title: Drip 'n Ship Versus Mothership for Endovascular Treatment: Modeling the Best Transportation Options for Optimal Outcomes.
abstract: There is uncertainty regarding the best way for patients outside of endovascular-capable or Comprehensive Stroke Centers (CSC) to access endovascular treatment for acute ischemic stroke. The role of the nonendovascular-capable Primary Stroke Centers (PSC) that can offer thrombolysis with alteplase but not endovascular treatment is unclear. A key question is whether average benefit is greater with early thrombolysis at the closest PSC before transportation to the CSC (Drip 'n Ship) or with PSC bypass and direct transport to the CSC (Mothership). Ideal transportation options were mapped based on the location of their endovascular-capable CSCs and nonendovascular-capable PSCs.
  
  
  
  Probability models for endovascular treatment were developed from the ESCAPE trial's (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) decay curves and for alteplase treatment were extracted from the Get With The Guidelines decay curve. The time on-scene, needle-to-door-out time at the PSC, door-to-needle time at the CSC, and door-to-reperfusion time were assumed constant at 25, 20, 30, and 115 minutes, respectively. Emergency medical services transportation times were calculated using Google's Distance Matrix Application Programming Interface interfaced with MATLAB's Mapping Toolbox to create map visualizations.
  
  
  
  Maps were generated for multiple onset-to-first medical response times and door-to-needle times at the PSCs of 30, 60, and 90. These figures demonstrate the transportation option that yields the better modeled outcome in specific regions. The probability of good outcome is shown.
  
  
  
  Drip 'n Ship demonstrates that a PSC that is in close proximity to a CSC remains significant only when the PSC is able to achieve a door-to-needle time of ≤30 minutes when the CSC is also efficient.
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Matthew S W
authors.initials: MS
authors.lastname: Milne
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Jessalyn K
authors.initials: JK
authors.lastname: Holodinsky
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Anders
authors.initials: A
authors.lastname: Nygren
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Chao
authors.initials: C
authors.lastname: Qiu
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.).
authors.forename: Mayank
authors.initials: M
authors.lastname: Goyal
authors.affiliation: From the Department of Biomedical Engineering, Schulich School of Engineering, Calgary, Alberta, Canada (M.S.W.M., A.N.); Department of Clinical Neurosciences, Hotchkiss Brain Institute (M.D.H., N.K.), Departments of Medicine, Radiology and Community Health Sciences (M.D.H., M.G.), and Departments of Community Health Sciences (J.K.H., M.D.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Alberta, Canada (C.Q.). nrkamal@ucalgary.ca.
authors.forename: Noreen
authors.initials: N
authors.lastname: Kamal
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000628:therapy*; D057510:Endovascular Procedures; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: endovascular therapy; probability; stroke; tissue-type plasminogen activator; uncertainty