Your comment has several things wrong with it. We never use perfusion imaging to make a decision on utilization of tPA. Clarifying ischemic penumbra also is far beyond the research phase- it is day to day clinical practice in decision making for mechanical thrombectomy. We generally take more patients to thrombectomy than we tPA, but this is given we are the major referral center for severe stroke. Any hospital without advanced capabilities holding onto a patient with symptoms of a severe stroke within the 24 hour window for thrombectomy without making an attempt to emergently transfer the patient to a comprehensive stroke center is not following the standard of care.