Kevin O’Connor, MD

Morey JR, Oxley TJ, Wei D, Kellner CP, Dangayach NS, Stein L, Hom D, Wheelwright D, Rubenstein L, Skliut M, et al. Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke: The NYC MIST Trial. Stroke. 2020;51:3495–3503.

Paradigms for stroke care include the drip-and-ship (DS) model and the mothership model, which prioritize minimizing time to intravenous thrombolysis and time to endovascular therapies, respectively. Possible sites of care include acute stroke ready hospitals (ASRHs), primary stroke centers (PSCs), thrombectomy-capable stroke centers (TSCs), and comprehensive stroke centers (CSCs). An additional model is the Mobile Interventional Stroke Team (MIST; “drip-and-drive”), comprising an interventional specialist and radiological technologist that travels to a TSC to perform acute endovascular procedures. In a prospective observational study, Morey et al. compared the MIST (n=64), DS (n=114), mothership (n=20), and hybrid DS/MIST (n=30) models in New York City.

The study found that the MIST and mothership models appeared to lead to better selected process metrics and improved early outcomes. MIST and mothership subjects had lower mean initial door-to-puncture (MIST, 144.4 minutes; mothership, 114 minutes) and initial door-to-recanalization times (MIST, 215 minutes; mothership, 193 minutes). Time delays inherent to the DS model (i.e., time at primary stroke center, transfer time) led to a mean initial door-to-recanalization time 83 minutes longer than the MIST model (298 minutes; 95% CI, 42.4–123.7, P<0.01). The mean initial door-to-puncture times and initial door-to-recanalization times for the DS and DS/MIST models were comparable. A larger proportion of MIST patients (n=22, 37.9%) had an NIHSS score of 0 or 1 at 5 days or at discharge compared to either the DS (n=19, 16.7%; P=0.0025) or DS/MIST (n=4, 14.3%; P=0.0315) models.

The median time from Emergency Medical Services contact to initial door was comparable for all models. The TSC/CSC door-to-puncture time for the DS (53 minutes) and DS/MIST models (48 minutes) was shorter than for the MIST (131 minutes) and mothership (103 minutes) models. There was no difference in median modified Rankin Scale (mRS) scores at 90-days between the models; however, the MIST model was associated with a tendency toward better outcomes (mRS ≤ 2; MIST 52.8% vs DS 38.9%; P=0.095).

As models of stroke care delivery continue to evolve, MIST may become an important option in some regions, particularly those with higher population densities. Generalizability to more rural areas is unclear.