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

INTRODUCTION

There is controversy if direct to comprehensive center "mothership" or stopping at primary center for thrombolysis before transfer to comprehensive center "drip-and-ship" are best models of treatment of acute stroke. In this study, we compare mothership and drip-and-ship models to evaluate the best option of functional outcome.

METHODS

Studies between 1990 and 2020 were extracted from online electronic databases. Clinical outcomes, critical time measurements, functional independence, and mortality were then compared.

RESULTS

A total of 7824 patients' data were retrieved from 13 publications (3 randomized control trials and 10 retrospective ones). In addition, 4639 (59.3%) patients were treated under mothership model, and 3185 (40.7%) followed the drip-and-ship model with mean age of 70.01 ± 3.58 versus 69.03 ± 3.36; p < 0.001, respectively. The National Institute Health Stroke Scale was 15.57 ± 3.83 for the mothership and 15.72 ± 2.99 for the drip-and-ship model (p ≤ 0.001). The mean symptoms onset-to-puncture time was significantly shorter in the mothership group compared to the drip-and-ship (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 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) (3-6) at 90 days in the drip-and-ship 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 mothership. 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 mothership model have significantly improved functional independence and recovery. Further studies are needed as the data from prospectively randomized studies are not of sufficient quality to make definite recommendations.

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

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.

Thrombectomy in stroke of unknown onset, wake up stroke and late presentations: Australian experience from 2 comprehensive stroke centres

Two recent randomized controlled trials (RCTs) showed selected patients treated with endovascular thrombectomy (EVT) more than 6 h from acute ischemic stroke (AIS) onset had significant improvement in functional outcome at 90 days compared with standard care alone. Our aim is to determine the outcome and predictors of good outcome in AIS patients undergoing EVT with unknown-onset, or late presentation, stroke after 6 h from time last seen well, or witnessed stroke onset, at two Australian comprehensive stroke centres. A retrospective analysis of functional outcome and mortality at 90-days from a prospective cohort of 56 consecutive patients with unknown-onset, or late presentation, stroke with large vessel occlusion (LVO) in the anterior cerebral circulation undergoing EVT over a 15-month period (2016-2017). We evaluated factors which correlated with good functional outcome defined as a 90-day modified Rankin scale (mRS) 0-2. Recanalization times and symptomatic intracranial haemorrhage (sICH) rates were also examined. A good functional outcome was achieved in 35 patients (62%). Eight patients died (14%). Median time-to-recanalization was 7.6 h. SICH occurred in four patients (7%). Factors which predicted good 90-day functional outcome included baseline National Institutes of Health Stroke Scale (NIHSS) < 16, 24 h NIHSS < 10, baseline Alberta Stroke Program Early CT Score (ASPECTS) ≥ 8, pre-procedural CT perfusion imaging and LVO lesion location. This study shows good 'real world' outcomes, comparable to published RCTs, in patients with unknown-onset, or late presentation, stroke treated with EVT more than 6 h from stroke onset.

[Outcomes of endovascular thrombectomy for acute stroke in regional vascular centers of a metropolis (St.-Petersburg)]

AIM

To assess technical results and close functional outcomes of acute ischemic stroke (AIS) in patients treated with endovascular thrombecomy (ET) in regional vascular centers (RVC) of St-Petersburg.

MATERIAL AND METHODS

Retrospective analysis of 183 patients with AIS, including 143 patients with AIS due to a large intracranial vessel occlusion in anterior (AC) and 25 patients in posterior cerebral (PC) circulation, 15 with isolated extracranial carotid occlusion treated in 6 RVC in 2017 was performed. All patients underwent ET.

RESULTS AND CONCLUSION

Effective reperfusion (mTICI 2b-3) was achieved in 71.5% (71.3% AC, 72% PC). On discharge, 35,7% patients had good (mRs 0-2) functional outcome (37.1% AC, 28% PC). The incidence of symptomatic intracranial hemorrhage (according to ECASS II criteria) was 10.7% (9.1% AC, 20% PC), the mortality was 29.2% (22.4% AC, 68% PC).). The results of our study show the possibility of effective and safe application of ET in patients with AIS in the anterior and posterior cerebral circulation in regional vascular centers of St.-Petersburg.