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Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis
  1. Mohammad Ismail1,
  2. Xavier Armoiry2,3,
  3. Noam Tau4,
  4. François Zhu5,
  5. Udi Sadeh-Gonik6,
  6. Michel Piotin7,
  7. Raphael Blanc7,
  8. Mikaël Mazighi7,
  9. Serge Bracard5,8,
  10. René Anxionnat5,8,
  11. Emmanuelle Schmitt5,
  12. Gioia Mione9,
  13. Lisa Humbertjean9,
  14. Jean-Christophe Lacour9,
  15. Sébastien Richard9,10,
  16. Charlotte Barbier1,
  17. Bertrand Lapergue11,
  18. Benjamin Gory5,8
  1. 1 Department of Neuroradiology, University Hospital of Caen, Caen, France
  2. 2 Centre Hospitalier Universitaire de Lyon, Lyon, France
  3. 3 Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, England
  4. 4 Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
  5. 5 Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
  6. 6 Department of Diagnostic and Interventional Neuroradiology, Sourasky Medical Center, Tel Aviv, Israel
  7. 7 Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
  8. 8 University of Lorraine, INSERM U1254, IADI, F-54000, Nancy, France
  9. 9 Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France
  10. 10 Centre d’Investigation Clinique Plurithématique CIC-P 1433, INSERM U1116, University Hospital of Nancy, Vandœuvre-lès-Nancy, France
  11. 11 Department of Stroke Center, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
  1. Correspondence to Dr Benjamin Gory, Department of Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, Hôpital Central, Nancy 54035, France; b.gory{at}


Background The effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT.

Purpose To compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)).

Methods We performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis.

Results Eight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64).

Conclusions Patients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

  • stroke
  • thrombectomy
  • thrombolysis

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  • MI and XA contributed equally.

  • Contributors MI: substantial contribution to conception of the work, acquisition, analysis, and interpretation of data. XA: substantial contribution to the acquisition, analysis, and interpretation of data. NT, FZ, US-G, MP, RB, MM, SB, RA, ES, GM, LH, J-CL, SR, BL: revision of the work for important intellectual content. CB: revision of the work for important intellectual content; substantial contribution to the conception of the work, acquisition, analysis, and interpretation of data. BG: revision of the work for important intellectual content; final approval of the version published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement N/A.