Drip-And-Ship versus Direct-To-Center Stroke Patients for Mechanical Thrombectomy – Comparison within a Supraregional Stroke Network in Rural Areas

Background: Since mechanical thrombectomy (MT) became standard of care in acute stroke due to large vessel occlusion (LVO), there is increasing need to achieve reorganization of acute stroke patient pathways. We examined the outcome of patients in the context direct-to-center (DTC) versus drip-and-ship (DS) in our tertiary endovascular stroke center as part of a dedicated supraregional stroke network (NEVAS), with five assigned regional hospitals in Bavaria (maximum distance of 100 kilometers).

Methods: We analysed prospective collected data between 01/2015 and 05/2018 of patients who underwent MT. Good functional outcome was defined as modified Rankin Scale (mRS) 0-2 at 90 days follow-up. Symptomatic intracerebral haemorrhage (sICH) was defined according to SITS-MOST criteria.

Results: MT was performed in 410 patients (mean age±SD 71.5±14.0, 46.6% female, 221 DTC-and 189 DS-patients). Median NIHSS score on admission was 16 and median premorbid mRS was 0. 84% of patients suffered from LVO in the anterior circulation. Thrombolysis was applied in 62%. Both groups did not differ significantly regarding all baseline parameters besides mRS at admission showing DS-patients more severely affected (p=0.005). Successful recanalization was comparable in both groups (79.3% vs. 77.8%). Both groups benefit from the treatment with the same median NIHSS score reduction from admission to discharge (16 to 7 vs. 17 to 6). Time delay in DS-patients from onset to revascularization was 96 min (212 min vs. 308 min, p=0.001). At 90 days follow-up, DTC-patients had a non-significant better functional outcome (33.5% vs. 24.3%, p=0.056), though occurrence of sICH (3.7% vs. 4.1%, p=0.854) and mortality (31.1% vs. 34.4%, p=0.387) did not differ between the groups.

Conclusion: Although longer process times, DS-patients significantly benefit from MT without any safety concerns. These results suggest that DS might be suitable to provide MT in rural areas when DTC is not feasible.