The results of the National Institute of Neurological Diseases and Stroke (NINDS) trial represent a real breakthrough, demonstrating that thrombolytic therapy with intravenous alteplase [t-PA, ‘Activase’; Genentech] is an effective treatment for acute ischacmic stroke.*While this approach does have risks, it means that ischaemic stroke can be treated as the life-threatening disease that it is. Investigators discussed the ‘real world approach’ to patient selection for thrombolysis and pre- and post-stroke management with alteplase for acute ischaemic stroke, at the 49th Annual Meeting of the American Academy of Neurology [Boston, US; April 1997].