BACKGROUND‐Acute treatment of ischemic stroke with tissue plasminogen activator requires confident diagnosis of ischemic stroke, a negative CT scan, and administration of the drug within 3 hours of onset of symptoms.REVIEW SUMMARY‐We report four cases that presented to our Emergency Department with apparent focal neurological deficits within 3 hours of onset. The Stroke Team was called, but all four patients turned out to have conditions other than ischemic stroke. One had a metastatic tumor that could be identified on the CT scan.CONCLUSIONS‐Other conditions can produce focal neurological signs of apparently acute onset. A physician who is experienced in the diagnosis of ischemic stroke, as well as in the interpretation of acute CT scans, should be involved in the evaluation of patients who have acute stroke for intravenous thrombolytic therapy.(THE NEUROLOGIST 6:220‐223, 2000)