Systematic review of organizational models for intra-arterial treatment of acute ischemic stroke

Background Intra-arterial treatment of acute ischemic stroke requires changes to acute stroke services since most hospitals do not have on-site intra-arterial treatment facilities. Aim To identify models for delivery of intra-arterial treatment and to compare process performance and clinical and radiological outcomes of the different models. Methods We systematically searched the literature and contacted experts in the field. We performed a qualitative synthesis to identify models, and a quantitative review and meta-analysis of clinical and radiological outcomes under different organizational models. Summary of review The searches retrieved 148 publications, of which 27 were used for the identification and description of models, and 9 for the comparison of the different models. We identified four main models: the mother-ship, drip-and ship, mobile interventionist, and mobile stroke unit models. There were no randomized-controlled trials of the different models, but non-randomized comparisons were possible using data from 8 observational studies and 1 randomized-controlled trial of intra-arterial therapy, of a total of 4127 patients. Comparison between the mother-ship and drip-and-ship models showed no difference in survival (OR 0.81; 95% CI 0.63-1.03), favorable functional outcome (OR 0.96; 95% CI 0.73-1.25), or arterial patency (OR 0.89; 95% CI 0.73-1.08). Conclusions Different organizational models exist for intra-arterial treatment of acute ischemic stroke, but there is insufficient evidence to recommend a particular, universal model. Until one model can be shown to be superior, the choice of model should depend on local factors and patient characteristics.