time is brain!  be fast! these well - known international slogans emphasize the importance of quick action in acute stroke . after a few minutes of circulation arrest , the brain tissue pathology can not be reversed : neurons die . according to the literature , in patients with a typical large - vessel acute ischemic stroke , 120 million neurons , 830 billion synapses , and 714 km of myelinated fibers are lost each hour . however , early thrombolysis may markedly reduce the ischemic core by increasing reperfusion in patients with penumbra . this is why immediate stroke care , including early recanalization of the occluded blood vessel , is so important . national census data showed that hungary had a population of 9,877,365 people at the end of 2013 . vas county in western hungary comprised a population of 257,688 people , 77,566 of whom resided in the county 's administrative center , szombathely . the markusovszky university teaching hospital ( muth ) provides tertiary care services for the entire vas county and is affiliated with the university of pcs . during the last few years , the medical center has undergone extensive infrastructural improvements and quality upgrades in its several comprehensive programs . the prehospital care of stroke patients has been improved in the country by providing more optimal treatment based on protocols on site and during transport as well . the cooperation between prehospital ambulance care and stroke centers is vital to secure an optimal care for stroke patients . according to who data , the number of new stroke events in europe is projected to rise from 1.1 to 1.5 million per year from 2000 to 2025 , largely due to population aging . in hungary , the number of acute stroke patients is estimated at 40,000 - 50,000 per year . the acute stroke mortality rate in the age group below 50 years is 8 - 10/100,000 residents in western european countries . in hungary , this number is 40/100,000 for women and 60/100,000 for men . stroke patients in hungary are 5 - 10 years younger than those in the developed industrial countries , and every fourth patient is under 60 . besides being the third leading cause of death , stroke is the first leading cause of disability and the second cause of dementia . thrombolytic therapy was 18% in 2011 ( 4.9% in 2003 ) in austria , and 16.7% in 2014 - 2015 in france , while this figure was only 3.2% in 2013 in hungary , even though the number of thrombolysis procedures doubled between 2008 and 2013 . the 3.2% thrombolysis rate was derived from 1,439 thrombolysis procedures performed at 37 active thrombolysis centers in 2013 across hungary . in the same year , 145 i.v . thrombolysis procedures were performed in the western transdanubia region , and the number of thrombolysis had most rapidly increased in szombathely and zalaegerszeg . at our medical center ( muth ) , in 2014 , we achieved a 4% thrombolysis rate with 32 thrombolysis procedures during a period of 9 months . the time - sensitive nature of cerebrovascular events has been increasingly appreciated in the last few years in hungary . the organization of stroke centers required careful coordination in patient care with well - defined work flow and standard operating procedures . as a result , our stroke center at the muth has been providing gradually improving acute stroke care , although still lagging behind that of western european countries . thrombolysis were reviewed in detail out of 1,514 patients with acute stroke at the muth in the two study periods ( 1 ) from october 2012 to june 2013 , prior to the initiation of the  lysis alarm program , and ( 2 ) from october 2013 to june 2014 , with the  lysis program in place . we used the national institute of health stroke scale ( nihss ) to assess neurological impairment and to monitor outcome . thrombolysis and to decrease the  stroke - to - door and the  door - to - needle time . this required the development of prehospital care , the organization of stroke teams and the proper coordination of patients within the hospital . when our  lysis alarm program started , we began collecting data of patients who received thrombolysis . in the  lysis alarm operation as soon as possible , the ambulance center informs the triage desk and the emergency physician , who alerts the neurologist and the radiologist about the impending arrival of an acute stroke patient . when the patient arrives , the team of specialists as well as the ct service is prepared . after being examined by the emergency physician and the neurologist , the patient is sent for cranial computed tomography ( ct ) imaging and ct angiography ( cta ) . if the diagnosis of acute ischemic stroke is confirmed based on the history , physical examination , laboratory tests , and ct / cta , and the patient qualifies for i.v . thrombolysis based on the guidelines by the ministry of national resources and the relevant medical regulations , i.v . recombinant tissue plasminogen activator , alteplase ( actilyse , boehringer ingelheim international ) , is infused at a rate of 0.9 mg / kg/60 min following the 10% bolus injection in the patient unit of the emergency department ( ed ) . the patient is monitored for 24 h after the intervention in the ed and then transferred to the department of neurology or , if needed , to the intensive care unit . in the scenario when an acute stroke patient is brought to the hospital by a family member or by ambulance service without an advance notification to the ed stroke team , the analyses were performed using the statistical package of social sciences ( spss ) version 19.0 software . thrombolysis were reviewed in detail out of 1,514 patients with acute stroke at the muth in the two study periods ( 1 ) from october 2012 to june 2013 , prior to the initiation of the  lysis alarm program , and ( 2 ) from october 2013 to june 2014 , with the  lysis program in place . we used the national institute of health stroke scale ( nihss ) to assess neurological impairment and to monitor outcome . thrombolysis and to decrease the  stroke - to - door and the  door - to - needle time . this required the development of prehospital care , the organization of stroke teams and the proper coordination of patients within the hospital . when our  lysis alarm program started , we began collecting data of patients who received thrombolysis . in the  lysis alarm operation as soon as possible , the ambulance center informs the triage desk and the emergency physician , who alerts the neurologist and the radiologist about the impending arrival of an acute stroke patient . when the patient arrives , the team of specialists as well as the ct service is prepared . after being examined by the emergency physician and the neurologist , the patient is sent for cranial computed tomography ( ct ) imaging and ct angiography ( cta ) . if the diagnosis of acute ischemic stroke is confirmed based on the history , physical examination , laboratory tests , and ct / cta , and the patient qualifies for i.v . thrombolysis based on the guidelines by the ministry of national resources and the relevant medical regulations , i.v . recombinant tissue plasminogen activator , alteplase ( actilyse , boehringer ingelheim international ) , is infused at a rate of 0.9 mg / kg/60 min following the 10% bolus injection in the patient unit of the emergency department ( ed ) . the patient is monitored for 24 h after the intervention in the ed and then transferred to the department of neurology or , if needed , to the intensive care unit . in the scenario when an acute stroke patient is brought to the hospital by a family member or by ambulance service without an advance notification to the ed stroke team , the analyses were performed using the statistical package of social sciences ( spss ) version 19.0 software . we used a statistical significance level of p < 0.05 . in the first study period ( october 2012-june 2013 ) , 777 patients were admitted with acute ischemic stroke . their average age was 57 years , there were 10 men and 9 women , and 9 had left - hemisphere , 6 had right - hemisphere , and 4 had brainstem strokes ( table 1 ) . following thrombolysis , the conditions of 10 out of the 19 thrombolyzed patients improved based on the nihss scores . of these 19 patients , 4 were younger than 45 years . during the second period ( october 2013-june 2014 ) , 737 patients were admitted with acute ischemic stroke , and 32 ( 4% ) received i.v . the average age of patients receiving thrombolysis was 66 years , there were 19 men and 13 women , and 15 had left - hemisphere , 14 had right - hemisphere , and 3 had brainstem strokes ( table 1 ) . the numbers of patients who underwent thrombolytic treatment increased by 2% between the first and second study periods (  test , p = 0.041 ) . the average  door - to - needle time decreased by 17 min ( table 1 ) , but it was still above the accepted maximum time period of 60 min . the number of successful thrombolysis procedures markedly increased in the second compared to the first period . in addition , the number of asymptomatic patients also rose , while the number of patients who died after thrombolysis decreased ( fig . 1 ; table 2 ) . we also looked at the thrombolysis outcomes in nihss - based severity subgroups of patients and found that in the period before lysis alarm , there were no successful lysis procedures in the group of stroke patients with serious neurological symptoms , while the success rate was 50% in the group of patients with moderate symptoms and 78% in the group of patients with mild symptoms . in the period after launching lysis alarm , the success rate was 50% in the serious symptoms group , 57% in the moderate symptoms group , and 81% in the mild symptoms group ( fig . all thrombolysis procedures were successful in the < 45-years age group , while all thrombolysis procedures were unsuccessful in the 70-years age group . the success rate was 50% in the middle - aged group . during the 9-month period after launching the  lysis alarm , we observed a significant improvement , with an 83% success rate of thrombolysis in the middle - aged group and a 54% success rate in the oldest age group ( fig . our  lysis alarm program resulted in a number of major benefits in acute stroke care . here , we demonstrate that the number of patients receiving thrombolysis increased and the treatment time decreased with the help of the local ambulance service after the inauguration of the  lysis alarm program . we are still at an early stage of our operation , continuously trying to improve the system by better coordinating the work elements and educating our staff , the primary care doctors , and patients . there is much room for improvement in filtering out patients who do not qualify for the program , further decreasing the  stroke - to - needle time , and better addressing contraindications of the thrombolysis treatment . overall , the number of thrombolysis cases at our hospital doubled in 1 year and exceeded the national average , while the treatment time of patients also improved . thanks to the  lysis alarm program , we have now more success stories and less bleeding complications associated with thrombolysis . in addition , fewer patients die of stroke after thrombolysis in our neurology department , and 47% of patients could be released with mild or no neurological symptoms ( table 2 ) . we plan to do more thrombolysis and to introduce neurointerventional procedures in the future , in order to provide a better quality of life for our stroke patients . to reach this goal , we need to further improve the prehospital and hospital care as well as to develop a better health culture in our immediate geographical environment and nationwide .
backgroundstroke is a devastating disease with increasing incidence and prevalence due to population aging . even with the best care , a proportion of patients dies or is left with significant neurological and cognitive disability . 
 organization of stroke centers markedly improved outcomes worldwide . 
 we initiated a 
 lysis alarm program in september 2013 at our medical center.methodsthis is a retrospective review of electronic data from patients with acute ischemic stroke before ( october 2012-june 2013 ) and after ( october 2013-june 2014 ) the  lysis alarm program was introduced at our medical center.resultsprior to the introduction of the stroke program , there were only 19 thrombolysis procedures in 777 acute stroke patients in 9 months , while this figure rose to 32 thrombolysis procedures in 737 acute stroke patients after the initiation of the program . 
 the  door - to - needle time decreased from 88 to 71 min when the two study periods were compared . 
 these changes were associated with decreased stroke mortality in patients receiving thrombolytic treatment ( 16% prior to the program and 9% during the program ) . in 2013 , there were 1,439 thrombolysis procedures , representing 3.2% of all stroke cases throughout hungary . 
 after the introduction of the  lysis alarm program , we have reached a 4% thrombolysis rate at our medical center.conclusionsour thrombolysis rate is higher than the national average , but still low compared to the rates of western european countries . 
 we are continuously working to enhance our stroke program . here 
 , we discuss those components that need to be further refined in order to improve stroke intervention and outcome .