Perspective:

Intravenous tissue plasminogen activator (tPA) was approved by the Food and Drug Administration in 1996 for the treatment of patients with acute ischemic stroke. Although tPA is the only acute medical therapy proven to reduce disability and improve outcomes in ischemic stroke, more than 15 years after its approval, it remains grossly underutilized, with only 2-8% receiving this therapy. There is substantial room and need for improvement regarding utilization of this effective therapy. There are many patients who should be treated with intravenous tPA, but do not receive such therapy, often for unclear, subjective, or invalid reasons. Available data suggest that patients taking warfarin and with INRs of 1.7 or lower can be safely treated without experiencing a significantly increased risk of symptomatic intracerebral hemorrhage. The real risk is undertreatment or in not treating otherwise eligible patients, who may then have prolonged morbidity from their stroke. Considering that intravenous tPA remains substantially underutilized in the United States for patients with stroke, with few if any alternate therapies, clinicians should ensure that all appropriately eligible patients receive this important therapy.