Another important milestone for stroke has been reached with the recent approval by NICE of alteplase for acute ischaemic stroke.1 This welcome decision provides a much needed boost for those struggling to implement acute stroke intervention, for acute stroke intervention is certainly struggling. The sad truth about alteplase for acute ischaemic stroke is that treatment is still unavailable in a surprisingly large number of large hospitals in the UK and elsewhere.

The decision by NICE was based on a rigorous examination of the randomised controlled trial (RCT) data, and it is reassuring to note that this was based, not on the main positive trial,2 but on independent systematic reviews of the totality of the data. For those not familiar with these data, the main concern has been that most of the evidence of the effectiveness of alteplase within the 3-hour time window is based on one study—the National Institute of Neurological Disorders and Stroke (NINDS) study.2 However, concerns about this study have been examined in an independent reanalysis of the NINDS data and the main findings confirmed.3 The large postmarketing surveillance audit of alteplase in Europe, SITS-MOST, has also been reassuring: provided that alteplase is delivered by doctors trained and experienced in the management of acute stroke, results …