Safety was also demonstrated with symptomatic intracranial hemorrhage (within 36 In the PRACTISE trial (Penumbra and Recanalisation Acute Computed Tomography in Ischaemic Stroke Evaluation), a multilevel intervention was conducted in a sample of 12 Dutch hospitals. After implementation of an intensive stroke treatment strategy, intervention hospitals treated 393 patients with IV alteplase (13.1% of all patients with acute stroke) versus 308 (12.2%) at control hospitals (adjusted OR, 1.25 The AVC (Impact of a Training Program and Organization on the Management of Stroke in the Acute Phase) II trial identified a similar magnitude of improvement (adjusted OR, 1.39 [95% CI, 1.01 2.02]) for overall fibrinolytic delivery between intervention and control groups) among 18 emergency units in France using a See Tables VI and VII in online Data Supplement 1. It is recommended that stroke systems of care be developed so that fibrinolytic-eligible patients and mechanical thrombectomy-eligible patients receive treatment in the fastest achievable onset-to-treatment time. I A Recommendation revised from 2013 AIS Guidelines. Treatment of AIS with IV tissue-type plasminogen activator is of proven benefit for select patients given up to 4.5 hours after symptom onset.48,49 Pooled data from RCTs indicate the benefit is greatest when treatment occurs early after stroke onset and declines with time.50 Registry data from AHA GWTG-Stroke hospitals confirm this temporal relationship. In an analysis of 58353 alteplase-treated patients, treatment started more rapidly (evaluated in 15-minute increments) was associated with reduced in-hospital mortality (OR, 0.96 [95% CI, 0.95 0.98]; P<0.001), reduced symptomatic intracerebral hemorrhage (sICH) (OR, 0.96 [95% CI, 0.95 0.98]; P<0.001), increased independent ambulation at discharge (OR, 1.04 [95% CI, 1.03 1.05]; P<0.001), and increased discharge to home (OR, 1.03 [95% CI, 1.02 1.04]; P<0.001). 