Latest evidence on transfer efficiency and patient outcomes in mothership versus drip-and-ship models for acute stroke management: a systematic review and meta-analysis.

BACKGROUND: Acute ischemic stroke requires urgent treatment, yet geographic disparities in specialized care necessitate two transport strategies: direct transfer to comprehensive stroke centers (mothership, MS) versus initial treatment at primary centers followed by transfer (drip-and-ship, DS). Optimal routing remains uncertain, particularly with extended treatment time windows. METHODS: Systematic review and meta-analysis adhering to PRISMA/MOOSE guidelines. Literature search of PubMed, Embase, and Cochrane through October 17, 2025, identified comparative studies evaluating MS versus DS in acute stroke. Outcomes included 90-day functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), reperfusion success (TICI 2b-3), and 90 days mortality. Random-effects models pooled odds ratios. RESULTS: Twenty-eight observational studies (10,059 patients) were included; no randomized controlled trial met the final inclusion criteria. MS demonstrated superior functional independence (OR 0.83, 95%CI 0.73-0.95, p = 0.008), with stronger effects in prospective studies. No mortality difference was observed (OR 1.05, 95%CI 0.92-1.21). MS significantly increased hemorrhage risk (OR 1.41, 95%CI 1.12-1.77, p = 0.003). Reperfusion rates did not differ between models. CONCLUSION: The mothership model improves functional outcomes but elevates hemorrhage risk without mortality benefit. Direct transport to comprehensive stroke centers is recommended when geographically feasible, accompanied by intensive post-procedural monitoring. Rural settings require tailored, context-specific strategies.