In reply: Stroke experts around the world consider that the evidence for thrombolysis with tissue plasminogen activator (tPA) within 3 hours is overwhelming. Licensing authorities such as the Therapeutic Goods Administration in Australia and the Food and Drug Administration in the United States have approved use of tPA after rigorous, independent analysis of all the available data. However, it seems that a minority of sceptical emergency physicians remains, who will probably never be convinced. Further trials in the sub-3-hour time window are unlikely to receive ethical approval. The focus of stroke research has now moved on. Current targets include expansion of the time window and alternative approaches to recanalisation such as intra-arterial thrombolysis and clot retrieval.

Hurley states that there was a baseline imbalance in the pivotal NINDS trial in favour of tPA. We think this old chestnut was laid to rest by an independent reanalysis of the NINDS data.1 The quoted Cochrane review included all thrombolytic agents (such as the now-abandoned streptokinase),2 whereas meta-analyses restricted to tPA alone are unequivocally positive.3 The figure presented by Hurley is misleading, combining both randomised controlled trials and selected population registries — yet excluding SITS-MOST, an observational study of 6483 patients.4

Both Toncich and Fatovich criticise the trial evidence. This contrasts not only with the virtually universal expert opinion of stroke clinicians, but also with the opinion of many emergency physicians.5,6 Indeed, the INSTINCT (Increasing Stroke Treatment through Interactive behavioral Change Tactics) trial aims to identify local barriers to the use of tPA in emergency departments, with the goal to increase appropriate use of tPA in acute ischaemic stroke.5

Finally, stroke physicians do not need to be neurologists. We consider that most general physicians, and indeed emergency physicians, should acquire the core skills to deliver intravenous tPA in acute ischaemic stroke. Would anyone familiar with modern stroke medicine deny tPA to an otherwise well 65-year-old with hemiparesis who presents 90 minutes after symptom onset? It is critical that all eligible patients in Australia are offered this licensed therapy.1-6