Differences in acute ischemic stroke quality of care and outcomes by primary stroke center certification organization. 45. Scott PA, Meurer WJ, Frederiksen SM, Kalbfleisch JD, Xu Z, Haan MN, Silbergleit R, Morgenstern LB; INSTINCT Investigators. A multi- level intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial. Lancet 46. Dirks M, Niessen LW, van Wijngaarden JD, Koudstaal PJ, Franke CL, van Oostenbrugge RJ, Huijsman R, Lingsma HF, Minkman MM, Dippel DW; for the PRomoting ACute Thrombolysis in Ischemic StrokE (PRACTISE) Investigators. Promoting throm- bolysis in acute ischemic stroke. Stroke. 2011;42:1325 1330. doi: 47. Haesebaert J, Nighoghossian N, Mercier C, Termoz A, Porthault S, Derex L, Gueugniaud PY, Bravant E, Rabilloud M, Schott AM; on behalf of the AVC II Trial Group. Improving access to throm- bolysis and inhospital management times in ischemic stroke: a stepped-wedge randomized trial. Stroke. 2018;49:405 411. doi: 48. Tissue plasminogen activator for acute ischemic stroke: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581 1587. 49. Hacke W, Kaste M, Bluhmki E, Brozman M, D valos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317 1329. doi: 10.1056/NEJMoa0804656 50. Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, Albers GW, Kaste M, Marler JR, Hamilton SA, et al; ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. Time to treat- ment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. 51. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, et al; DAWN Trial Investigators. 