Mechanical Thrombectomy and Functional Outcomes After Stroke

To the Editor The 2015 American Heart Association/American Stroke Association focused update for the early management of acute ischemic stroke recommended endovascular therapy as an adjunctive therapy to intravenous thrombolysis.¹ Dr Badhiwala and colleagues² performed a meta-analysis regarding endovascular thrombectomy for acute ischemic stroke and found that endovascular thrombectomy was associated with improved functional outcomes (odds ratio [OR], 1.56 [95% CI, 1.14-2.13]; P = .005) and no significant difference in all-cause mortality (OR, 0.87 [95% CI, 0.68-1.12]; P = .27) at 90 days compared with standard medical care. The authors included the SYNTHESIS (Intra-arterial vs Systemic Thrombolysis for Acute Ischemic Stroke) expansion trial,³ which randomized patients with acute ischemic stroke to receive endovascular therapy alone (without intravenous tissue plasminogen activator [tPA]) vs tPA. We argue that the SYNTHESIS study³ should have been excluded from the analysis because it is fundamentally different from the other included studies. Including SYNTHESIS in the Badhiwala et al analysis could have underestimated the effect of interventional treatment on important outcomes.