Mothership and Drip-and-Ship Strategies in Mechanical Thrombectomy for Acute Ischemic Stroke

Study objective The optimal out-of-hospital referral pathway for patients with acute ischemic stroke due to large vascular occlusion (AIS-LVO)—direct transport to a comprehensive center (mothership) versus initial evaluation at a local hospital followed by transfer (drip-and-ship)—remains controversial. This systematic review and meta-analysis aimed to evaluate the comparative effectiveness of mothership and drip-and-ship strategies on clinical outcomes. Methods We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception to March 18, 2025, to identify studies comparing mothership and drip-and-ship paradigms in AIS-LVO patients treated with mechanical thrombectomy. Random-effects meta-analyses were conducted to calculate pooled odds ratios (ORs) for primary outcomes, including 90-day modified Rankin Scale (mRS) 0 to 2, 90-day mRS 0 to 3, successful recanalization, symptomatic intracranial hemorrhage, and 90-day mortality. Results A total of 42 studies comprising 25,005 patients were included. Clinically, mothership was associated with an increased likelihood of achieving 90-day mRS 0 to 2 (OR 1.15, 95% confidence interval [CI] 1.03 to 1.29, I 2 =53%). However, no differences were observed for 90-day mRS 0 to 3 (OR 1.12, 95% CI 0.97 to 1.29; I 2 =52%), successful recanalization (OR 1.03, 95% CI 0.90 to 1.18; I 2 =60%), symptomatic intracranial hemorrhage (OR 0.84, 95% CI 0.69 to 1.02; I 2 =22%), and 90-day mortality (OR 0.99, 95% CI 0.85 to 1.15; I 2 =60%). Conclusion The mothership strategy may improve 90-day mRS 0 to 2 compared with the drip-and-ship, whereas no significant differences were observed in broader functional outcomes, recanalization rates, hemorrhagic complications, or mortality.