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Target stroke guidelines recommend a door-to-needle time of ≤60 minutes for acute ischemic stroke (AIS) patients treated with intravenous (IV) tissue-type plasminogen activator (tPA). We sought to analyze all diagnostic steps involved in the acute evaluation and treatment of AIS with IV tPA and to look for causes of delay in door to needle time (DNT).A review of AIS patients treated in the emergency department with IV tPA. Times comparing intervals from door to head computed tomography (CT), CT result, electrocardiogram (ECG), chest radiograph, and IV tPA treatment. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and logistic regression was used as appropriate.A total of 79 AIS patients, with 22 (28%) receiving IV tPA ≤60 minutes were analyzed. Patients were more likely to get treated with IV tPA in ≤60 minutes if symptom onset was >90 minutes (OR 3.52; 1.03-12.1; P < .05) or if the ECG was done after the head CT (OR 3.67; 1.29-10.5; P < .02). Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 13 (16%) patients.An ECG performed before the head CT is completed increased CT time by 6 minutes and a chest radiograph obtained before the head CT increased CT time by 13 minutes. DNT ≤60 minutes for AIS patients are affected by the order of diagnostic studies. In a minority of patients the DNT is affected by non-modifiable issues.