BACKGROUND: We used data from the Minnesota Stroke Registry to examine rates of intravenous thrombolytic therapy in acute ischemic stroke and identifed opportunities to improve the utilization of this treatment. METHODS: We analyzed a total of 1010 acute ischemic stroke patients who had been entered into the registry by 13 participating hospitals during the first three quarters of the 2008 calendar year. RESULTS: Of the 1010 patients only 121 (12%) came within 2 hours of symptom onset. Intravenous recombinant tissue plasminogen activator (rt-PA) was administered to 32/55 (58%) of the patients who arrived within 2 hours of symptom onset and met eligibility criteria for this treatment. The remaining 66 patients had a documented reason for non-treatment. The most common reason (22/66) for non-treatment was rapid resolution of symptoms or mild stroke. Out of those 22 patients, 20 were ambulating independently prior to admission and only 9/20 (45%) ambulated independently at discharge. CONCLUSION: Further community education on the need for immediate medical attention after stroke is needed. Patients appropriately excluded from rt-PA treatment due to mild deficits or rapidly improving symptoms seem to have poor discharge outcomes. This subgroup of patients will have to be studied further, preferably in the context of a clinical trial.