(COR I; LOE A) Within 3 h Age For otherwise medically eligible patients 18 y of age, IV alteplase administration within 3 h is equally recommended for patients 80 and >80 y of age. (COR I; LOE A) Within 3 h Severe stroke For severe stroke, IV alteplase is indicated within 3 h from symptom onset of ischemic stroke. Despite increased risk of hemorrhagic transformation, there is still proven clinical benefit for patients with severe stroke symptoms. (COR I; LOE A) Within 3 h Mild disabling stroke For otherwise eligible patients with mild but disabling stroke symptoms, IV alteplase is recommended for patients who can be treated within 3 h of ischemic stroke symptom onset or patient last known well or at baseline state (COR I; LOE B-R) 3 4.5 h* IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% of dose given as bolus over 1 min) is also recommended for selected patients who can be treated within 3 and 4.5 h of ischemic stroke symptom onset or patient last known well. Physicians should review the criteria outlined in this table to determine patient eligibility. (COR I; LOE B-R) 3 4.5 h Age IV alteplase treatment in the 3- to 4.5-h time window is recommended for those patients 80 y of age, without a history of both diabetes mellitus and prior stroke, NIHSS score 25, not taking any OACs, and without imaging evidence of ischemic injury involving more than one-third of the MCA territory. (COR I; LOE B-R) Urgency Treatment should be initiated as quickly as possible within the above-listed time frames because time to treatment is strongly associated with outcomes. 