Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis

Abstract

BackgroundThe effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT.PurposeTo compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)).MethodsWe performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis.ResultsEight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64).ConclusionsPatients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy

“…Among strategies to improve EVT availability for stroke patients are telemedical stroke networks which have been shown to effectively facilitate early initiation of treatment 4,5 . In these networks patients are admitted to the nearest community hospital for telemedicine based assessment of intravenous thrombolysis (IVT) followed by transfer to the stroke center if eligibility for EVT is determined ("drip-and-ship") [6][7][8][9] . Depending on the geographical extent of stroke networks, patients may have to be transferred over long distances.…”

Organizing Healthcare for Optimal Acute Ischemic Stroke Treatment

“…32 A recent meta-analysis of observational studies showed that the 90dayoutcome is better in patients who are directly admitted to CSCs (adjusted relative risk=0.87, 95% CI=0.77-0.98). 33 However, a multicenter registry found an association between the DS paradigm and poor functional outcomes. 34 These contradictory results indicate that RCTs are needed to provide robust findings for determining the best organizational paradigm, also while applying different instruments for a prehospital triage, such as a stroke scale predicting LVO or a mobile stroke ambulance.…”

Endovascular thrombectomy at low‐volume centres: A Bayesian solution

“…Patients with a large vessel occlusion (LVO) needing EVT might profit from bypassing local stroke units avoiding the delay associated with drip and ship. 9 In contrast, the delay associated with transport to a comprehensive stroke centre with EVT capability is significant and can lead to a decrease in good functional outcome and an increase in symptomatic intracranial haemorrhage. 10 Knowing about these contradictory demands, the claim has reverberated that general interventional radiologists should be trained to perform the procedure in the setting of LVO stroke.…”