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Background: Intravenous tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke, although only 2% of patients with stroke receive intravenous tPA nationally. Objective: To determine the rate of tPA use for stroke in the Cleveland, Ohio, community and the reasons why patients were excluded from thrombolysis treatment. Design: Retrospective cohort study. Setting: Community. Subjects: Patients admitted because of stroke to the 9 Cleveland Clinic Health System hospitals from June 15, 1999, to June 15, 2000. Main Outcome Measures: Utilization of intravenous tPA and reasons for ineligibility. Results: There were 1923 admissions for ischemic stroke in the 1-year period. Of these, 288 (15.0%) arrived within the 3-hour time window, and approximately 6.9% were considered eligible for tPA. The most common reasons for exclusion among patients arriving within 3 hours were mild neurologic impairment and rapidly improving symptoms. The overall rate of tPA use among patients presenting within 3 hours was 19.4%, and the rate of use among eligible patients was 43.4% (n = 56). The use of tPA did not differ significantly according to race or sex. Conclusions: Only 15% of patients arrived within the 3-hour time window for intravenous tPA, making delay in presentation the most common reason patients were ineligible for IV thrombolysis. Neurologic criteria were the second most common group of exclusions. Overall tPA use was low, but it was used in nearly half of all patients with no documented contraindications. Intravenous tPA use in a community setting can compare favorably with the rate of use seen in academic medical settings. [ABSTRACT FROM AUTHOR]