Drip-and-Ship Versus Mothership Transport for Acute Ischemic Stroke: Meta-Analysis Stratified by Stroke-System Integration

Drip-and-Ship Versus Mothership Transport for Acute Ischemic Stroke: Meta-Analysis Stratified by Stroke-System Integration

Authors: Martins GS, Lima OGS, Oliveira HP, Nascimento LR, Oliveira Junior T, Günkan A, Ferreira MY, Bocanegra-Becerra JE, Serulle Y
Journal: Journal of Emergency Medicine, May 2026

Conclusions:

  • Direct transport to a thrombectomy-capable center—the mothership model—was associated with faster reperfusion and better 90-day functional outcomes than initial transport to a local hospital followed by transfer.

  • The functional advantage of mothership transport persisted regardless of how well integrated the regional stroke system was.

  • Successful recanalization, symptomatic intracranial hemorrhage, and mortality were similar between transport strategies.

  • Practical takeaway: when a large-vessel occlusion is strongly suspected and direct transport does not create an excessive delay, bypassing a non-thrombectomy hospital may improve the chance of functional independence.

Practice Takeaways:

  • For suspected large-vessel occlusion, every transfer step matters: the mothership strategy shortened time to recanalization by roughly 1.5 hours.

  • The benefit was primarily functional rather than mortality-based—patients were more likely to recover independence even though survival and procedural success were similar.

  • These findings support using validated prehospital LVO screening tools and clear bypass protocols when a thrombectomy center is reasonably accessible.

  • The study does not mean every possible LVO patient should automatically bypass the nearest hospital. The tradeoff still depends on:

    • Additional transport time

    • Thrombolysis eligibility

    • Diagnostic uncertainty

    • Weather and geography

    • EMS capability

    • Door-in-door-out performance at the closer hospital

  • A highly efficient drip-and-ship pathway may still be appropriate in rural or geographically constrained systems, but system integration alone did not erase the observed advantage of direct transport.

  • Because most included studies were observational, selection bias and differences in geography, stroke severity, and prehospital triage may partly explain the results.

Results:

  • 37 studies involving 21,644 patients were included.

  • Mean patient age:

    • Drip-and-ship: 70.1 years

    • Mothership: 70.7 years

  • Symptom onset to recanalization:

    • Mothership: 251 ± 111 minutes

    • Drip-and-ship: 347 ± 128 minutes

    • Approximate difference: 96 minutes faster with direct transport.

  • Mothership transport was associated with:

    • Higher rates of 90-day functional independence, defined as mRS 0–2.

    • Lower rates of poor functional outcome, defined as mRS 3–6.

  • Reported effect estimates:

    • Functional independence: OR 0.78 (95% CI 0.70–0.86)

    • Poor outcome: OR 1.30 (95% CI 1.17–1.45)

  • The odds ratios appear to have been calculated with drip-and-ship as the reference exposure, because their numerical direction otherwise conflicts with the authors’ stated conclusion favoring mothership transport.

  • No significant differences were found in:

    • Successful recanalization

    • Symptomatic intracranial hemorrhage

    • Mortality

  • Stroke-system integration did not significantly modify the comparative outcomes of the two transport models.

Methods:

  • Systematic review and random-effects meta-analysis of studies comparing:

    • Drip-and-ship: initial treatment at a local stroke center, with thrombolysis when appropriate, followed by transfer for thrombectomy.

    • Mothership: direct transport to a thrombectomy-capable center.

  • Databases searched:

    • PubMed

    • Embase

    • Cochrane

  • Search period extended from database inception through March 2026.

  • Studies had to report 90-day functional outcomes.

  • Outcomes included:

    • Modified Rankin Scale

    • Recanalization

    • Symptomatic intracranial hemorrhage

    • Mortality

  • Analyses were stratified by the degree of regional stroke-system integration.

Martins, G.S., de Santana Lima, O.G., Oliveira, H.P., do Nascimento, L.R., de Oliveira Junior, T., Günkan, A., Ferreira, M.Y., Bocanegra-Becerra, J.E. and Serulle, Y., 2026. Drip-and-Ship versus Mothership Model in Acute Ischemic Stroke: A Meta-analysis Stratified by Stroke System Integration. The Journal of Emergency Medicine.

 

Back to blog