Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region

You didn't report the results correctly. Both methods were a complete failure at getting to 100% recovery. You're using the tyranny of low expectations to justify failure as success!

Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region 

Sérgio Ferreira Cristina , Alberto Fior, Marta Alves, Ana Luísa Papoila, Ana Paiva Nunes

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Published: December 18, 2022 (see history)

DOI: 10.7759/cureus.32659

Cite this article as: Ferreira Cristina S, Fior A, Alves M, et al. (December 18, 2022) Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region. Cureus 14(12): e32659. doi:10.7759/cureus.32659

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Abstract

Introduction

Endovascular treatment (EVT) with mechanical thrombectomy and acute carotid stenting has become an integral part of the treatment of acute ischemic stroke with large vessel occlusion. Despite being included in the most recent stroke guidelines, only comprehensive centers can offer EVT and thus patients frequently need to be transferred from primary hospitals. We aimed to assess which pre-hospital model of care - direct admission to a comprehensive stroke center (mothership) or transfer to a comprehensive stroke center after the first admission to the nearest hospital (drip-and-ship) - had the most benefit in stroke patients in a Portuguese urban region.

Methods

We selected patients admitted to a comprehensive stroke center who underwent EVTs between January 2018 and December 2020, in Lisbon, Portugal. We used data from the Safe Implementation of Treatments in Stroke (SITS) International registry on stroke severity, previous modified Rankin Scale (mRS), time from symptom onset to the first admission, time from symptom onset to the procedure, and mRS three months post stroke. We defined an unfavorable outcome as having an mRS >2 at three months post stroke. For patients with previous mRS >2, an unfavorable outcome was defined as any increase in mRS at three months post stroke.

Results

We analyzed the data of 1154 patients, of which 407 were admitted through a mothership approach and 747 through a drip-and-ship approach. Both groups were similar regarding sociodemographic characteristics, stroke risk factors, previous disability, and stroke severity. Median onset-to-door time was higher (126 vs 110 minutes, p-value=0.002) but onset-to-procedure time was lower (199 vs 339 minutes, p-value<0.001) in the mothership group. The mothership group had a higher proportion of patients with mRS <3 at three months post stroke than the drip-and-ship group (41.3% vs 34.9%, p-value=0.035). Mortality was similar in both groups. A multivariate logistic regression model confirmed a lower probability of unfavorable outcomes with the mothership approach (OR = 0.677, 95% CI 0.514-0.892, p-value=0.006). Surprisingly, onset-to-procedure time did not have an impact on functional outcomes.

Conclusion

Our findings show that the mothership model results in better functional outcomes for patients with acute ischemic stroke with large vessel occlusion. Further studies are needed to better define patient selection for this strategy and the impact of a mothership model in comprehensive stroke centers.

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

 Since you don't tell us how many 100% recovered  from either method I can only assume both were complete failures at that. Don't try to justify your tyranny of low expectations by using weasel words of significantly improved.

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

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Ahmed Mohamed, Nida Fatima, Ashfaq Shuaib, ...

First Published May 13, 2021 Review Article Find in PubMed 

https://doi.org/10.1177/17474930211013285

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Abstract

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(Not cured?) functional independence and recovery. Further studies are needed as the data from prospectively randomized studies are not of sufficient quality to make definite recommendations.

Keywords Drip and ship, mothership, stroke, endovascular treatment

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Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis

 So neither way is effective. My effective definition is 100% RECOVERY. Will you stop using your fucking tyranny of low expectations to justify failure?

Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis

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Xiao Wu, Charles R Wira, Charles C Matouk, ...

First Published April 15, 2021 Research Article Find in PubMed 

https://doi.org/10.1177/17474930211008701

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Abstract

Background

Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients.

Methods

A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs).

Results

The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse.

Conclusion

Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients and can provide a framework for real-world data input.

Keywords Stroke, thrombectomy, transfer, outcomes

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Drip and ship versus direct to endovascular thrombectomy: The impact of treatment times on transport decision-making

What a pile of shit. Better outcomes rather than full recovery. Do these people not know what the goal for stroke is? 100% recovery for all.  And suggesting 30 minute door to needle time is wrong, it needs to be in the ambulance(negative time). 
http://journals.sagepub.com/doi/abs/10.1177/2396987318759362?platform=hootsuite

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Jessalyn K Holodinsky, Alka B Patel, John Thornton, ...

First Published February 14, 2018 Research Article

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Abstract

Introduction

In ischaemic stroke care, fast reperfusion is essential for disability free survival(How fast does it need to be?). It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke.

Materials and methods

Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google’s Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3.

Results

Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model.

Discussion

This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy.

Conclusions

Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.

Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion

So fucking what about faster treatment times? Were the results better? 100% recovery? Doesn't anyone in stroke know how to measure the correct endpoints? My god, the incompetency out there in the stroke world is amazing.
http://stroke.ahajournals.org/content/48/12/3295?etoc=

Daniel Wei, Thomas J. Oxley, Dominic A. Nistal, Justin R. Mascitelli, Natalie Wilson, Laura Stein, John Liang, Lena M. Turkheimer, Jacob R. Morey, Claire Schwegel, Ahmed J. Awad, Hazem Shoirah, Christopher P. Kellner, Reade A. De Leacy, Stephan A. Mayer, Stanley Tuhrim, Srinivasan Paramasivam, J Mocco, Johanna T. Fifi

https://doi.org/10.1161/STROKEAHA.117.018149

Stroke. 2017;48:3295-3300

Originally published November 16, 2017

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Abstract

Background and Purpose—Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model.

Methods—We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion.

Results—Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (P<0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (P=0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat (P<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship (P=0.0704).

Conclusions—Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.