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Introduction: The optimal pathway for ultra-early diagnostics and treatment in patients with acute stroke remains uncertain. The aim of this study was to investigate how three different methods of simulated, rural prehospital computed tomography (CT) affected the time to prehospital treatment decision in acute stroke., Materials and Methods: In this pragmatic, simulation, pilot study of prehospital CT we investigated a conventional ambulance with transport to a standard care rural stationary CT machine managed by paramedics, a Mobile Stroke Unit (MSU), and a helicopter with a simulated CT machine. Each modality completed 20 real-life dispatches combined with simulation of predetermined animated patient cases with acute stroke symptoms and CT images. The primary endpoint of the study was the time from alarm to treatment decision., Results: Median time from alarm to the treatment decision differed significantly between the three groups ( p  = 0.0005), with 38 min for rural CT, 33 min for the MSU, and 30 min for the helicopter. There was no difference in time when comparing rural CT with MSU, nor when comparing the MSU with the helicopter. There was a difference in time to treatment decision between the rural CT and the helicopter ( p  < 0.0001). The helicopter had significantly lower estimated time from treatment decision to hospital ( p  = 0.001)., Disscussion/conclusion: Prehospital CT can be organized in several ways depending on geography, resources and need. Further research on paramedic run rural CT, MSU in rural areas, and helicopter CT is needed to find the optimal strategy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.