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). Patient factors most strongly associated with shorter onset-to-treatment times include greater stroke severity, arrival by ambulance, and arrival during regular hours.41 With respect to endovascular treatment, a pooled analysis of 5 randomized trials comparing endovascular therapy (EVT) with medical therapy alone in which the majority of the patients were treated within 6 hours found that the odds of improved disability outcomes at 90 days (as measured by the modified Rankin Scale [mRS] distribution) declined with longer time from symptom onset to arterial puncture.42 The 6- to 16- and 6- to 24-hour treatment windows trials, which used advanced imaging to identify a relatively uniform patient group, showed limited variability of treatment effect with time in these highly The absence of detailed screening logs in these trials limits estimations of the true impact of time in this population. To ensure that the highest proportion of eligible patients presenting in the 6- to 24-hour window have access to mechanical thrombectomy, evaluation and treatment should be as rapid as possible. See Table VIII in online Data Supplement 1. Establishing and monitoring target time goals for ED door-to-treatment IV fibrinolysis time can be beneficial to monitor and enhance system performance. I B-NR New recommendation. 