This material is not likely to be on your boards; however, knowledge about the evolving landscape of the delivery of stroke care is important for the practicing vascular neurologist. Years after IV t-PA was approved by the FDA in 1996, studies showed that the medication was vastly underutilized with mixed outcomes. In turn, the Brain Attack Coalition (BAC) made the initial recommendations for the development of Primary Stroke Centers to promote better standardization of safe and effective acute stroke care. Since then, there has been an emphasis by the American Heart Association/American Stroke Association (AHA/ASA), The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS) to evaluate specific stroke measures and hospital outcomes. In search of faster, more effective administration of lytics, many investigators have focused on the prehospital setting.