Mothership versus drip-and-ship models in acute stroke care : a time-sensitive meta-analysis

Abstract

Background Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large vessel occlusion. 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 and safety outcomes between these 2 models and assess the impact of onset‐to‐groin puncture delay on outcomes. Methods We conducted a systematic review and meta‐analysis following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD420251034209). We searched PubMed, EMBASE, and Cochrane CENTRAL up to March 9, 2025. We included randomized trials, cohort studies enrolling patients with anterior circulation large vessel occlusion treated with mechanical thrombectomy. The primary outcome was 90‐day functional independence (modified Rankin Scale score, 0–2). Secondary outcomes included excellent outcome (modified Rankin Scale score 0–1), successful recanalization, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and 90‐day mortality. Risk of bias was assessed using Risk of Bias in Non‐randomized Studies of Interventions and Risk of Bias 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 (odds ratio, 1.12 [95% CI, 0.94–1.32]). 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 onset‐to‐groin time delay of approximately 43 minutes between the two models of care was identified as the threshold beyond which the mothership model conferred superior outcomes. Conclusions 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.