INTRODUCTION: We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020. PATIENTS AND METHODS: We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively. RESULTS: The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90-4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63-26.43) per 100,000 and 17.14% (95% CI: 12.98-21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96-9.77) per 100,000 and 6.91% (95% CI: 5.15-8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016. CONCLUSION: Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

Center for Research and Education University Hospital of North Norway and Department of Clinical Medicine UiT The Arctic University of Norway Tromsø Norway

Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy

Department of Clinical Neurosciences University of Medicine and Pharmacy 'Carol Davila' Bucharest and Department of Neurology University Hospital Bucharest Romania

Department of Clinical Sciences Section of Neurology Lund University Skåne University Hospital Lund Sweden

Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Neurology Copenhagen University Hospital Bispebjerg Copenhagen Denmark

Department of Neurology Inselspital Bern and Medical Faculty University of Bern Bern Switzerland

Department of Neurology University Hospital Basel University of Basel Basel Switzerland

Division of Cardiology Department of Medicine University of Washington Seattle WA USA

Institute for Stroke and Dementia Research University Hospital Ludwig Maximilian University Munich and German Center for Neurodegenerative Diseases Munich Germany

International Clinical Research Center and Department of Neurology St Anne's University Hospital in Brno and Faculty of Medicine at Masaryk University Brno Czech Republic

Irish Heart Foundation Dublin Ireland

Stroke Alliance for Europe Brussels Belgium

Stroke and Neurology Department Mater University Hospital and Stroke Clinical Trials Network Ireland University College Dublin Dublin Ireland

Stroke Center Lisbon Central University Hospital and Faculty of Medicine University of Lisbon Lisbon Portugal

Stroke Unit Department of Neuroscience San Camillo Forlanini Hospital Rome Italy

Stroke Unit Santa Maria della Misericordia Hospital University of Perugia Perugia Italy

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