tPA for the Management of Acute Ischemic Stroke - FreeOAM vs. {industry funded} Guidelines

In noon conference today, the presenting resident reviewed the AHA/ASA March 2013 guidelines on management of acute ischemic stroke. It was a good overview of the guidelines, but there wasn't a lot of room for debate on the evidence for and against tPA in this scenario. Luckily I've been privy to the tPA in acute stroke debate in the #FOAMed community.

Mini FOAMed Lit Review on the use of tPA for the management of acute ischemic stroke:

1. Emergency Med Lit of Note were out of the gate quick early this year to question the integrity of the ACEP guidelines on this topic.
2. theNNT convinced me with their thorough evidence based review. Their "red light" made it clear to me what the answer is on this topic. 
3. Recently LiTFL posted a two part series on this topic by Michelle Johnston. She left the final decision on the validity of tPA use for this indication to the reader, but her analysis is thorough and presents a strong case to exercise caution when considering tPA. 
4. Just this morning ALiEM's Todd Seigel posted a review focused primarily on the NINDS study, AHA, & ACEP guidelines. His post stands in contrast to the other FOAM contributions to this debate, and Graham Walker of theNNT & MDCalc was quick to point out this contrast. 

But can FOAMed stand up to 3 major organizations (AHA, ASA & ACEP) all arguing strongly for use of tPA in select patient groups?

Thankfully, there's at least one organization that has stood strong & reasonable. The AAEM have put out statements, commentaries, educational material, & letters all asking for an injection of evidence-based, calmly considered, carefully weighed thought, skepticism, debate, and further investigation on this topic. 

Despite some guidelines, it can at least be said, tPA for the management of acute ischemic stroke is not the standard of care.