The year 2006 sees the end of the first decade of delivering intravenous thrombolysis for acute ischaemic stroke. Few other treatments have had to endure the scrutiny that tissue plasminogen activator (tPA) has been subjected to over that time, in part because of the real concerns of harming patients when treating them outside of the so-called NINDS box guidelines. However, part of the reluctance of physicians to take up this therapy is that it requires the re-engineering of everyday clinical practice. Unlike other stroke treatments, the press of time forces doctors to make rapid decisions while patients are examined and, crucially, imaged immediately on arrival at the hospital. So, what are the insights that these 10 years have given us? Has the disruption been worth it? What does the future hold?

The efficacy studies of intravenous thrombolysis have been well publicised and widely discussed, the most frequent concern being the safe translation of the trial results into real-life clinical practice. Large prospective registries, mandated by governments …