TPA is no longer a Level A recommendation, it’s now Level B and states that it “should be offered and may be given” for suspected ischemic stroke within 3 hours. The language used for 3-4.5 hours has also be revised.
American College of Emergency Physicians; American Academy of Neurology. Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2013 Feb;61(2):225-43. doi: 10.1016/j.annemergmed.2012.11.005.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Use of Intravenous tPA for Ischemic Stroke:, Brown MD, Burton JH, Nazarian DJ, Promes SB. Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department. Ann Emerg Med. 2015 Sep;66(3):322-333.e31. doi: 10.1016/j.annemergmed.2015.06.031.