Despite earnest attempts to increase the use of IV thrombolysis, overall usage remains very low even with the expansion of the time window for treatment to 4.5 hours. Although 20%–30% of patients arrive within 3 hours of symptom onset1 only 1%–3% of all ischemic stroke patients receive thrombolysis.2 A substantial number of patients who would otherwise qualify for treatment do not receive it due to strict application of thrombolytic exclusion criteria. This reason for low rates of IV thrombolysis has received little attention. Importantly, few, if any, of the commonly cited IV recombinant tissue plasminogen activator (rtPA) exclusion criteria are evidence-based. Most, if not all, were derived from expert medical opinion at the time of the original National Institute of Neurological Disorders and Stroke trial. Unfortunately, such expert medical opinion is commonly found to be wanting, including in cerebrovascular disease.3 Moreover, in recent years numerous studies suggest that IV rtPA can be used safely and effectively in many of these excluded groups, such as those with fluctuating symptom severity, seizure at stroke onset, …