Stroke is one of the leading causes of mortality and disability globally, as well as in Taiwan. The approval and application of intravenous thrombolysis by recombinant tissue plasminogen activator (IV tPA) within three-hour therapeutic window since 1996 in the USA has fundamentally changed the treatment protocol and care pathway of acute ischemic stroke. Taiwan Stroke Society revised the recommended criteria and eligibility for IV tPA treatment in Taiwan in the 2018 guidelines and made suggestions to the government and National Health Insurance Administration.
　　Although the benefit of IV tPA for the eligible patients with acute ischemic stroke is well established, there were minority, estimated only 6-10%, receiving the treatment. Among reasons for exclusion for IV tPA, the most common one is delayed presentation to the hospitals. With accumulating evidence of benefits, the treatment window was extended to 4.5 hours in Europe and other countries with excluding some medical conditions. Public health education should be emphasized to shorten pre-hospital delay.
　　Certain conditions, such as ages older than 80 years, were contraindicated for IV tPA in the original regulation in Taiwan. Although the treatment is associated with more intracerebral hemorrhagic, the benefits overweight the risk considering the individual medical conditions. For the patients with mild or rapid improving symptoms, IV tPA is indicated for those with potentially disabling stroke symptoms, including severe monoparesis, aphasia, hemianopia, and neglect. The treating physicians are advised to  judge whether other patients with nondisabling symptoms are indicated for IV tPA.
　　Particular attention should be given in acute ischemic stroke patients taking warfarin or other non-vitamin K antagonist oral anticoagulants (NOAC), including presenting coagulation profiles, time of last dose, the specific NOAC medication and the indication of reversal agents. Endovascular thrombectomy might be considered instead of IV tPA for those with occlusion of intracranial large arteries.
　　The robust evidence of efficacy of endovascular thrombectomy with bridging therapy of intravenous thrombolysis since 2015 had again changed the paradigm of treatment of acute ischemic stroke. The medical systems and public health agencies should aim to establish a stroke care system for majority requiring eligible medical treatment and a timely access for those indicating for endovascular thrombectomy.