Comparison of mothership versus drip-and-ship models in treating patients with acute ischemic stroke: A systematic review and meta-analysis

Abstract

Introduction There is controversy if direct to comprehensive center “mothership” (MS) or stopping at primary center for thrombolysis before transfer to comprehensive center “drip-and- ship” (DS) are best models of treatment of acute stroke. In this study, we compare MS and DS models to evaluate the best option of functional outcome. Methods Studies between 1990 and 2020 were extracted from online electronic databases. We compared the clinical outcomes, critical time measurements, functional independence and mortality were then compared. Results A total of 7,824 patients’ data were retrieved from 13 publications (3 randomized control trials and 10 retrospective ones). 4,639 (59.3%) patients were treated under MS model and 3,185 (40.7%) followed the DS model with mean age of 70.01±3.58 vs. 69.03±3.36; p< 0 .001, respectively. The National Institute Health Stroke Scale was 15.57±3.83 for the MS and 15.72±2.99 for the DS model (p=<0.001). The mean symptoms onset-to-puncture time was significantly shorter in the MS group compared to the DS (159.69 min vs. 223.89 min; p=<0.001, respectively). Moreover, the collected data indicated no significant difference between symptom’s onset to intravenous (IV) thrombolysis time and stroke onset-to-successful recanalization time (p=0.205 and p=<0.001, respectively). Patients had significantly worse functional outcome [modified rankin score (mRS)] (3-6) at 90-days in the DS model [Odds Ratio (OR): 1.47, 95% Confidence Interval (CI): 1.13-1.92, p<0.004] and 1.49-folds higher likelihood of symptomatic intracerebral hemorrhage (OR: 1.49, 95%CI: 1.22-1.81, p<0.0001) compared to MS. However, there were no statistically significant difference in terms of mortality (OR: 1.16, 95%CI: 0.87-1.55, p=0.32) and successful recanalization (OR: 1.12, 95%CI: 0.76-1.65, p=0.56) between the two models of care. Conclusion Patients in the MS model have significantly improved functional independence and recovery. Further studies are needed as the data from prospectively randomized studies is not of sufficient quality to make definite recommendations.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management

“…Despite many efforts to speed up and optimise acute stroke patient management, still only 0.8-1.3% of acute ischaemic stroke (AIS) patients receive their intravenous thrombolysis (IVT) within the so-called golden hourthe first 60 min after symptom onset, when chances of full recovery are highest. 1,2 Many reports on stroke scales, [3][4][5][6][7] emergency medical service (EMS) training and educational programmes, [8][9][10][11][12] structured EMS pre-notification to hospital stroke teams, [13][14][15] emergency department streamlining [16][17][18][19][20] and different triage pathways (mothership vs drive the doctor vs drip and ship) [21][22][23][24][25][26][27][28][29][30][31] have all demonstrated an improvement of treatment numbers and times, but timely delivery of the available and highly beneficial reperfusion therapies [IVT and mechanical thrombectomy (MT)] to AIS patients is still underachieved. Furthermore, delays in onset to treatment times correlate to longer bolus to reperfusion times in AIS patients with proximal intracranial occlusions treated with IVT.…”

Praxis der präklinischen Schlaganfallversorgung im deutschsprachigen Raum

“…Inwiefern ein längerer Transport in ein Thrombektomiezentrum unter Umgehung einer Stroke Unit mit der Möglichkeit einer CT-Diagnostik und Thrombolyse zu rechtfertigen ist, ohne den Patienten durch verzögerte Lyse zu gefährden, bleibt eine entscheidende Frage, die weiterhin Gegenstand wissenschaftlicher Kontroversen ist. [ 20 , 30 ]. Grundlage dieser Entscheidung wird immer auch die lokale Versorgungsinfrastruktur sein.…”

Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region

“…There is still ongoing debate as to which model of pre-hospital care (mothership or drip-and-ship model) offers better outcomes and regional differences might play an important role in choosing either model [16][17][18][19][20][21].…”

“…Several studies have compared outcomes from the use of the drip-and-ship and mothership models, and, although most seem to favor the mothership approach (particularly, due to higher functional independence), regional differences in geography and healthcare organization make it difficult to understand the benefit for each country and region [16][17][18][19][20][21].…”