Mothership versus drip‐and‐ship models in acute stroke care: a time‐sensitive meta‐analysis
File(s)
Accepted version
Author(s)
D'Anna, Lucio
Type
Journal Article
Abstract
Background. Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Optimizing pre-hospital triage strategies is crucial. Whether the mothership model or the drip-and-ship model provides superior outcomes remains unclear. This systematic review and meta-analysis aimed to compare functional, procedural, and safety outcomes between these two models, and assess the impact of onset-to-groin puncture delay on outcomes.
Methods. We conducted a systematic review and meta-analysis following PRISMA guidelines, registered in PROSPERO (CRD420251034209). We searched PubMed, EMBASE, and Cochrane CENTRAL up to March 9, 2025. We included randomized trials and cohort studies enrolling patients with anterior circulation LVO treated with MT. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0–2). Secondary outcomes included excellent outcome (mRS 0–1), successful recanalization, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and 90-day mortality. Risk of bias was assessed using ROBINS-I and RoB 2.0 tools. Meta-regression was performed to evaluate the effect of onset-to-groin puncture time differences on outcomes.
Results. Nineteen studies (16,485 patients) were included. The mothership model and drip-and-ship model showed no significant difference in achieving 90-day functional independence (OR 1.12, 95% CI 0.94–1.32; p=0.199). Meta-regression showed that longer delays to thrombectomy in the drip-and-ship model significantly reduced the odds of functional independence (p<0.001). A delay of approximately 43 minutes was identified as the threshold beyond which the mothership model conferred superior outcomes. No significant differences were found in rates of excellent outcome, successful reperfusion, symptomatic hemorrhage, any intracranial hemorrhage, or mortality.
Conclusions. Although overall functional outcomes were comparable between strategies, time to thrombectomy critically influenced results. Direct transport to a thrombectomy-capable center should be prioritized when secondary transfer is expected to delay treatment, as functional outcomes worsen significantly beyond this threshold.
Methods. We conducted a systematic review and meta-analysis following PRISMA guidelines, registered in PROSPERO (CRD420251034209). We searched PubMed, EMBASE, and Cochrane CENTRAL up to March 9, 2025. We included randomized trials and cohort studies enrolling patients with anterior circulation LVO treated with MT. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0–2). Secondary outcomes included excellent outcome (mRS 0–1), successful recanalization, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and 90-day mortality. Risk of bias was assessed using ROBINS-I and RoB 2.0 tools. Meta-regression was performed to evaluate the effect of onset-to-groin puncture time differences on outcomes.
Results. Nineteen studies (16,485 patients) were included. The mothership model and drip-and-ship model showed no significant difference in achieving 90-day functional independence (OR 1.12, 95% CI 0.94–1.32; p=0.199). Meta-regression showed that longer delays to thrombectomy in the drip-and-ship model significantly reduced the odds of functional independence (p<0.001). A delay of approximately 43 minutes was identified as the threshold beyond which the mothership model conferred superior outcomes. No significant differences were found in rates of excellent outcome, successful reperfusion, symptomatic hemorrhage, any intracranial hemorrhage, or mortality.
Conclusions. Although overall functional outcomes were comparable between strategies, time to thrombectomy critically influenced results. Direct transport to a thrombectomy-capable center should be prioritized when secondary transfer is expected to delay treatment, as functional outcomes worsen significantly beyond this threshold.
Date Acceptance
2025-11-19
Citation
Journal of the American Heart Association
ISSN
2047-9980
Publisher
Wiley
Journal / Book Title
Journal of the American Heart Association
Copyright Statement
Copyright This paper is embargoed until publication. Once published the Version of Record (VoR) will be available on immediate open access.
License URL
Publication Status
Accepted