Intravenous alteplase or tissue plasminogen activator (tPA) has been the standard of care with proven efficacy for acute ischemic stroke for over a decade. Despite this, only a small fraction of potentially eligible stroke patients receive this medication. There seems to be a fear among practitioners of legal repercussions as a result of an increased risk of intracerebral hemorrhage due to tPA. This review of legal cases involving tPA will show that instead, physicians are often found liable as a result of not treating with tPA.