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Background: The prognosis of stroke patients can be improved by adherence to clinical guidelines., Objective: To analyse the current state of organisation of prehospital stroke treatment in Germany, Austria and Switzerland with a focus on guideline adherence., Materials and Methods: All medical directors of emergency medical services (MDEMS) in Germany ( n  = 178), Austria ( n  = 9) and Switzerland ( n  = 32) were invited to complete an anonymous online survey (unipark.com, Tivian XI GmbH, Cologne, Germany) which was available for 10 weeks from April-June 2020. Participants were asked for information regarding structural organisation, clinical treatment and strategic/tactical aspects., Results: The survey was completed 69 times and 65 datasets were analysed (4 participants without MDEMS status): 73.8% ( n  = 48) were MDEMS from Germany, 15.4% ( n  = 10) from Switzerland and 10.8% from Austria ( n  = 7). The survey results show relevant differences in the infrastructure of and the approach to prehospital stroke treatment. Standard operating procedures for stroke treatment were in place in 93.3% ( n  = 61) of the EMS areas. Furthermore, 37% ( n  = 24) of the EMS areas differentiated between stroke with mild and severe symptoms and 15.4% ( n  = 10) used specific scores for the prehospital prediction of large vessel occlusion strokes (LVOS)., Conclusions: Our data highlight the heterogeneity of prehospital stroke treatment in Germany, Austria and Switzerland. Consistent use of appropriate scores for LVOS prediction and a higher adherence to recent clinical guideline in general are measures that should be taken to optimise the prehospital treatment of stroke patients., (© The Author(s) 2023.)