Mothership versus Drip-and-Ship Model for Mechanical Thrombectomy in Acute Stroke: A Systematic Review and Meta-Analysis for Clinical and Radiological Outcomes

Abstract

Background and Purpose Substantial uncertainty exists on the benefit of organizational paradigms in stroke networks. Here we systematically reviewed and meta-analyzed data from studies comparing functional outcome between the mothership (MS) and the drip and ship (DS) models.Methods The meta-analysis protocol was registered international prospective register of systematic reviews (PROSPERO) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Central databases were searched for randomized-controlled clinical trials (RCTs), retrospective and prospective studies comparing MS versus DS. Primary endpoints were functional independence at 90 days (modified Rankin Scale <3) and successful recanalization (Thrombolysis in Cerebral Infarction Scale [TICI] >2a); secondary endpoints were 3-month mortality and symptomatic intracranial haemorrhage (sICH). Odds ratios for endpoints were pooled using the random effects model and were compared between the two organizational models.Results Overall, 18 studies (n=7,017) were included in quantitative synthesis. MS paradigm was superior to DS model for functional independence (odds ratio, 1.34; 95% confidence interval, 1.16 to 1.55; I2=30%). Meta-regression analysis revealed association between onset-to-needle time and good functional outcome, with longer onset-to-needle time being detrimental. Similar rates of recanalization, sICH and mortality at 90 days were documented between MS and DS.Conclusions Patients with acute ischemic stroke eligible for reperfusion strategies might benefit more from MS paradigm as compared to DS. RCTs are needed to further refine best management taking into account logistics, facilities and resources.

The stroke mothership model survived during COVID-19 era: an observational single-center study in Emilia-Romagna, Italy

“…The global stroke-to-treatment time was similar in 2019 vs 2020 and it might reflect the adherence to the predefined stroke network also during the COVID-19 outbreak. Overall, the boat seemed to have survived the COVID-19 storm, although inhospital path can still be improved/shortened [11].…”

Impact of the SARS-COV-2 Pandemic on the Endovascular Treatment of Acute Stroke – an Italian Single-Center Experience

“…Keeping a pre-hospital organization around a tertiary referral center capable of thrombectomy is essential for holding the quality of care in stroke to the highest standards [ 15 , 16 ] . Recent meta-analysis have favoured the “Directly to mothership” model over the “Drip and ship” one [ 17 , 18 ] , and a study done in another Italian hospital (Ospedale Maggiore, Bologna) during the SARS-CoV-2 pandemic also shared this view [ 19 ] . However, in the specific setting of NCGH, the sudden shut down of SC and redirection of stroke patients directly to the ER-NCGH, already overwhelmed with the surge of the SARS-CoV-2 infection, may not have worked in its favour.…”

Efficacy and safety of bridging thrombolysis initiated before transfer in a drip-and-ship stroke service

“…4 Consequently, exposure times to intravenous thrombolysis before starting endovascular therapy were rather short. Furthermore, in light of the neutral results of a first randomised clinical trial investigating prehospital triage for patients with suspected LVO to enable direct transfer to an 'endovascular-ready hospital' 5 and conflicting data from observational studies, [6][7][8][9] a controversial debate regarding the optimal stroke service structure continues. 10 The basic rationale of a drip-and-ship stroke service, that is, admission to the nearest primary stroke centre, is to provide intravenous thrombolysis as early as possible.…”