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.