therapy Odds ratio (death or dependency) Number needed to treat Reference 2012, GUL et al. 2018) Aspirin n/a 0.96 110 (International Stroke Trial Collaborative Group 1997) Treatment of acute haemorrhagic stroke is geared towards limiting the mass effect of the bleeding and management of acute complications such as a decreased level of consciousness. Blood pressure is often elevated in patients suffering from a haemorrhagic stroke and should be acutely lowered to stop haematoma expansion. For patients taking anticoagulants or antiplatelet drugs, these should be urgently discontinued and anticoagulant effects should be reversed immediately with appropriate agents (HEMPHILL et al. 2018). After an initial emergency evaluation, patients should be managed in a dedicated stroke unit so that patient deterioration can be detected and reacted to swiftly, including invasive measures to reduce intracranial pressure by ventricular drainage or surgery. There remains a lack of clear criteria for the primary surgical management for removing a haemorrhage and decisions should be made on a per patient basis (HEMPHILL et al. 2018, Fig. 6). 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 10 Fig. 6 Flowchart depicting the acute stroke pathway 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 11 Local Solutions In Germany, stroke mortality rates have decreased by 50 % since the 1990s (RÜCKER et al. 2018). This success was driven by local innovations and a coordinated national plan for fast access to specialised acute treatment and care within stroke units (LANGHORNE et al. 2020). In the past 30 years, more than 300 stroke units have been certified by the German Stroke Society and today, more than 70 % (BUSSE et al. 2013) of all stroke patients are treated in a certified stroke unit. Recently, interdisciplinary neurovascular specialist networks have been implemented nationally to improve care for complex and severe stroke cases. These neurovascular networks provide smaller hospitals, connected within the network, with fast access to expertise in the areas of neurology, neurosurgery, and vascular surgery at a central coordinating centre. Hospitals in the network share common standards and referral pathways i.e. for mechanical thrombectomy or specialised neurointensive care and in many cases are directly linked through telemedicine (BUSSE et al. 2013). Despite this success in making specialised care available, only ~15 % of acute stroke patients (WEBER et al. 2019) receive treatment with intravenous recombinant plasminogen activator (rTPA) and only 5 % receive mechanical thrombectomy with large variances between regions (WEBER et al. 2019). The benefits of thrombolysis and mechanical thrombectomy are time-dependent. Thrombolysis is limited to a narrow window of 4.5 hours after symptom onset (EMBERSON et al. 2014); mechanical thrombectomy is indicated for patients with large artery occlusion in the anterior circulation for up to 24 hours after symptom onset regardless of whether they received thrombolysis for the same event (NOGUEIRA et al. 2018). Reasons for delays in initiating treatment include prehospital delays, such as the time it takes a patient to decide to call emergency services and the time from emergency call to arrival at the hospital, as well as in-hospital delays. To reduce in-hospital delays and increase the number of patients receiving thrombolysis, structured stroke alarm systems, including pre-notification of the arrival of emergency medical services (EMS), and single-call activation of dedicated stroke teams have been implemented successfully in many emergency care units, reducing door-to-treatment time to under 45 minutes (KÖHRMANN et al. 2011). Alongside similar initiatives in other regions of Germany, the Center for Stroke Research Berlin (CSB) was founded as an integrated centre for treatment and research to develop innovative concepts to improve acute and long-term care. Its research focuses on three goals: to protect the brain, prevent complications, and restore function. To further reduce the delay in initiating treatment, the CSB, together with the Berlin Fire Brigade, developed a specialised ambulance vehicle, the Stroke Emergency Mobile (STEMO), equipped with a CT scanner and point-of-care laboratory to allow for prehospital thrombolysis. This has shortened the time-to-treatment by 25 minutes and increased the number of patients treated with thrombolysis by 50 % (KUNZ et al. 2016, Fig. 7). Moreover, STEMO treatment reduces long-term disability (EBINGER et al. 2021). With the advent of mechanical thrombectomy at interventional centres and the availability of neurovascular networks, two approaches for patients with suspected large vessel occlusion have come up for debate: ‘drip and ship’, meaning primary transportation to the closest stroke unit and secondary transportation to an interventional centre if large vessel occlusion is confirmed, or the ‘direct to mothership’ approach with direct transportation of severely affected patients to a neurointerventional