Thrombolytic therapy for acute ischemic stroke within the 3-h time window has been approved. In the US, where FDA approval has existed for about 4 years, less than 2% of stroke patients presently receive thrombolytic therapy. This review illustrates all completed trials of intravenous and intra-arterial thrombolytic therapy for carotid artery and vertebrobasilar artery stroke and includes recommendations for therapy, diagnostic procedures and their effect on patient selection, meta-analyses, phase IV trials, and cost efficacy analyses.