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Acute ischemic stroke remains an important public health concern with limited therapeutic options at this time. Intravenous rt-PA has been shown to improve acute stroke outcomes if given within 3 hours of symptom onset. Intravenous thrombolysis beyond 3 hours in unselected patients has been shown to be ineffective. Rt-PA-associated sICH is the most important complication of treatment; unfortunately, there are no clinical features that predict sICH with high sensitivity or specificity. There are no patient subgroups in which rt-PA is proven to be of extra benefit, or risk, although it is a common practice, supported by a guideline statements, to withhold therapy from patients with CT evidence of established infarction in more than one third of the MCA territory. Observational studies of rt-PA therapy in community practice suggest that it has a similar safety profile as that seen in the 1995 NINDS trial. The proportion of all United States ischemic stroke patients who receive rt-PA is low, mostly because of the restrictive time window for treatment, and also because of inadequate stroke systems of care. Written clinical protocols, an identified acute stroke team, and reorganization of the emergency department to prioritize the stroke evaluation are essential for providing quality acute stroke care. Clinical management should focus on rapid evaluation and transport to the CT scanner. Newer throm-bolytic agents such as desmoteplase, as well as adjunct therapies for enhanced thrombolysis or neuroprotection, are currently under investigation and may, in the future, allow the use of thrombolysis to be expanded to a larger group of patients.

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