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Recombinant tissue plasminogen activator (rt-PA) was approved by the FDA in 1996 for the treatment of acute ischemic stroke. Despite its proven efficacy, however, rt-PA therapy has not been widely used among ischemic stroke patients. Studies have estimated that only 1.8% to 3.0% of all ischemic stroke patients in the United States are treated with rt-PA; the upper end of that range was not achieved until FY 2007. There are many reasons why rt-PA is not administered to more stroke patients, the most important of which is prehospital delays in presentation. Within the US population, only 8% of ischemic stroke patients present to an emergency department eligible for rt-PA. In addition, several important systems issues regarding the hospital of presentation affect whether a patient receives rt-PA, such as protocols for acute stroke patient triaging, stroke education for local EMS and ED staff, and 24-hour CT availability.