan-Meier method as well as univariate and multivariate Cox proportional hazard regression models. RESULTS: The mean follow-up period was 29.91 months. The two intra-arterial chemotherapy groups did not differ significantly in sample size, demographic data or therapeutic covariates. The Cis/5-FU iaCh regimen was associated with significantly better overall survival (median OS 2.6 years vs. 1.3 years; p=0.002) and had a beneficial effect on survival (HR=3.62, p=0.015). Side effects occurred at a frequency similar to that described in the literature for intravenous chemotherapy (ivCh). CONCLUSIONS: These results suggest a preference for administering Cis/5-FU for iaCh. Nevertheless, due to economic considerations in healthcare expenditures, there is no future for iaCh in the treatment of head and neck carcinomas because ivCh is known to be equivalent.

Intra-arterial Thrombectomy with Stent Retriever for Acute Ischemic Stroke ­ a Retrospective, Single-centered Study from Brazil

Objective To report our initial experience with intra-arterial thrombectomy (IAT) with stent retriever for acute ischemic stroke. Methods We conducted a retrospective review of patients with acute ischemic stroke who underwent IAT from September 2010 to August 2016. Results Forty-one patients were included; mean age was 57 years (range: 29­85), and 54% were women. There were 32 anterior circulation occlusions, and 11 posterior circulation occlusions. The mean value of the National Institutes of Health Stroke Scale (NIHSS) upon admission (available in 9/41 patients) was 14 (range: 6­20). Nineteen patients had favorable outcomes (modified Rankin Scale [mRS]: 0­2 at 6 months), and 22 had unfavorable outcomes (mRS: 3­6 at 6 months). The mortality rate was 37% (15/41). Favorable outcomes were associated with revascularization within the first 360 minutes of the onset of symptoms (p » 0.000001), and satisfactory revascularization (thrombolysis in cerebral infarction [TICI] scale: 2b or 3) (p » 0.0018). Conclusion It is of paramount importance to educate stroke teams on the benefits of IAT for acute ischemic stroke and the population on identifying stroke and seeking immediate care following symptom onset.

Objetivo Relatar nossa experiência inicial com trombectomia intra-arterial (TIA) com uso de stent retriever em acidente vascular encefálico isquêmico (Avei) agudo. Métodos Análise retrospectiva de pacientes com Avei submetidos a TIA de setembro de 2010 a agosto de 2016. Resultados Foram incluídos 41 pacientes; a idade média foi 57 anos (intervalo: 29­85), e 54% dos pacientes eram mulheres. Trombos ocluindo vasos da circulação anterior foram encontrados em 32 casos, e 11 na circulação posterior. A média do valor da Escala de Acidente Vascular Encefálico do National Institutes of Health (NIH) na admissão (disponível para 9 dos 41 pacientes) foi 14 (intervalo: 6­20). Um total de 19 pacientes teve resultados favoráveis (Escala de Rankin modificada [ERm]: 0­2 em 6 meses), e 22 tiveram resultados não favoráveis (ERm: 3­6 em 6 meses). A mortalidade foi de 37% (15/41). Resultados favoráveis foram associados com revascularização dentro dos primeiros 360 minutos de instalação dos sintomas (p » 0.000001) e revascularização satisfatória (escala de trombólise em infarto cerebral [TEIC]: 2b ou 3) (p » 0.0018). Conclusão É de suma importância educar as equipes de acidente vascular encefálico sobre os benefícios da TIA para Avei agudo, e a população, na identificação do Avei, para que seja buscado atendimento imediato após o início dos sintomas.

Embolización de metástasis hepáticas en insulinoma maligno: de la hipoglicemia a la hiperglicemia / Embolisation of liver metastasis in malignant insulinoma: from hyperglycaemia to hypoglycaemia

Resumen Se describe el caso de un paciente de 75 años sin antecedentes de relevancia, que fue diagnosticado con insulinoma maligno en estado avanzado, con metástasis hepáticas, con síntomas por hipoglucemia hiperinsulinémica refractaria al tratamiento, y con diazóxido y octreotide de acción corta. El paciente presentó una respuesta clínica poco esperada a la embolización transarterial de metástasis hepáticas, pues a pesar de que persisten las lesiones tumorales, desarrolló hiperglucemia persistente y requirió manejo con insulina. Adicionalmente, se hace una breve revisión de la literatura sobre las opciones terapéuticas disponibles para el tratamiento sintomático de la hipoglucemia hiperinsulinémica.

Abstract The case is presented of a 75 year-old man who was diagnosed with malignant insulinoma in an advanced stage with diffuse liver metastases and symptoms due to hyperinsulinaemic hypoglycaemia refractory to treatment with diazoxide and short-acting octreotide. The patient had an unexpected clinical response to trans-arterial embolisation of liver metastases, since, despite still having the tumour, he developed persistent hyperglycaemia that required insulin treatment. A brief review of the literature is also presented on the treatment options for hyperinsulinaemic hypoglycaemia.

Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success / 대한뇌졸중학회지

The overwhelming clinical benefit of intra-arterial stroke therapy owes to the major advance in revascularization brought on by the current generation of thrombectomy devices. Nevertheless, there remains a sizeable proportion of patients for whom substantial reperfusion cannot be achieved or is achieved too late. This article addresses the persistent challenges that face neurointerventionists and reviews technical refinements that may help to mitigate these obstacles to procedural success. Insights from in vitro modeling and clinical research are organized around a conceptual framework that examines the interaction between the device, the thrombus and the vessel wall.