Intravenous thrombolysis (IVT) with alteplase remains the standard treatment for acute ischemic stroke. Although IVT can be started up to 4.5hours after symptoms’ onset, it is all the more effective and safe when started early. It allows a 10% absolute reduction in the risk of handicap or death at 3 months, despite a 2–7% risk of symptomatic intracranial hemorrhage. Current research efforts involve firstly trying to treat a larger proportion of patients by overcoming some of the contraindications to IVT and secondly assessing combined or alternative treatments to achieve a higher early recanalization rate.