Outcomes of thrombolytic therapy in acute ischemic stroke: mothership, drip-and-ship, and ship-and-drip paradigms

Abstract

Background: Chulalongkorn Stroke Center is a comprehensive stroke center (CSC) located in Bangkok, Thailand. Our stroke network consists of different levels of spoke hospitals, ranging from community hospitals where thrombolytic treatment is not available, to those capable of onsite thrombolytic therapy. This study aimed to assess the time to treatment and outcomes among acute ischemic stroke patients who received thrombolytic treatment in the Chulalongkorn Stroke Network by 1.) Direct arrival at the CSC (mothership) 2.) Telestroke-assisted thrombolytic treatment with secondary transfer to the CSC (drip-and-ship) 3.) Referral from community hospital to the CSC for thrombolytic treatment (ship-and-drip).Methods: Acute ischemic stroke patients who received thrombolytic treatment during January 2016-December 2017 in the Chulalongkorn Stroke Network were studied. Time to treatment and clinical outcomes were compared among treatment groups.Results: There were 273 patients in the study including 147, 87, and 39 patients in mothership, drip-and-ship, and shipand-drip paradigms, respectively. The door-to-needle-time (DTN) and onset-to-needle-time (OTN) times were significantly longest in ship-and-drip group (146.5 ± 62/205.03 ± 44.88 mins) compared to mothership (38 ± 23/155.2 ± 60.54 mins) and drip-and-ship (63.0 ± 44/166.09 ± 87 mins), P < 0.05. There was no significant difference regarding functional independence defined by modified Rankin Scale (mRS) ≤ 2 at 3 months (P = 0.12), in-hospital mortality (P = 0.37), mortality at 3 months (P = 0.73), and symptomatic intracerebral hemorrhage (P = 0.24) among groups.Conclusion: Thrombolytic treatment with drip and ship method under teleconsultation is feasible in Thailand. There was no difference of clinical outcome among the 3 treatment paradigms. However, DTN time and OTN time were longest in the ship-and-drip paradigm.

Stroke Incidence, Rate of Thrombolytic Therapy, Mortality in Thailand from 2009 to 2021

“…Outcomes of patients with acute ischemic stroke treated with rtPA by internist or an emergency physician under the guidance of a neurologist, the results were not different from the neurologist [9], [10]. Therefore, the mortality rate for patients with acute ischemic stroke treated with rtPA in each health area was similar as shown in Table 10.…”

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

“…Then, 21 articles were filtered based on the exclusion criteria, while the rest was researched further (n = 19). Therefore, 19 articles were included in our study: 12 retrospective articles, 11,13,15,19,22,24,27–30,32,33 2 RCTs, 14,23 and 5 prospective papers. 10,12,16,18,31 These studies were conducted in the USA (n = 5), 11,15,16,22,29 Thailand (n = 1), 19 Germany (n = 3), 10,18,30 Australia (n = 2), 14,28 South Korea (n = 3), 14,31,33 Ireland (n = 1), 27 and France (n = 3).…”

“…Therefore, 19 articles were included in our study: 12 retrospective articles, 11,13,15,19,22,24,27–30,32,33 2 RCTs, 14,23 and 5 prospective papers. 10,12,16,18,31 These studies were conducted in the USA (n = 5), 11,15,16,22,29 Thailand (n = 1), 19 Germany (n = 3), 10,18,30 Australia (n = 2), 14,28 South Korea (n = 3), 14,31,33 Ireland (n = 1), 27 and France (n = 3). 12,24,32 Other studies were conducted throughout international multicenters.…”

“…10,21,30–32 A similar trend could be seen when reporting the stroke-related mortalities. Only six studies 13,16,19,22,27,32 reported a clear higher percentage of deaths in the MS group. All the functional independence results indicate a clear advantage for the MS model.…”

“…The main factor that determines good response to MT is the time of intervention that is measured with door to groin puncture and time of achieving meaningful recanalization (grade 2 b or 3 of reperfusion). 10–19 Comprehensive stroke programs have invested considerable time and effort to improve the time to treatment and thus improve outcome. The distance and time to a comprehensive stroke center (CSC) can pose challenges on how best to improve time to groin puncture for LVOs.…”