The Stockholm Stroke Triage Project: Outcomes of Endovascular Thrombectomy Before and After Triage Implementation.

BACKGROUND AND PURPOSE: The Stockholm Stroke Triage System (SSTS) is a prehospital algorithm for detection of endovascular thrombectomy (EVT)-eligible patients, combining symptom severity assessment and ambulance-to-hospital teleconsultation, leading to a decision on primary stroke center bypass. In the Stockholm Region (6 primary stroke centers, 1 EVT center), SSTS implementation in October 2017 reduced onset-to-EVT time by 69 minutes. We compared clinical outcomes before and after implementation of SSTS in an observational study. METHODS: We prospectively recruited patients transported by Code Stroke ambulance within the Stockholm region under the SSTS, treated with EVT during October 2017 to October 2019, and compared to EVT patients from 2 previous years. OUTCOMES: shift in modified Rankin Scale (mRS) scores, mRS score 0 to 1, mRS score 0 to 2, and death (all 3 months), National Institutes of Health Stroke Scale (NIHSS) score change 24-hour post-EVT, recanalization (Thrombolysis in Cerebral Infarction 2b-3), and symptomatic intracranial hemorrhage. mRS outcomes were adjusted for age and baseline NIHSS. RESULTS: Patients with EVT in the SSTS group (n=244) were older and had higher baseline NIHSS versus historical controls (n=187): median age 74 (interquartile range, 63-81) versus 71 (61-78); NIHSS score 17 (11.5-21) versus 15 (10-20). During SSTS, median onset-to-puncture time was 136 versus 205 minutes (P<0.001). Adjusted common odds ratio for lower mRS in SSTS patients was 1.7 (95% CI, 1.2-2.3) versus controls. During SSTS, 83/240 (34.6%) versus 44/186 (23.7%) reached 3-month mRS score 0 to 1 (P=0.014), adjusted common odds ratio 2.3 (95% CI, 1.4-3.6). Median NIHSS change 24-hour post-EVT was 6 versus 4 (P=0.005). Differences in Thrombolysis in Cerebral Infarction, symptomatic intracranial hemorrhage, and death were nonsignificant. CONCLUSIONS: With an onset to arterial puncture time reduction by 69 minutes, outcomes in thrombectomy-treated patients improved significantly after region-wide large artery occlusion triage system implementation. These results warrant replication studies in other geographic and organizational circumstances.

Prehospital Triage Accuracy in Patients With Stroke Symptoms Assessed Within 6 to 24 Hours or With an Unknown Time of Onset.

BACKGROUND AND PURPOSE: The Stockholm Stroke Triage System, implemented in 2017, identifies patients with high likelihood of large vessel occlusion (LVO) stroke. A previous report has shown Stockholm Stroke Triage System notably reduced time to endovascular thrombectomy (EVT). As the indication for EVT now includes patients up to 24 hours, we aimed to assess Stockholm Stroke Triage System triage accuracy for LVO stroke and EVT treatment for patients presenting late (within 6-24 hours or with an unknown onset), put in contrast to triage accuracy within 0 to 6 hours. METHODS: Between October 2017 and October 2018, we included 2905 patients with suspected stroke, transported by priority 1 ground ambulance to a Stockholm Region hospital. Patients assessed 6 to 24 hours from last known well or with unknown onset were defined as late-presenting; those within <6 hours as early-presenting. Triage positivity was defined as transport to comprehensive stroke center because of suspected stroke, hemiparesis and high likelihood of EVT-eligible LVO per teleconsultation. RESULTS: Overall triage accuracy was high in late-presenting patients (90.9% for LVO, 93.9% for EVT), with high specificity (95.7% for LVO, 94.5% for EVT), and low to moderate sensitivity (34.3% for LVO, 64.7% for EVT), with similar findings in the early-presenting group. CONCLUSIONS: Our results may support using the Stockholm Stroke Triage System for primary stroke center bypass in patients assessed by ambulance up to 24 hours from time of last known well.

Evidence for a distinct neuro-immune signature in rats that develop behavioural disability after nerve injury.

BACKGROUND: Chronic neuropathic pain is a neuro-immune disorder, characterised by allodynia, hyperalgesia and spontaneous pain, as well as debilitating affective-motivational disturbances (e.g., reduced social interactions, sleep-wake cycle disruption, anhedonia, and depression). The role of the immune system in altered sensation following nerve injury is well documented. However, its role in the development of affective-motivational disturbances remains largely unknown. Here, we aimed to characterise changes in the immune response at peripheral and spinal sites in a rat model of neuropathic pain and disability. METHODS: Sixty-two rats underwent sciatic nerve chronic constriction injury (CCI) and were characterised as either Pain and disability, Pain and transient disability or Pain alone on the basis of sensory threshold testing and changes in post-CCI dominance behaviour in resident-intruder interactions. Nerve ultrastructure was assessed and the number of T lymphocytes and macrophages were quantified at the site of injury on day six post-CCI. ATF3 expression was quantified in the dorsal root ganglia (DRG). Using a multiplex assay, eight cytokines were quantified in the sciatic nerve, DRG and spinal cord. RESULTS: All CCI rats displayed equal levels of mechanical allodynia, structural nerve damage, and reorganisation. All CCI rats had significant infiltration of macrophages and T lymphocytes to both the injury site and the DRG. Pain and disability rats had significantly greater numbers of T lymphocytes. CCI increased IL-6 and MCP-1 in the sciatic nerve. Examination of disability subgroups revealed increases in IL-6 and MCP-1 were restricted to Pain and disability rats. Conversely, CCI led to a decrease in IL-17, which was restricted to Pain and transient disability and Pain alone rats. CCI significantly increased IL-6 and MCP-1 in the DRG, with IL-6 restricted to Pain and disability rats. CCI rats had increased IL-1ß, IL-6 and MCP-1 in the spinal cord. Amongst subgroups, only Pain and disability rats had increased IL-1ß. CONCLUSIONS: This study has defined individual differences in the immune response at peripheral and spinal sites following CCI in rats. These changes correlated with the degree of disability. Our data suggest that individual immune signatures play a significant role in the different behavioural trajectories following nerve injury, and in some cases may lead to persistent affective-motivational disturbances.

Factors facilitating or hampering nurses identification of stroke in emergency calls.

AIMS: To explore the factors that facilitate or hamper identification of stroke in emergency calls concerning patients with stroke who have fallen or been in a lying position. BACKGROUND: Early identification of stroke in emergency calls is vital but can be complicated as the patients may be unable to express themselves and the callers generally are bystanders. In a previous study, we found presentation of fall or the patient being in a lying position to be the major problem in 66% of emergency calls concerning, but not dispatched as acute stroke. DESIGN: A qualitative study using interpretive phenomenology. METHODS: Analysis of transcribed emergency calls concerning 29 patients with stroke diagnoses at hospital discharge, in 2011 and presented with fall/lying position. FINDINGS: Patients' ability to express themselves, callers' knowledge of the patient and of stroke, first call-takers' and nurses' authority, nurses' coaching and nurses' expertise skills facilitated or hindered the identification of stroke. Certain aspects are adjustable, but some are determined by the situation or on callers' and patients' abilities and thus difficult to change. Nurses' expertise skills were the only theme found to have a decisive effect of the identification of stroke on its own. CONCLUSION: To increase identification of stroke in emergency calls concerning stroke, the first call-takers' and nurses' action, competence and awareness of obstacles are crucial and if strengthened would likely increase the identification of stroke in emergency calls. In complicated cases, nurses' expertise skills seem essential for identification of stroke.

Face Arm Speech Time Test use in the prehospital setting, better in the ambulance than in the emergency medical communication center.

BACKGROUND: Prehospital identification of acute stroke increases the possibility of early treatment and good outcome. To increase identification of stroke, the Face Arm Speech Time (FAST) test was introduced in the Emergency Medical Communication Center (EMCC). This substudy aims to evaluate the implementation of the FAST test in the EMCC and the ambulance service. METHODS: The study was conducted in the region of Stockholm, Sweden during 6 months. The study population consisted of all calls to the EMCC concerning patients presenting at least one FAST symptom or a history/finding making the EMCC or ambulance personnel to suspect stroke within 6 h. Positive FAST was compared to diagnosis at discharge. Positive predictive values (PPV) for a stroke diagnosis at discharge were calculated. RESULTS: In all, 900 patients with a median age of 71 years were enrolled, 667 (74%) by the EMCC and 233 (26%) by the ambulances. At discharge, 472 patients (52%) were diagnosed with stroke/transient ischemic attack (TIA), 337 identified by the EMCC (71%) and 135 (29%) by the ambulances. The PPV for a discharge diagnosis of stroke/TIA was 51% (CI 47-54%) in EMCC-enrolled and 58% (CI 52-64%) in ambulance-enrolled patients. With a positive FAST the PPV of a correct stroke/TIA diagnosis increased to 56% (CI 52-61%) and 73% (CI 66-80%) in EMCC- and ambulance-enrolled patients, respectively. Positive FAST from EMCC was also found in 44% of patients with a nonstroke diagnosis at discharge. A stroke/TIA diagnosis at discharge but negative FAST was found in 58 and 27 patients enrolled by the EMCC and ambulances, respectively. CONCLUSIONS: The PPV of FAST is higher when used on the scene by ambulance than by EMCC. FAST may be a useful prehospital tool to identify stroke/TIA but has limitations as the test can be negative in true strokes, can be positive in nonstrokes, and FAST symptoms may be present but not identified in the emergency call. For the prehospital care situation better identification tools are needed.

Callers' Descriptions of Stroke Symptoms during Emergency Calls in Victims Who Have Fallen or Been Found Lying Down: A Qualitative Content Analysis.

Early identification of stroke symptoms is essential. The rate of stroke identification by call-takers at emergency medical communication centres (EMCCs) varies, and patients who are found in a lying down position are often not identified as having an ongoing stroke. OBJECTIVES: this study aimed to explore signs and symptoms of stroke in patients who had fallen or were found in a lying position. DESIGN: a retrospective exploratory qualitative study design was used. METHOD: a total of 29 emergency calls to EMCCs regarding patients discharged with a stroke diagnosis from a large teaching hospital in Stockholm, Sweden, in January-June 2011, were analysed using qualitative content analysis. RESULTS: during the emergency calls, the callers described a sudden change in the patient's health status including signs such as the patient's loss of bodily control, the patient's perception of a change in sensory perception, and the callers' inability to communicate with the patient. CONCLUSIONS: The callers' descriptions of stroke in a person found in a lying position are not always as described in assessment protocols describing the onset of a stroke. Instead, the symptom descriptions are much vaguer. Therefore, to increase identification of stroke during emergency calls, there is a need for an increased understanding of how callers describe stroke symptoms and communicate with the call-takers.

Impact of prehospital stroke triage implementation on patients with intracerebral hemorrhage.

Background: Little is known about how prehospital triage using large vessel occlusion (LVO) stroke prediction scales affects patients with intracerebral hemorrhage (ICH). Objectives: We aimed to investigate whether the Stockholm Stroke Triage System (SSTS) implemented in 2017 has affected timing and outcomes of acute ICH neurosurgery, and to assess system triage accuracy for ICH with a neurosurgical indication or LVO thrombectomy. Design: Observational cohort study. Methods: In the Stockholm Region, we compared surgical timing, functional outcome, and death at 3 months in patients transported by code-stroke ground ambulance who had ICH neurosurgery, 2 years before versus 2 years after SSTS implementation. We also calculated triage precision metrics for treatment with either ICH neurosurgery or thrombectomy. Results: A total of 36 patients undergoing ICH neurosurgery were included before SSTS implementation and 30 after. No significant difference was found in timing of neurosurgery [median 7.5 (4.9-20.7) versus 9.1 (6.1-12.5) h after onset], distribution of functional outcomes (median 4 versus 4), and death at 3 months [3/29 (9%) versus 5/35 (17%)] before versus after implementation, respectively. The SSTS routed a larger proportion of patients subsequently undergoing ICH neurosurgery directly to the comprehensive stroke center: 13/36 (36%) before versus 18/30 (60%) after implementation. Overall system triage accuracy for ICH neurosurgery or thrombectomy was high at 90%, with 92% specificity and 65% sensitivity. Conclusion: The SSTS, initially designed for prehospital LVO stroke triage, routed more patients with neurosurgical indication for ICH directly to the comprehensive stroke center. This did not significantly affect surgical timing or outcomes.

Higher prehospital priority level of stroke improves thrombolysis frequency and time to stroke unit: the Hyper Acute STroke Alarm (HASTA) study.

BACKGROUND AND PURPOSE: Early initiated treatment of stroke increases the chances of a good recovery. This randomized controlled study evaluates how an increased priority level for patients with stroke, from level 2 to 1, from the Emergency Medical Communication Center influences thrombolysis frequency, time to stroke unit, and whether other medical emergencies reported negative consequences. METHODS: Patients aged 18 to 85 years in Stockholm, Sweden, with symptoms of stroke within 6 hours were randomized from the Emergency Medical Communication Center or emergency medical services to an intervention group, priority level 1, immediate call of an ambulance, or to a control group with standard priority level, that is, priority level 2 (within 30 minutes). Before study start, an educational program on identification of stroke and importance of early initiated treatment was directed to all medical dispatchers and ambulance and emergency department personnel. RESULTS: During 2008, 942 patients were randomized of which 53% (n=496) had a final stroke/transient ischemic attack diagnosis. Patients in the Emergency Medical Communication Center randomized intervention group reached the stroke unit 26 minutes earlier than the control group (P<0.001) after the emergency call. Thrombolysis was given to 24% of the patients in the intervention group compared with 10% of the control subjects (P<0.001). The higher priority level showed no negative effect on other critical ill patients requiring priority level 1 prehospital attention. CONCLUSIONS: This randomized study shows negligible harm to other medical emergencies, a significant increase in thrombolysis frequency, and a shorter time to the stroke unit for patients with stroke upgraded to priority level 1 from the Emergency Medical Communication Center and through the acute chain of stroke care.

Prehospital stroke mimics in the Stockholm Stroke Triage System.

Introduction: In 2017, Stockholm implemented a new prehospital stroke triage system (SSTS) directing patients with a likely indication for thrombectomy to the regional comprehensive stroke center (CSC) based on symptom severity and teleconsultation with a physician. In Stockholm, 44% of patients with prehospital code stroke have stroke mimics. Inadvertent triage of stroke mimics to the CSC could lead to inappropriate resource utilization. Aims: To compare the characteristics between (1) triage-positive stroke mimics and stroke (TP mimics and TP stroke) and (2) triage-negative stroke mimics and stroke (TN mimics and TN stroke) and to (3) compare the distribution of stroke mimic diagnoses between triage-positive and triage-negative cases. Methods: This prospective observational study collected data from October 2017 to October 2018, including 2,905 patients with suspected stroke who were transported by code-stroke ambulance to a Stockholm regional hospital. Patients directed to the CSC were defined as triage-positive. Those directed to the nearest stroke center were defined as triage-negative. Results: Compared to individuals with TP stroke (n = 268), those with TP mimics (n = 55, median 64 vs. 75 years, P < 0.001) were younger and had lower NIHSS score (median 7 vs. 15, P < 0.001). Similarly, those with TN mimics (n = 1,221) were younger than those with TN stroke (n = 1,361, median 73 vs. 78 years, P < 0.001) and had lower NIHSS scores (median 2 vs. 4, P < 0.001). Functional paresis was more common in those with TP mimics than in those with TN mimics, 18/55 (32.7%) vs. 82/1,221 (6.7%), P < 0.001. Systemic infection was less common in those with TP mimics than in those with TN mimics, 1/55 (1.8%) vs. 160/1,221 (13.1%), P < 0.011. There was a trend toward "syncope, hypotension, or other cardiovascular diagnosis" being less common in those with TP mimics than in those with TN mimics, 1/55 (1.8%) vs. 118/1,221 (9.7%), P < 0.055. Conclusions: In the SSTS, those with triage-positive and triage-negative stroke mimics were younger and had less severe symptoms than patients with stroke. All patients with TP mimics who had hemiparesis but overall exhibited less severe symptoms against true stroke but more severe symptoms than those with TN mimics were triaged to the nearest hospital. Over-triage of functional paresis to the CSC was relatively common. Meanwhile, a large majority of cases with minor symptoms caused by stroke mimics was triaged correctly by the SSTS to the nearest stroke center.

Analysis and modelling of mistriage in the Stockholm stroke triage system.

Introduction: The Stockholm Stroke Triage System (SSTS) is a prehospital triage system for detection of patients eligible for endovascular thrombectomy (EVT). Assessment of hemiparesis combined with ambulance-hospital teleconsultation is used to route patients directly to the thrombectomy centre. Some patients are not identified and require secondary transport for EVT (undertriage) while others taken to the thrombectomy centre do not undergo EVT (overtriage). The aims of this study were to characterize mistriaged patients, model for and evaluate alternative triage algorithms. Patients and methods: Patients with suspected stroke transported by priority 1 ground ambulance between October 2017 and October 2018 (n = 2905) were included. Three triage algorithms were modelled using prehospital data. Decision curve analysis was performed to calculate net benefit (correctly routing patients for EVT without increasing mistriage) of alternative models vs SSTS. Results: Undertriage for EVT occurred in n = 35/2582 (1.4%) and overtriage in n = 239/323 (74.0%). Compared to correct thrombectomy triages, undertriaged patients were younger and had lower median NIHSS (10 vs 18), despite 62.9% with an M1 occlusion. In overtriaged patients, 77.0% had a stroke diagnosis (29.7% haemorrhagic). Hemiparesis and FAST items face and speech were included in all models. Decision curve analysis showed highest net benefit for SSTS for EVT, but lower for large artery occlusion (LAO) stroke. Discussion: Undertriaged patients had lower NIHSS, likely due to better compensated proximal occlusions. SSTS was superior to other models for identifying EVT candidates, but lacked information allowing comparison to other prehospital scales. Conclusion: Using prehospital data, alternative models did not outperform the SSTS in finding EVT candidates.

Sex Equitable Prehospital Stroke Triage Using Symptom Severity and Teleconsultation.

Objectives: We aimed to determine whether there are sex differences in prehospital accuracy of the Stockholm Stroke Triage System (SSTS) to predict large artery occlusion (LAO) stroke, and endovascular thrombectomy (EVT), and whether clinical characteristics differ between men and women undergoing "code stroke" ambulance transport. Materials and Methods: This prospective observational study collected data between October 2017 and October 2018. We included 2,905 patients, transported as "code stroke," by nurse-staffed ground ambulance, to a Stockholm Region hospital. Exclusion criteria were private or helicopter transport, onset outside Stockholm, and in-hospital stroke. We compared overall accuracy, sensitivity, specificity, positive and negative predictive values, and clinical characteristics between sexes. Results: No significant sex differences in SSTS predictive performance for LAO or EVT were found, overall accuracy for LAO 87.3% in women vs. 86.7% in men. Women were median 4 years older and more frequently had stroke mimics (46.2 vs. 41.8%). Women more commonly had decreased level of consciousness (14.0 vs. 10.2%) and moderate-to-severe motor symptoms (by 2.7-3.8 percentage points), and less commonly limb ataxia (7.2 vs. 9.7%). Conclusions: The SSTS had equal predictive performance for LAO and EVT among men and women, despite minor sex differences in the clinical characteristics in patients undergoing ambulance transport for suspected stroke.

Implementation of a Prehospital Stroke Triage System Using Symptom Severity and Teleconsultation in the Stockholm Stroke Triage Study.

Importance: To our knowledge, it is unknown whether a prehospital stroke triage system combining symptom severity and teleconsultation could accurately select patients for primary stroke center bypass and hasten delivery of endovascular thrombectomy (EVT) without delaying intravenous thrombolysis (IVT). Objective: To evaluate the predictive performance of the newly implemented Stockholm Stroke Triage System (SSTS) for large-artery occlusion (LAO) stroke and EVT initiation. Secondary objectives included evaluating whether the Stockholm Stroke Triage System shortened onset-to-puncture time for EVT and onset-to-needle time (ONT) for IVT. Design, Setting, and Participants: This population-based prospective cohort study conducted from October 2017 to October 2018 across the Stockholm region (Sweden) included patients transported by first-priority ("code stroke") ambulance to the hospital for acute stroke suspected by an ambulance nurse and historical controls (October 2016-October 2017). Exclusion criteria were in-hospital stroke and helicopter or private transport. Of 2909 eligible patients, 4 (0.14%) declined participation. Exposures: Patients were assessed by ambulance nurses with positive the face-arm-speech-time test or other stroke suspicion and were evaluated for moderate-to-severe hemiparesis (≥2 National Institutes of Health stroke scale points each on the ipsilateral arm and leg [A2L2 test]). If present, the comprehensive stroke center (CSC) stroke physician was teleconsulted by phone for confirmation of stroke suspicion, assessment of EVT eligibility, and direction to CSC or the nearest primary stroke center. If absent, the nearest hospital was prenotified. Main Outcomes and Measures: Primary outcome: LAO stroke. Secondary outcomes: EVT initiation, onset-to-puncture time, and ONT. Predictive performance measures included sensitivity, specificity, positive and negative predictive values, the overall accuracy for LAO stroke, and EVT initiation. Results: We recorded 2905 patients with code-stroke transports (1420 women [49%]), and of these, 323 (11%) had A2L2+ teleconsultation positive results and were triaged for direct transport to CSC (median age, 73 years [interquartile range (IQR), 64-82 years]; 55 women [48%]). Accuracy for LAO stroke was 87% (positive predictive value, 41%; negative predictive value, 93%) and 91% for EVT initiation (positive predictive value, 26%; negative predictive value, 99%). Endovascular thrombectomy was performed for 84 of 323 patients (26%) with triage-positive results and 35 of 2582 patients (1.4%) with triage-negative results. In EVT cases with a known onset time (77 [3%]), the median OPT was 137 minutes (IQR, 118-180; previous year, 206 minutes [IQR, 160-280]; n = 75) (P < .001). The regional median ONT (337 [12%]) was unchanged at 115 minutes (IQR, 83-164; previous year, 115 minutes [IQR, 85-161]; n = 360) (P = .79). The median CSC IVT door-to-needle time was 13 minutes (IQR, 10-18; 116 [4%]) (previous year, 31 minutes [IQR, 19-38]; n = 45) (P < .001). Conclusions and Relevance: The Stockholm Stroke Triage System, which combines symptom severity and teleconsultation, results in markedly faster EVT delivery without delaying IVT.

Identification of stroke during the emergency call: a descriptive study of callers' presentation of stroke.

OBJECTIVES: To evaluate symptoms presented by the caller during emergency calls regarding stroke, and to assess if symptoms in the Face-Arm-Speech-Time Test (FAST) are related to identification of stroke. SETTING: Emergency calls to the Emergency Medical Communication Center (EMCC) concerning patients discharged with stroke diagnosis in a large teaching hospital in Stockholm, Sweden, in January-June 2011. PARTICIPANTS: The emergency calls of 179 patients who arrived at hospital by ambulance, and who were discharged with a stroke diagnosis and consented to participate were included in the study. OUTCOME MEASURES: Frequencies of stroke symptoms presented and a comparison of symptoms presented in calls with dispatch code stroke or other dispatch code. RESULTS: Of the 179 emergency calls analysed, 64% were dispatched as 'Stroke'. FAST symptoms, that is, facial or arm weakness or speech disturbances, were presented in 64% of the calls and were spontaneously revealed in 90%. Speech disturbance was the most common problem (54%) in all calls, followed by fall/lying position (38%) and altered mental status (27%). For patients with dispatch codes other than stroke, the dominating problem presented was a fall or being in a lying position (66%), followed by speech disturbance (31%) and altered mental status (25%). Stroke-specific symptoms were more common in patients dispatched as stroke. FAST symptoms were reported in 80% of patients dispatched as stroke compared with 35% in those dispatched as something else. CONCLUSIONS: This study implicates that fall/lying position and altered mental status could be considered as possible symptoms of stroke during an emergency call. Checking for FAST symptoms in these patients might uncover stroke symptoms. Future studies are needed to evaluate if actively asking for FAST symptoms in emergency calls presenting falls or a lying position can improve the identification of stroke. TRIAL REGISTRATION NUMBER: Stroke2010/703-31/2.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities.

BACKGROUND: The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. METHOD: A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. RESULTS: In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. CONCLUSION: Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.