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Comment & Response
April 26, 2016

Mechanical Thrombectomy and Functional Outcomes After Stroke—Reply

Author Affiliations
  • 1Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
  • 2Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
JAMA. 2016;315(16):1792-1793. doi:10.1001/jama.2016.0389

In Reply Dr Elgendy and colleagues suggest that the SYNTHESIS1 trial should have been excluded from our meta-analysis because the endovascular therapy group did not receive intravenous tPA. At the time SYNTHESIS1 and the Interventional Management of Stroke III (IMS III)2 were designed, there was limited data on combining intravenous tPA with endovascular thrombectomy.3 The rationale for combination therapy was the yet unproven assumption that endovascular thrombectomy and intravenous tPA could work in synergy; however, there was also concern about a possible higher risk of hemorrhagic transformation, especially at full doses of tPA. Reflecting these opposing hypotheses, the SYNTHESIS1 trial aimed to evaluate direct endovascular intervention, whereas IMS III2 sought to test the safety and efficacy of endovascular therapy after intravenous thrombolysis. With the state of the available literature, we thought it would be most informative to perform an overall pooled analysis of endovascular thrombectomy (with or without intravenous tPA) vs standard medical care, and subsequent analyses stratified by concurrent use of intravenous tPA with mechanical thrombectomy. We found more favorable functional outcomes when thrombectomy was combined with intravenous tPA than when performed in isolation. This has important implications on a systems level, as it lends support to “drip-and-ship” (tPA intravenous drip and shipping patients to the angiogram catheter suite for endovascular thrombectomy) paradigms of care. Moreover, Elgendy and colleagues allude to the THERAPY and THRACE trials. Both studies have yet to be published, and only intermediary results from THRACE are available. The inclusion of incomplete data from these trials, yet selective exclusion of SYNTHESIS,1 could bias their meta-analysis.4

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