Introduction
Recent evidence has prompted an interim revision of the existing 2022 Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, related to the delivery of endovascular treatment for patients with acute ischemic stroke.Reference Heran, Lindsay and Gubitz1 This manuscript presents an update of the recommendations for endovascular treatment, addressing the issues of posterior circulation stroke, stroke with large core and stroke with medium vessel occlusion (MeVO).
These updated recommendations supersede the endovascular thrombectomy (EVT) recommendations included in the 2022 publication of the CSBPR acute stroke management module only as they pertain to these topics.Reference Heran, Lindsay and Gubitz1 Additional resources to support timely implementation and quality monitoring are available at www.strokebestpractices.ca.
Methodology
The methodology for the development of the CSBPR has been previously publishedReference Heran, Lindsay and Gubitz1 and can be found in detail at www.strokebestpractices.ca. Interim analyses are undertaken when new evidence emerges for a topic covered within the module that has a direct impact on current practice and warrants an immediate shift in the recommendations ahead of the prescheduled full module update.
For the interim analysis, the chairs and expert advisors of the acute stroke management scientific writing group were convened, and a structured literature review was conducted (to April 2025). The evidence was synthesized, and draft recommendations were developed. These underwent review by a broader set of collaborators, and final wording was confirmed through consensus.
Synthesis of the literature
Over the past decade, the use of EVT for acute ischemic stroke has evolved, particularly in terms of patient selection criteria. Initially, EVT was limited to individuals with anterior circulation large vessel occlusion (LVO), small infarct core (Alberta Stroke Program Early CT Score [ASPECTS] ≥ 6) and treatment within a narrow time window (typically up to 6 hours from symptom onset). The superiority of EVT over best medical management was established in landmark trials such as MR CLEAN,Reference Berkhemer, Fransen and Beumer2 ESCAPEReference Goyal, Demchuk and Menon3 and SWIFT PRIME.Reference Saver, Goyal and Bonafe4 Subsequent studies, including DAWNReference Nogueira, Jadhav and Haussen5 and DEFUSE 3,Reference Albers, Marks and Kemp6 expanded eligibility to patients presenting up to 24 hours from last known well, provided there was a mismatch between clinical deficit and infarct core identified through advanced imaging. More recently, trials including SELECT-2,Reference Sarraj, Hassan and Abraham7 ANGEL-ASPECTReference Huo, Ma and Tong8 and TENSIONReference Bendszus, Fiehler and Subtil9 have further studied the benefits of EVT in patients with larger infarct cores (e.g., ASPECTS 3–5 or core volumes up to 100–150 mL). Treatment with EVT has been explored for the treatment of basilar artery occlusions (ATTENTION,Reference Tao, Nogueira and Zhu10 BAOCHE Reference Jovin, Li and Wu11 and BASICSReference Langezaal, van der Hoeven and MontAlverne12) and for medium and distal occlusions (ESCAPE-MeVOReference Goyal, Ospel and Ganesh13 and DISTALReference Psychogios, Brehm and Ribo14).
Evidence from a series of trials suggests that EVT without intravenous thrombolysis was not non-inferior to thrombectomy preceded by thrombolysis with alteplase in eligible patients.Reference Majoie, Cavalcante and Gralla15 The BRIDGE-TNK trial found that outcomes were better in patients who received both tenecteplase and thrombectomy than those receiving thrombectomy alone.Reference Qiu, Li and Sang16
The treatment of patients with medium to large core infarcts has been investigated in several recent trials using various inclusion criteria. LASTE,Reference Costalat, Jovin and Albucher17 TENSION,Reference Bendszus, Fiehler and Subtil9 ANGEL-ASPECTReference Huo, Ma and Tong8 and SELECT-2,Reference Sarraj, Hassan and Abraham7 all enrolled patients with anterior circulation LVO and low ASPECTS scores or large infarct volumes. LASTE included 333 patients with ASPECTS 0–5 (if less than 80 years old) identified on non-contrast CT, randomized within 6.5 hours of symptom onset. TENSION enrolled 253 patients with ASPECTS 3–5, on baseline CT or diffusion-weighted imaging – magnetic resonance imaging (DWI-MRI) and occlusion defined by computed tomography angiography (CTA) or magnetic resonance angiography (MRA), treated within 12 hours. SELECT-2 included 352 patients with ASPECTS 3–5 or infarct core measuring 50–100 mL using CT perfusion or DWI-MRI, with a treatment window of up to 24 hours. ANGEL-ASPECTS included 456 patients with either an ASPECTS of 3–5 (regardless of core volume) or an ASPECTS of 0–2 with an infarct core volume of 70–100 mL, assessed within 24 hours of symptom onset. Additionally, patients with ASPECTS >5 were included only if they had a core volume between 70 and 100 mL and presented between 6 and 24 hours after onset.
All four trials were stopped early as EVT was associated with significantly improved functional outcomes (favorable shift in the distribution of modified Rankin scores (mRS) at 90 days compared to best medical management alone). The benefit was consistent across subgroups, including those with ASPECTS as low as 3 and large core volumes. While symptomatic intracranial hemorrhage (sICH) occurred more frequently in the EVT group, overall mortality was either unchanged or reduced. The results were similar in RESCUE-Japan LIMIT,Reference Yoshimura, Sakai and Yamagami18 although less benefit was seen in this trial. The TESLA trial,Reference Yoo, Zaidat and Sheth19 which included patients with ASPECTS 2–5 up to 24 hours from last known well, was terminated early due to slow enrollment but did not find a significant difference in mean average utility-weighted mRS score at 90 days nor in the percentage of patients with an mRS score of 0–2 at 90 days (14.5% vs. 8.9%, relative risk (RR) = 1.64, 95% confidence intervals (CI) 0.86–3.12), although it did find a higher percentage of patients with an mRS score of 0–3 at 90 days in the EVT group. Across all trials, the majority of patients (61%–69%) were dead or severely disabled at 90 days, despite EVT.
The use of EVT for MeVOs, including occlusions in the M2/M3 segments of the middle cerebral artery (MCA), anterior cerebral artery (ACA) and posterior cerebral artery (PCA), was investigated in several trials. In the ESCAPE-MeVO trial,Reference Goyal, Ospel and Ganesh13 EVT in addition to best medical management was not associated with benefit compared with best medical management alone. The likelihood of the primary outcome (mRS 0–1 at 90 days) was not significantly higher in the EVT group (adjusted common RR = 0.95, 95% CI 0.79 to 1.15), nor was the likelihood of an mRS score of 0–2 at 90 days (adjusted RR = 0.92, 95% CI 0.80 to 1.05). Mortality was significantly higher in the EVT group (13.3% vs. 8.4%, hazard ratio (HR) = 1.82, 95% CI 1.06 to 3.12), as was the incidence of serious adverse events (33.9% vs. 25.7%). The DISTAL trial,Reference Psychogios, Brehm and Ribo14 which included 543 patients with an isolated occlusion of medium or distal vessels (M2 [44.0%], M3 [26.9%], M1 [13.4%], P2 [13.4%] and P1 [5.5%] segments), found no significant difference between groups in the distribution of mRS scores at 90 days (median mRS score was 2 vs. 2; common OR = 0.90; 95% CI 0.67 to 1.22). Preliminary results from the DISCOUNT trial (NCT05030142), which was terminated early following the first interim analysis, also suggest harm associated with EVT treatment. The primary outcome (mRS 0–2 at 90 days) occurred in significantly fewer patients undergoing EVT than best medical management (60% vs. 77%; adjusted OR = 0.42, 95% CI 0.2–0.88) and sICH occurred more often in the EVT group (12% vs. 6%).
Intra-arterial thrombolysis administered following EVT may help dissolve residual thrombus in distal vessels, potentially enhancing microvascular reperfusion and functional outcomes without a significant increase in the risk of sICH. Preliminary results presented at the International Stroke Conference in 2025, from the ANGEL-TNK (NCT05624190) and PEARL trials (NCT05856851) (both not yet published) suggest that patients with anterior circulation LVO infarcts who achieved near-complete or complete reperfusion (expanded Thrombolysis in Cerebral Infarction score of 3 or 2b50) following EVT and received thrombolysis with either tenecteplase or alteplase post-EVT had higher odds of having an mRS score of 0–1 at 90 days. There were no differences between the groups in the percentage of patients who experienced sICH. In three previous trials, including ATTENTION-IA,Reference Hu, Tao and Wang20 POST-UKReference Liu, Guo and Li21 and POST-TNK,Reference Huang, Yang and Liu22 patients who received intra-arterial thrombolysis did not have a higher likelihood of achieving an mRS score of 0–1 at 90 days compared with patients who did not receive thrombolysis, nor did thrombolysis reduce the risk of 90-day mortality. The CHOICE trialReference Renú, Millán and San Román23 was terminated early after enrolling 121 patients (1,825 planned) due to slow enrollment during the Covid-19 pandemic. A significantly higher percentage of patients who were treated with intra-arterial alteplase (0.225 mg/kg) achieved an mRS score of 0–1 at 90 days compared with those who received placebo (59% vs. 40.4%, adjusted risk difference = 18.4%, 95% CI 0.3%–36.4%, p = .047).
For large artery occlusions in the posterior circulation, four Randomized Controlled Trial (RCTs) have compared EVT with best medical management only. In the BEST trial, which was terminated early due to a high rate of crossovers and low enrollment,Reference Liu, Dai and Ye24 the proportion of patients with a favorable outcome (mRS 0–3) at 90 days was significantly higher in the EVT group based on the per-protocol and as-treated analyses, though not according to the intention-to-treat analysis. In the BASICS trial,Reference Langezaal, van der Hoeven and MontAlverne12 the percentage of patients in the EVT group who experienced a favorable (mRS 0–3) or excellent (mRS 0–2) outcome at 90 days was not significantly higher in the EVT group. The results of these two RCTs and three observational studies were pooled in a systematic review by Katsanos et al,Reference Katsanos, Safouris and Nikolakopoulos25 which found no significant difference between the groups for the primary outcome of mRS score 0–3 at 90 days (RR = 0.97, 95% CI 0.64–1.47), mRS 0–2, all-cause mortality or functional outcome (ordinal shift analysis), with significant heterogeneity. More recently, the ATTENTION trial,Reference Tao, Nogueira and Zhu10 which included 342 patients, presenting within 12 hours of symptom onset with National Institutes of Health Stroke Scale (NIHSS) ≥10, found a significantly higher percentage of patients achieving mRS score 0–3 in the EVT group compared to the medical management group (46.0% vs. 22.8%; adjusted RR = 2.06, 95% CI 1.46 to 2.91, number needed to treat (NNT) = 4). Mortality at 90 days was also lower (36.7% vs. 55.3%: adj RR = 0.66, 95% CI 0.52 to 0.82, NNT = 5.4). A similar benefit of EVT was also demonstrated in the BAOCHE trial,Reference Jovin, Li and Wu11 which included 217 patients enrolled 6–24 hours after symptom onset and with NIHSS ≥6. Enrollment was halted early due to the superiority of thrombectomy, whereby the odds of a favorable outcome (mRS 0–3) at 90 days were significantly higher in that group (46% vs. 24%, adjusted OR = 1.81, 95% CI 1.26 to 2.60, NNT = 4.5).
Sedation
A limited number of RCTs have specifically compared the use of general anesthesia versus conscious sedation during EVT. The results are conflicting. Results from the AMETIS trialReference Chabanne, Geeraerts and Begard26 indicated that conscious sedation increased the probability of a good outcome (mRS 0–2) at 90 days by 29%, although 10.9% of the conscious sedation patients converted to general anesthesia. Previous single-center trials including GOLIATH,Reference Simonsen, Yoo and Sørensen27 AnStroke TrialReference Löwhagen Hendén, Rentzos and Karlsson28 and SIESTA trialsReference Schönenberger, Uhlmann and Hacke29 reported that general anesthesia was associated with better outcome (mRS 0–2 at 90 days). In those three studies, up to 15% of cases planned for conscious sedation were converted to general anesthesia. Preliminary results from the SEdation Versus General Anesthesia for Endovascular Therapy in Acute Ischemic Stroke (SEGA, NCT03263117) also suggest that general anesthesia was associated with a significantly higher likelihood of functional independence measured by mRS at 90 days (odds ratio (OR) = 1.22). A systematic review including the results of GOLIATH, AnStroke and SIESTA, in addition to data from a pilot study of 40 patients,Reference Campbell, Diprose and Deng30 found that the odds of successful recanalization and good functional outcome were significantly higher in the general anesthesia group (OR = 2.14, 95% CI 1.26–3.62, p = 0.005 and OR = 1.71, 95% CI 1.13–2.59; p = 0.01, respectively), with no significant differences between groups in the risk of mortality or intracerebral hemorrhage. A Cochrane reviewReference Tosello, Riera and Tosello31 included the results of seven RCTs and reported on both short- and long-term outcomes. In the short-term (≤1 month), general anesthesia was not associated with better early neurological recovery or stroke-related mortality but was associated with a decreased risk of adverse events and greater likelihood of artery revascularization. In the long term (>1 month), the likelihood of having a good functional outcome (mRS ≤ 2) at 90 days was not significantly higher in the general anesthesia group.
The outcomes of patients who received general anesthesia or conscious sedation have also been examined within the landmark EVT RCTs. Using the results from seven RCTs (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE and THRACE), Campbell et al.Reference Campbell, van Zwam and Goyal32 performed a patient-level meta-analysis comparing the outcomes of patients randomized to the EVT groups who had received general anesthesia or not. The odds of improved outcome without general anesthesia were significantly higher in ordinal analysis of mRS scores. The authors estimated that for every 100 patients treated under general anesthesia, 18 patients would have worse functional outcome, including 10 who would not achieve functional independence. There was no increased risk of 90-day mortality associated with general anesthesia.
CSBPR interim recommendations for EVT, update 2025
These recommendations replace existing recommendations contained in the 2022 CSBPR Acute Stroke Management Module, Section 5.4: Endovascular Thrombectomy.Reference Heran, Lindsay and Gubitz1
5.4 Endovascular Thrombectomy for Acute Ischemic Stroke
5.4.1 Endovascular Thrombectomy Selection Criteria and Management
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i. EVT should be offered within a coordinated system of care, including coordination among emergency medical services, access to rapid neurovascular (brain and vascular) imaging, the emergency department, the stroke team and radiology, local experts in neuro intervention, anesthesia and access to a stroke unit for ongoing management [Strong recommendation; High quality of evidence].
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ii. EVT is indicated in patients based on imaging selection, most commonly performed with non-contrast CT head and CT angiography (including extracranial and intracranial arteries) [Strong recommendation; High quality of evidence].
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iii. EVT may be indicated in patients who have received intravenous thrombolysis, as well as those who are not eligible for intravenous thrombolysis [Strong recommendation; High quality of evidence].
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iv. Intravenous thrombolysis should be provided to all eligible patients, including those patients who are also eligible for EVT [Strong recommendation; High quality of evidence].
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a. For patients who are also eligible for intravenous thrombolysis, this should be initiated while simultaneously preparing the angiography suite for EVT [Strong recommendation; High quality of evidence]. Treatment with either intravenous thrombolysis or EVT should not be delayed for any reason.
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b. For patients undergoing EVT following or concurrently with the administration of intravenous thrombolysis, there should not be a delay in proceeding to EVT to determine clinical effectiveness of thrombolysis [Strong recommendation; High quality of evidence].
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v. EVT should be offered to all patients meeting four eligibility criteria: patient, symptom, occlusion and brain tissue criteria [Strong Recommendation; High Quality Evidence].
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a. Patient criteria:
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1. Age greater than 18 years
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AND
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2. Baseline independent function
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b. Symptom criteria:
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1. Disabling acute ischemic stroke (e.g., NIHSS >5)
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AND
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2. Last known well within 24 hours.
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c. Occlusion criteria:
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1. Relevant intracranial occlusion of a large vessel of the anterior circulation (e.g., intracranial ICA, MCA-M1) OR relevant occlusion of the basilar artery
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AND
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2. The occlusion is technically accessible in the opinion of the treating neurointerventionalist.
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d. Brain parenchyma criteria:
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1. Assessment of the estimated volume of infarcted tissue as seen on imaging, using CT and CT angiography-based assessment of collaterals, or CT and CT perfusion, or MRI. In the anterior circulation, a ‘small core’ is usually consistent with an ASPECTS score of 6 or greater and a ‘moderate core’ is usually consistent with an ASPECT score of 3–5.
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vi. Decisions about EVT should be undertaken in a team approach involving a physician with stroke expertise and a neurointerventionalist, on the basis of shared decision-making with the individual with stroke, and their family/substitute decision-maker [Strong recommendation, Moderate quality evidence].
5.4.1 Clinical Considerations
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1. When a patient who is eligible for both intravenous thrombolysis and EVT presents directly to an EVT-capable hospital, a decision not to administer intravenous thrombolysis and proceed straight to EVT must balance both the patient-related and operational factors in play at that moment, for that patient. The overarching focus is to improve patient outcomes while safely reducing door-to-needle and door-to-puncture times. The main driver for an excellent outcome remains ‘time is brain’.
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2. Plain CT, CTA with assessment of collaterals and/or perfusion imaging may all be used to assess the volume of core infarct in patients eligible for thrombectomy. In patients who are beyond 6 hours from last known well, CTA collaterals or perfusion imaging should be used to identify the candidates most likely to benefit.
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3. Outcomes after EVT for acute ischemic stroke can be difficult to predict. However, the greatest likelihood of excellent functional outcome (mRS 0–1) is seen in patients with baseline functional independence, who are treated early after symptom onset and who have a small amount of infarcted core on parenchymal imaging.
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4. Patient age, comorbidities, baseline functional status, frailty and the degree of ischemic damage (core – e.g. ASPECTS 6–10 vs. ASPECTS 3–5) are clinically relevant variables that all contribute to determining prognosis. All of these variables should be taken into account when considering EVT in patients who do not meet guideline-based criteria.
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5. Patients with a moderate to large core of infarcted tissue in the anterior circulation who are otherwise eligible for EVT may do better with EVT than with medical management alone, though determining candidacy for EVT must clearly take into account all relevant variables including age, comorbidities, functional status and frailty. In cases where prognosis is poor, as determined by the degree of established infarction/core based on imaging findings, treatment may not be indicated.
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6. At present, data from randomized clinical trials do not support the uniform use of EVT in patients with MeVOs (M2, A2 or P2). Patients with these occlusions in these locations who are otherwise eligible may be considered for EVT after consultation between a physician with stroke expertise and the neurointerventionalist.
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7. Evidence for the use of intra-arterial thrombolysis in conjunction with EVT is continuing to be explored. More data are required before making a recommendation regarding IA thrombolysis.
5.4.2 Sedation for Endovascular Interventions
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i. For endovascular interventions, procedural sedation is generally preferred over intubation and general anesthesia for most patients undergoing EVT [Strong recommendation; Moderate quality of evidence].
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ii. General anesthesia is appropriate if medically indicated (e.g., for airway compromise, respiratory distress, depressed level of consciousness, severe agitation or other indication potentially impairing the technical ability to perform the procedure, as determined by the treating physician). General anesthesia may also be considered when technical complexity is anticipated during the stroke intervention. In such cases, excessive and prolonged hypotension and time delays should be avoided [Strong recommendation; Moderate quality of evidence].
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iii. A process should be in place at EVT enabled centers to activate notification of Anesthesiology without delay when deemed necessary for patients who meet criteria for EVT [Strong recommendation; Moderate quality of evidence].
Note: Refer to www.strokebestpractices.ca for additional information on pre- and post-procedural care of an individual undergoing EVT.
Summary
These updated recommendations reflect the emerging and evolving evidence supporting EVT for acute ischemic stroke. Specifically, the results of recent randomized trials demonstrate that patients with basilar artery occlusion stroke benefit from EVT, while patients with MeVO stroke do not. Several trials have now reported that carefully selected patients with moderate sized infarcts (e.g., ASPECTS 3–5) achieve better functional outcomes with EVT than with medical management alone. However, the prognosis of these patients is much poorer as compared to those with ASPECTS >5, and combined with other clinical factors, careful selection of patients is still required. There was consensus among the writing group that a nuanced consideration of all relevant variables including baseline independence, comorbidities and frailty should be taken into account when considering each patient’s candidacy for EVT. There has been no change to the fact that EVT should be offered within an integrated and coordinated system of care that minimizes door-to-imaging and door-to-puncture times in order to optimize patient outcomes. Efforts should be made to implement these updated recommendations at stroke centers across Canada.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/cjn.2025.10444.
Acknowledgments
Heart & Stroke gratefully acknowledges the Acute Stroke Management writing group leaders and members, all of whom have volunteered their time and expertise to the update of these recommendations. Members of the Canadian Stroke Consortium were involved in all aspects of the development of these recommendations. We acknowledge and thank M. Patrice Lindsay, senior editor and co-writer of this manuscript, and Norine Foley and the evidence analysis team at workHORSE. These recommendations underwent external review by Andrew Demchuk, Jai Shankar, Michael Kelly and Robert Fahed. The Heart & Stroke internal teams contributed to the dissemination and publication of these recommendations (Translation, Communications, Knowledge Translation, Lived Experience Engagement Support, Health Systems and Digital Solutions).
Author contributions
Manraj Heran (First Author) and Michel Shamy (Senior Author) are cochairs of the 2022 Acute Stroke Management expert writing group and the 2025 update working group and are lead authors contributing to all aspects of the development, data analysis, writing, editing and final approval of this manuscript; David Volders is incoming chair of the acute stroke management writing group and contributor to the development and writing of this manuscript; Michael D Hill, Dyan Blacquiere, Anita Mountain and Gord Gubitz are expert advisors to the acute writing group and contributors to the development and writing of this manuscript; M. Patrice Lindsay is senior editor and a corresponding author involved in all aspects of scientific literature review, writing group deliberations, external review process and manuscript preparation. Rebecca Lund is Manager Stroke at the Heart and Stroke Foundation and a contributor to this manuscript and supporting documents and also a corresponding author. Norine Foley conducted the evidence searches and completed the evidence tables and evidence summaries supporting this guideline update and contributed to the writing of this manuscript.
Funding statement
The development of the CSBPR is funded by Heart & Stroke. No funds for the development of these recommendations come from commercial interests, including pharmaceutical and device companies. Writing group members and external reviewers are volunteers who do not receive any remuneration for their participation. All participants complete a conflict-of-interest declaration prior to participating.
Competing interests
The following authors have identified actual or potential conflicts of interest which have been mitigated through the design of a multidisciplinary writing group model and additional measures by the advisory committee as required. David Volders receives consulting fees from Penumbra. M Patrice Lindsay receives consulting fees from the Canadian Neurological Sciences Federation, received an honorarium from CHEP Plus, paid to self, and voluntary member of Canadian Institutes for Health Research – Institute for Circulatory and Respiratory Health advisory board. Michael D Hill holds research grants from NoNO Inc. for the ESCAPE-NA1 trial, ESCAPE-NEXT trial; Canadian Institutes for Health Research for the ESCAPE-NA1 trial, ESCAPE-NEXT trial; Medtronic for the ESCAPE-MeVO Study; Canadian Institutes for Health Research for the TEMPO-2 trial; Heart and Stroke Foundation of Canada for the TEMPO-2 trial; Consulting fees from Sun Pharma and Brainsgate Inc. – Paid work for adjudication of clinical trial outcomes; Patents – US Patent 62/086,077 Licensed to Circle NVI, US Patent 10,916,346 Licensed to Circle NVI; Data Safety Monitoring Board Chair – Oncovir Hiltonel trial (end 2023) and DUMAS trial (end 2023); Data Safety Monitoring Board member ARTESIA trial (end 2023); BRAIN-AF trial (end 2023); LAAOS-4 trial (ongoing); President – Canadian Neurological Sciences Federation (not for profit); Stock – Circle Inc., Basking Biosciences – Private stock ownership. Dylan Blacquiere received payment or honoraria for support for travel/presentation from Diabetes Canada; participation on a data safety Advisory board, Roche Canada; Board Member, Canadian Stroke Consortium; Advisory Board Chair, Canadian Stroke Best Practice Recommendations (voluntary). Anita Mountain holds grants or contracts as a Qualified site investigator for research supported by Brain Canada, Heart and Stroke Foundation of Canada, Canadian Partnership for Stroke Recovery/CIHR/Governors of the University of Calgary. No payments to self. Support for research coordinator and research activities related to research grants from primary organization; Leadership or fiduciary role as Rehabilitation co-chair for Canadian Stroke Best Practice Recommendations Advisory Committee, no payments. Michel Shamy holds research grants from the Heart and Stroke Foundation, University of Ottawa Department of Medicine, Brain Heart Interconnectome, Canadian Institutes for Health Research, New Frontiers in Research funder. The following authors have no conflicts of interest to declare: Manraj KS Heran, Gord Gubitz, Rebecca Lund and Norine Foley.
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