site (ABILLEIRA et al. 2019). In a simulation experiment using real-life data, researchers from the CSB demonstrated a favourable outcome for the ‘direct to mothership’ approach if the additional delay to thrombolysis is under 30 minutes in urban settings and under 50 minutes in rural settings (SCHLEMM et al. 2019, 2020). Correctly identifying these patients, however, remains a prerequisite for adequate care. To this end, the CSB has developed a telemedicine network for acute stroke care within the ANNOTeM project and has expanded it to include healthcare providers in rural areas across north-eastern Germany (WEBER et al. 2020). The Berlin Stroke Alliance was established by the CSB in 2008 to ensure close follow-up and optimal long-term care. It connects institutions along the continuum of care, providing a single point of contact for patients and improving patient education (Berliner Schlaganfall Allianz e.V. 2020). Emmrich, J. V., Knauss, S., Endres, M., Current advances, challenges, and opportunities in stroke research, management, and care NAL-live 2021.2, v1.0, doi:10.34714/leopoldina_NAL-live_0002_01000 12 Fig. 7 (A) Catchment areas of Stroke Emergency Mobile Units (STEMOs) stationed at three locations in Berlin. Insets show the STEMO vehicle (B) mounted with a mobile CT scanner (C). Adapted from (EBINGER et al. 2021). (Images courtesy of the Berlin Fire Brigade.) An Emphasis on Stroke Prevention Global stroke mortality and age-adjusted incidence declined during the last two decades mainly due to improvements in acute stroke care, effective prevention strategies, first-and-foremost treatment of hypertension, and anticoagulation for atrial fibrillations. However, the overall stroke burden continues to increase rapidly in terms of absolute numbers of people affected by and living with stroke and stroke-related disabilities (FEIGIN et al. 2016a). This suggests that current primary prevention efforts for stroke are insufficient in stemming the tide of the growing stroke burden. Furthermore, stroke prevention strategies are mostly based on high-income country data available from registries and disease surveillance databases. It remains uncertain whether these strategies can be equally effective in low- and middle-income countries, where a younger age of onset, higher rates of haemorrhagic strokes, and increased exposure to modifiable risk factors, such as air pollution, indicate the need for population-specific stroke prevention strategies. Notably, the World Health Organization regards primary prevention as the most costeffective strategy for reducing the overall stroke burden, especially in low-resource communities where access to emergency care and acute stroke treatment is limited. Primary Prevention Lifestyle changes, treatment with lipid-lowering drugs, antihypertensive medication or anticoagulation in patients with atrial fibrillation and additional risk factors are effective and cost-efficient for both primary and secondary prevention of stroke. The largest case-control study to date, which included 26,919 participants from 32 countries Emmrich, J. V., Knauss, S., Endres, M., Current advances, challenges, and opportunities in stroke research, management, and care NAL-live 2021.2, v1.0, doi:10.34714/leopoldina_NAL-live_0002_01000 13 (INTERSTROKE Study) found a 47.9 % population-attributable risk of hypertension (99 % CI 45.1 – 50.6; 45.7 % (42.4 – 49.0) for ischaemic stroke and 56.4 % (52.0 – 60.6) for haemorrhagic stroke) (O’DONNELL et al. 2016). Antihypertensive therapy versus a placebo reduced the risk of stroke by 32 % (95 % CI 24 – 39). Atrial fibrillation contributes up to a 17.1 % population-attributable risk for ischaemic stroke (ibid.), but long-term treatment with anticoagulants can almost halve this risk in high-risk groups (FRIBERG et al. 2012). Interestingly, more than half of the modifiable risk factors can be mitigated by lifestyle changes, highlighting the importance of education and primary prevention. Tab. 3 Leading modifiable risk factors for stroke, accounting for 91 % of population-attributable risk (O’DONNELL et al. 2016). Modified Alternative Healthy Eating Index, mAHEI. Odds ratio (99 % confidence interval) Population attributable risk (99 % confidence interval) Hypertension 2.98 (2.72 - 3.28) 47.9 % (45.1 - 50.6) Regular physical activity 0.60 occurred, it is paramount to aggressively target modifiable risk factors. In order to manage a non-cardioembolic acute stroke, antiplatelet therapy using aspirin, or a short-term dual antiplatelet therapy using a combination of aspirin and clopidogrel for patients with TIA or minor stroke, should be initiated as soon as possible after symptom onset. Aspirin monotherapy remains the mainstay of long-term secondary stroke prevention. Patients with atrial fibrillation should receive long-term anticoagulant therapy using an oral direct thrombin inhibitor or a factor Xa inhibitor following a careful risk-benefit assessment to avoid bleeding complications. Additionally, treatment with lipid-lowering drugs, such as statins can be effective even in patients without elevated cholesterol levels, reducing the risk of recurrent stroke by almost 20 % (TRAMACERE et al. 2019). For some causes of stroke, such as carotid artery stenosis, a narrowing of the main vessels supplying the brain, mostly caused by atherosclerosis, or a patent foramen