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Comment & Response |

Mechanical Thrombectomy and Functional Outcomes After Stroke—Reply

Jetan H. Badhiwala, MD1; Farshad Nassiri, MD1; Saleh A. Almenawer, MD2
[+] 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.
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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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April 26, 2016
Islam Y. Elgendy, MD; Deepak L. Bhatt, MD, MPH; Anthony A. Bavry, MD, MPH
1Department of Medicine, University of Florida, Gainesville
2Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
JAMA. 2016;315(16):1791. doi:10.1001/jama.2016.0380.
April 26, 2016
Filipe Brogueira Rodrigues, MD; Peter Langhorne, PhD; João Costa, MD, PhD
1Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
3Center for Evidence Based Medicine, University of Lisbon, Lisbon, Portugal
JAMA. 2016;315(16):1791-1792. doi:10.1001/jama.2016.0383.
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