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

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.

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.

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.

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.