Intravenous Tissue Plasminogen Activator for Large Vessel Ischemic Stroke-Is There Still a Role

While the efficacy of Intravenous tissue plasminogen activator (tPA) is well established, its impact on large vessel occlusion (LVO) is controversial. Whether IV tPA should be bypassed in favor of endovascular thrombectomy (MT) will be addressed. Compelling evidence exists to suggest tPA administration might be bypassed in tPA eligible patients in favor of MT for LVO. A trial of MT with patients randomized for IV tPA within the 4.5-h time window should conducted at comprehensive stroke centers demonstrating equipoise between time to tPA or MT with time to treatment from ED arrival of 45 min. We may do well to consider the systems pathway taken by interventional cardiologists 15 years ago.