1,4-dihydroxy quininib modulates the secretome of uveal melanoma tumour explants and a marker of oxidative phosphorylation in a metastatic xenograft model

Uveal melanoma (UM) is an intraocular cancer with propensity for liver metastases. The median overall survival (OS) for metastatic UM (MUM) is 1.07 years, with a reported range of 0.84-1.34. In primary UM, high cysteinyl leukotriene receptor 1 (CysLT(1)) expression associates with poor outcomes. CysLT(1) antagonists, quininib and 1,4-dihydroxy quininib, alter cancer hallmarks of primary and metastatic UM cell lines in vitro. Here, the clinical relevance of CysLT receptors and therapeutic potential of quininib analogs is elaborated in UM using preclinical in vivo orthotopic xenograft models and ex vivo patient samples. Immunohistochemical staining of an independent cohort (n = 64) of primary UM patients confirmed high CysLT(1) expression significantly associates with death from metastatic disease (p = 0.02; HR 2.28; 95% CI 1.08-4.78), solidifying the disease relevance of CysLT(1) in UM. In primary UM samples (n = 11) cultured as ex vivo explants, 1,4-dihydroxy quininib significantly alters the secretion of IL-13, IL-2, and TNF-alpha. In an orthotopic, cell line-derived xenograft model of MUM, 1,4-dihydroxy quininib administered intraperitoneally at 25 mg/kg significantly decreases ATP5B expression (p = 0.03), a marker of oxidative phosphorylation. In UM, high ATP5F1B is a poor prognostic indicator, whereas low ATP5F1B, in combination with disomy 3, correlates with an absence of metastatic disease in the TCGA-UM dataset. These preclinical data highlight the diagnostic potential of CysLT(1) and ATP5F1B in UM, and the therapeutic potential of 1,4-dihydroxy quininib with ATP5F1B as a companion diagnostic to treat MUM

High Cysteinyl Leukotriene Receptor 1 Expression Correlates with Poor Survival of Uveal Melanoma Patients and Cognate Antagonist Drugs Modulate the Growth, Cancer Secretome, and Metabolism of Uveal Melanoma Cells

Simple Summary This research investigates the disease relevance and therapeutic potential of cysteinyl leukotriene receptors in uveal melanoma (UM), a rare eye cancer that often spreads to the liver. Unfortunately, there are no therapies available to stop the spread of UM and patients are often faced with an extremely poor prognosis. We assess whether the cysteinyl leukotriene receptors (CysLT(1) and CysLT(2)) are relevant to the progression of UM. Using UM patient samples, we identified that increased levels of CysLT(1) in tumours is associated with reduced patient survival. Using UM cell lines and zebrafish models, we found that drugs targeting CysLT(1), but not CysLT(2), can alter hallmarks of cancer including cell growth, proliferation, and metabolism. This study is the first to examine the relationship of the CysLT receptors with clinical features of UM. Our data strengthen the importance of CysLT signalling in UM and suggest that antagonism of CysLT(1) may be of therapeutic interest in the disease. Metastatic uveal melanoma (UM) is a rare, but often lethal, form of ocular cancer arising from melanocytes within the uveal tract. UM has a high propensity to spread hematogenously to the liver, with up to 50% of patients developing liver metastases. Unfortunately, once liver metastasis occurs, patient prognosis is extremely poor with as few as 8% of patients surviving beyond two years. There are no standard-of-care therapies available for the treatment of metastatic UM, hence it is a clinical area of urgent unmet need. Here, the clinical relevance and therapeutic potential of cysteinyl leukotriene receptors (CysLT(1) and CysLT(2)) in UM was evaluated. High expression of CYSLTR1 or CYSLTR2 transcripts is significantly associated with poor disease-free survival and poor overall survival in UM patients. Digital pathology analysis identified that high expression of CysLT(1) in primary UM is associated with reduced disease-specific survival (p = 0.012; HR 2.76; 95% CI 1.21-6.3) and overall survival (p = 0.011; HR 1.46; 95% CI 0.67-3.17). High CysLT(1) expression shows a statistically significant (p = 0.041) correlation with ciliary body involvement, a poor prognostic indicator in UM. Small molecule drugs targeting CysLT(1) were vastly superior at exerting anti-cancer phenotypes in UM cell lines and zebrafish xenografts than drugs targeting CysLT(2). Quininib, a selective CysLT(1) antagonist(,) significantly inhibits survival (p < 0.0001), long-term proliferation (p < 0.0001), and oxidative phosphorylation (p < 0.001), but not glycolysis, in primary and metastatic UM cell lines. Quininib exerts opposing effects on the secretion of inflammatory markers in primary versus metastatic UM cell lines. Quininib significantly downregulated IL-2 and IL-6 in Mel285 cells (p < 0.05) but significantly upregulated IL-10, IL-1 beta, IL-2 (p < 0.0001), IL-13, IL-8 (p < 0.001), IL-12p70 and IL-6 (p < 0.05) in OMM2.5 cells. Finally, quininib significantly inhibits tumour growth in orthotopic zebrafish xenograft models of UM. These preclinical data suggest that antagonism of CysLT(1), but not CysLT(2), may be of therapeutic interest in the treatment of UM

FGF21 gene therapy as treatment for obesity and insulin resistance

Prevalence of type 2 diabetes (T2D) and obesity is increasing worldwide. Currently available therapies are not suited for all patients in the heterogeneous obese/T2D population, hence the need for novel treatments. Fibroblast growth factor 21 (FGF21) is considered a promising therapeutic agent for T2D/obesity. Native FGF21 has, however, poor pharmacokinetic properties, making gene therapy an attractive strategy to achieve sustained circulating levels of this protein. Here, adeno-associated viral vectors (AAV) were used to genetically engineer liver, adipose tissue, or skeletal muscle to secrete FGF21. Treatment of animals under long-term high-fat diet feeding or of ob/ob mice resulted in marked reductions in body weight, adipose tissue hypertrophy and inflammation, hepatic steatosis, inflammation and fibrosis, and insulin resistance for > 1 year. This therapeutic effect was achieved in the absence of side effects despite continuously elevated serum FGF21. Furthermore, FGF21 overproduction in healthy animals fed a standard diet prevented the increase in weight and insulin resistance associated with aging. Our study underscores the potential of FGF21 gene therapy to treat obesity, insulin resistance, and T2D.This work was supported by grants from Ministerio de Economía y Competi- tividad (MINECO) and FEDER, Plan Nacional I+D+I (SAF2014-54866R), andGeneralitat de Catalunya (2014SGR1669and ICREA Academia Award to F.B.), Spain, from the European Commission (MYOCURE, PHC-14-2015 667751) and the European Foundation for the Study of Diabetes (EFSD/MSD European Research Programme on Novel Therapies for Type 2 Diabetes,2013). V.J. was recipient of a post-doctoral research fellowship from EFSD/ Lilly. E.C., V.S., and C.M. received a predoctoral fellowship from Ministerio de Educación, Cultura y Deporte, and J.R. from Ministerio de Economía y Competitividad, Spain. The authors thank Marta Moya and Maria Molas for technical assistance.S

The role of the microenvironment in cancer progression and metastasis: an immunogenomics approach

[eng] Cancer is a heterogeneous disease, in which many cell types interact with cancer cells, forming a complex network. The crosstalk between the cancer cells and the immune microenvironment is determinant in tumor growth and dissemination. The study of tumor immunity has improved during the last years thank to the emergence of omics technologies and immunogenomics approaches. On the other side, tumor microenvironment varies significantly depending on tumor type, molecular subgroups and stage of the disease, among others. Understanding the singularities of the tumor microenvironment in these different contextures will help to improve patients’ management towards a personalized selection of immune treatments. In this thesis, we have exploited omics data by bioinformatic means for deciphering the molecular mechanisms underlying tumor progression and metastasis, as well as for the identification of new immune biomarkers for patients’ stratification that correlates with clinical outcomes. This thesis provides threeThree comprehensive immunogenomics studies covering the crosstalk between tumor-immune system and its association with clinical outcomesare presented. First, we studied the role of the immune microenvironment in uveal melanoma primary tumors. We performed a meta-analysis that associates immune infiltration with poor prognosis, and we proved the additive role of immune activation and angiogenesis in uveal melanoma progression. Second, we gave new insights in the immunogenic potential of driver mutations in GNAQ and GNAjj genes in uveal melanoma patients, and proposed a candidate target for neoantigen vaccine therapy in uveal melanoma patients. Third, we performed a pan-cancer immune characterization of metastatic samples, and demonstrated that metastatic samples in the same location share immune phenotypes regardless of their primary tumor origin. A novel clustering found a subset of metastases that could be susceptible to respond to immunotherapy, and identified CDmr expression as a candidate biomarker of high immunogenic metastases. This thesis provides three comprehensive immunogenomics studies covering the crosstalk between tumor-immune system and its association with clinical outcomes. The work presented here can pave the way for future immunogenomics studies towards precision oncology in solid tumors.[spa] El cáncer es una enfermedad heterogénea, en la que distintos tipos celulares interaccionan con las células tumorales formando una compleja red de comunicación. Esta comunicación entre el microambiente y las células cancerígenas juega un papel determinante en el crecimiento tumoral. El estudio de la inmunidad tumoral ha mejorado en los últimos años, gracias a los avances en las tecnologías ómicas y los métodos de inmunogenómica. Por otro lado, el microambiente tumoral puede variar significativamente en distintos contextos, dependiendo del tipo tumoral, estadío y subgrupo molecular, entre otros. Una correcta comprensión de estas singularidades es clave para mejorar el manejo de los pacientes, así como para el avance hacia inmunoterapias más dirigidas y efectivas. En esta tesis, se han usado distintas herramientas bioinformáticas con el objetivo de descifrar los mecanismos moleculares asociados con la progresión metastásica, y de identificar nuevos biomarcadores inmunes que correlacionan con respuesta clínica. Esta tesis contribuye al avance hacia la oncología de precisión en dos contextos tumorales. En primer lugar, se ha estudiado el papel del microambiente tumoral en melanoma uveal primario. Mediante un estudio de meta-análisis, se ha descrito que la infiltración de células inmunes está asociada con un peor pronóstico, confirmando el papel divergente del sistema inmune en esta enfermedad. Asimismo, se ha encontrado que mutaciones recurrentes en los genes GNAQ y GNAjj pueden generar inmunogenicidad y podrían ser posibles candidatos para terapias personalizadas en pacientes con melanoma uveal. En segundo lugar, hemos realizado un estudio pan-cancer en muestras metastáticas que demuestra que las metástasis en pulmón tienen un perfil inmune característico independientemente del tumor primario. Se ha identificado un subgrupo de metástasis con alta activación inmune que podrían responder a inmunoterapia, y se ha identificado la expresión del gen CDmr como candidato a biomarcador de este subgrupo. Los resultados presentados pueden servir como punto de partida para futuros estudios en inmunogenómica hacia la personalización de la inmunoterapia en tumores sólidos

Epigenomic data integration for characterization of promoter regions

Curs 2015-2016Understanding the regulatory machinery is one of the current challenges for research in cancer epigenomics. Regulation of gene expression is a complex process with many components involved in it such as histone modifications, DNA methylation and chromatin accessibility, among others. In this project we are going to explore the Blueprint database of human hematopoietic cells in order to characterize regulatory regions on samples from this dataset. For this purpose we are going to carry out a number of steps to analyse the DNA methylation, epigenomic features and RNA-seq. The characterization of methylation across 92 samples of 12 different cell types have determined that methylation state at promoters and CpG islands are cell type-specific. Exploration and integration of epigenomics in one sample of cell type monocyte was carried out. We have seen the implications of two marks studied (histone modification H3K4me3 and open chromatin state) in gene expression. This characterization of promoters functionality enabled us to create a pipeline for the identification of novel regulatory regions based in the integration of epigenomic features and RNA-seq data, which we later reproduced in four samples. This project could be a start point of a bigger project for the cell type-specific promoters discovery within the Blueprint projects.Director/a: Emanuele Reineri Co-director/a: Simon Heat

The role of the microenvironment in cancer progression and metastasis: an immunogenomics approach

Programa de Doctorat en Medicina i Recerca Translacional[eng] Cancer is a heterogeneous disease, in which many cell types interact with cancer cells, forming a complex network. The crosstalk between the cancer cells and the immune microenvironment is determinant in tumor growth and dissemination. The study of tumor immunity has improved during the last years thank to the emergence of omics technologies and immunogenomics approaches. On the other side, tumor microenvironment varies significantly depending on tumor type, molecular subgroups and stage of the disease, among others. Understanding the singularities of the tumor microenvironment in these different contextures will help to improve patients’ management towards a personalized selection of immune treatments. In this thesis, we have exploited omics data by bioinformatic means for deciphering the molecular mechanisms underlying tumor progression and metastasis, as well as for the identification of new immune biomarkers for patients’ stratification that correlates with clinical outcomes. This thesis provides threeThree comprehensive immunogenomics studies covering the crosstalk between tumor-immune system and its association with clinical outcomesare presented. First, we studied the role of the immune microenvironment in uveal melanoma primary tumors. We performed a meta-analysis that associates immune infiltration with poor prognosis, and we proved the additive role of immune activation and angiogenesis in uveal melanoma progression. Second, we gave new insights in the immunogenic potential of driver mutations in GNAQ and GNAjj genes in uveal melanoma patients, and proposed a candidate target for neoantigen vaccine therapy in uveal melanoma patients. Third, we performed a pan-cancer immune characterization of metastatic samples, and demonstrated that metastatic samples in the same location share immune phenotypes regardless of their primary tumor origin. A novel clustering found a subset of metastases that could be susceptible to respond to immunotherapy, and identified CDmr expression as a candidate biomarker of high immunogenic metastases. This thesis provides three comprehensive immunogenomics studies covering the crosstalk between tumor-immune system and its association with clinical outcomes. The work presented here can pave the way for future immunogenomics studies towards precision oncology in solid tumors.[spa] El cáncer es una enfermedad heterogénea, en la que distintos tipos celulares interaccionan con las células tumorales formando una compleja red de comunicación. Esta comunicación entre el microambiente y las células cancerígenas juega un papel determinante en el crecimiento tumoral. El estudio de la inmunidad tumoral ha mejorado en los últimos años, gracias a los avances en las tecnologías ómicas y los métodos de inmunogenómica. Por otro lado, el microambiente tumoral puede variar significativamente en distintos contextos, dependiendo del tipo tumoral, estadío y subgrupo molecular, entre otros. Una correcta comprensión de estas singularidades es clave para mejorar el manejo de los pacientes, así como para el avance hacia inmunoterapias más dirigidas y efectivas. En esta tesis, se han usado distintas herramientas bioinformáticas con el objetivo de descifrar los mecanismos moleculares asociados con la progresión metastásica, y de identificar nuevos biomarcadores inmunes que correlacionan con respuesta clínica. Esta tesis contribuye al avance hacia la oncología de precisión en dos contextos tumorales. En primer lugar, se ha estudiado el papel del microambiente tumoral en melanoma uveal primario. Mediante un estudio de meta-análisis, se ha descrito que la infiltración de células inmunes está asociada con un peor pronóstico, confirmando el papel divergente del sistema inmune en esta enfermedad. Asimismo, se ha encontrado que mutaciones recurrentes en los genes GNAQ y GNAjj pueden generar inmunogenicidad y podrían ser posibles candidatos para terapias personalizadas en pacientes con melanoma uveal. En segundo lugar, hemos realizado un estudio pan-cancer en muestras metastáticas que demuestra que las metástasis en pulmón tienen un perfil inmune característico independientemente del tumor primario. Se ha identificado un subgrupo de metástasis con alta activación inmune que podrían responder a inmunoterapia, y se ha identificado la expresión del gen CDmr como candidato a biomarcador de este subgrupo. Los resultados presentados pueden servir como punto de partida para futuros estudios en inmunogenómica hacia la personalización de la inmunoterapia en tumores sólidos

Functional Outcome of Intravenous Thrombolysis in Patients With Lacunar Infarcts in the WAKE-UP Trial

Importance: The rationale for intravenous thrombolysis in patients with lacunar infarcts is debated, since it is hypothesized that the microvascular occlusion underlying lacunar infarcts might not be susceptible to pharmacological reperfusion treatment. Objective: To study the efficacy and safety of intravenous thrombolysis among patients with lacunar infarcts. Design, Setting, and Participants: This exploratory secondary post hoc analysis of the WAKE-UP trial included patients who were screened and enrolled between September 2012 and June 2017 (with final follow-up in September 2017). The WAKE-UP trial was a multicenter, double-blind, placebo-controlled randomized clinical trial to study the efficacy and safety of intravenous thrombolysis with alteplase in patients with an acute stroke of unknown onset time, guided by magnetic resonance imaging. All 503 patients randomized in the WAKE-UP trial were reviewed for lacunar infarcts. Diagnosis of lacunar infarcts was based on magnetic resonance imaging and made by consensus of 2 independent investigators blinded to clinical information. Main Outcomes and Measures: The primary efficacy variable was favorable outcome defined by a score of 0 to 1 on the modified Rankin Scale at 90 days after stroke, adjusted for age and severity of symptoms. Results: Of the 503 patients randomized in the WAKE-UP trial, 108 patients (including 74 men [68.5%]) had imaging-defined lacunar infarcts, whereas 395 patients (including 251 men [63.5%]) had nonlacunar infarcts. Patients with lacunar infarcts were younger than patients with nonlacunar infarcts (mean age [SD], 63 [12] years vs 66 [12] years; P = .003). Of patients with lacunar infarcts, 55 (50.9%) were assigned to treatment with alteplase and 53 (49.1%) to receive placebo. Treatment with alteplase was associated with higher odds of favorable outcome, with no heterogeneity of treatment outcome between lacunar and nonlacunar stroke subtypes. In patients with lacunar strokes, a favorable outcome was observed in 31 of 53 patients (59%) in the alteplase group compared with 24 of 52 patients (46%) in the placebo group (adjusted odds ratio [aOR], 1.67 [95% CI, 0.77-3.64]). There was 1 death and 1 symptomatic intracranial hemorrhage according to Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria in the alteplase group, while no death and no symptomatic intracranial hemorrhage occurred in the placebo group. The distribution of the modified Rankin Scale scores 90 days after stroke also showed a nonsignificant shift toward better outcomes in patients with lacunar infarcts treated with alteplase, with an adjusted common odds ratio of 1.94 (95% CI, 0.95-3.93). Conclusions and Relevance: While the WAKE-UP trial was not powered to demonstrate the efficacy of treatment in subgroups of patients, the results indicate that the association of intravenous alteplase with functional outcome does not differ in patients with imaging-defined lacunar infarcts compared with those experiencing other stroke subtypes.status: publishe

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field

Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data

Background: Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. Methods: We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0–1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0–2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4–6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. Findings: Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10–2·03]; p=0·011), with low heterogeneity across studies (I 2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05–1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06–2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4–6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52–1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03–4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [<1%], adjusted OR 5·58 [1·22–25·50]; p=0·024). Interpretation: In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. Funding: None

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

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p&lt;0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between 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