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Introduction: Telestroke is used increasingly at hospitals where on-site stroke expert support is not available. Even at tertiary teaching hospitals senior stroke experts are not generally on-site out of hours. Here front-line decision-making is made either by junior doctors with or without telephone back-up by more senior staff or senior staff drives in from home to attend the case in person. Telestroke for remote expert support is not commonly used in this setting.Hypothesis: That telestroke at a tertiary centre is feasible without adversely affecting quality of care.Methods: This is a sequential comparison capturing all stroke patients thrombolyzed out-of-hours 12 months before implementation of tertiary hospital telestroke and 12 months after. Main outcomes were thrombolysis rate, treatment times and symptomatic intracerebral hemorrhage rate. Participating neurologists were surveyed about their experience.Results: Over the 24-month study period, 80 patients (38 pre- and 42 telestroke) were thrombolyzed out of 584 patients admitted with ischemic stroke. The overall thrombolysis rate of all patients presenting with ischemic stroke was 20.2% pre- and 21.6% post-telestroke with 26.0% and 28.8% out-of-hours rates respectively. Median (IQR) out-of-hours door-to-needle time was 65 (45-100) minutes before and 57 (41-78.5) minutes after with 45.7% treated within 60 minutes of arrival pre and 52.3% post (OR (95%CI) 1.30 (0.53-3.17);p=0.56). Median door-to-CT time dropped from 34 (26-58) pre to 25.5 (17.5-46.5) post (p=0.21). The sICH rate was 2.6% pre- and 2.3% post-telestroke (OR (95%CI) 0.38 (0.03-4.41); p=0.42). The neurologists were highly satisfied with the new model as it meant they no longer had to drive in from home out-of-hours and co-ordination of on-call activities, which include provincial telestroke was less stressful.Conclusion: Tertiary center telestroke can be safely implemented to reduce on-call burden for neurologists while maintaining a high thrombolysis rate and acceptable door-to-needle times and sICH rates. Especially where the same neurologists also support out-of-hours regional telestroke managing both patient groups in the same manner can streamline processes of care.