In Reply We thank the authors of both letters for raising interesting points.
Li and Johnson point out that onset-to-thrombolysis times during regular care in Berlin, Germany, compared favorably with many other cities around the world. The fact that the use of the Stroke Emergency Mobile (STEMO) led to a reduction of alarm-to-treatment times, even in this competitive scenario, raises hopes for other regions. Reduction of in-hospital door-to-needle times has been propagated for years, with evidence piling up that onset-to-thrombolysis times have to be minimized for better outcomes.1 However, despite ongoing efforts, there are few reports of substantial time savings.2,3 As the authors wrote, “every location has its own issues.” For instance, it is difficult to compare the centralized stroke care in Helsinki, Finland, with long onset-to-door times4 with Berlin, Germany, with relatively short distances. Many of the necessary steps in acute management have been moved to the prehospital phase in centralized settings.2 However, even with the excellent Helsinki door-to-needle times, the onset-to-thrombolysis times remained greater than those of conventional care within Berlin (median, 119 minutes; interquartile range, 80-176 minutes vs median, 105.0 minutes; interquartile range, 82-146 minutes).2,5 To avoid misunderstandings, we advocate reducing door-to-needle times; however, so far, to our knowledge, no one has proven that this leads to faster onset-to-thrombolysis times compared with prehospital thrombolysis.