BACKGROUND AND PURPOSE: To determine utility of transcranial triplex sonography (TCTS) to select IV tPA unresponsive acute stroke patients for interventional treatment. METHODS: 44 acute stroke patients with CT Angiography documented arterial occlusion were included. COGIF score of residual flow in the relevant artery was monitored with TCTS before and after IV tPA infusion, and before, at the end of, and 6 and 24 hours after intra-arterial intervention, if applied. There were 10 patients who had not received rtPA, 12 patients who received IV rtPA and TCTS monitoring, 7 patients who underwent interventional treatment after IV rtPA and TCTS, 13 patients who had IV rtPA but no TCTS, and 2 patients who directly underwent to interventional treatment without TCTS monitoring. RESULTS: Without exception, TCTS allowed identification of the presence and site of clots in all patients including those in the basilar artery. In comparison with no TCTS groups, patients monitored with TCTS had similar door-to-needle time (66±30 vs. 67±25 min.), symptomatic hemorrhage rate (10.5% vs 6.7%), any hemorrhage rate (37% vs. 47%), and 3-month functional outcomes (modified Rankin score of 0-2: 42% vs. 47%). A multiple regression analysis documented a correlation between increase in COGIF score and better prognosis (modified Rankin score 1 point shift). CONCLUSIONS: This study confirmed once again the high diagnostic potential of TCTS in acute stroke patients. The bridging of neurointerventional treatment to IV thrombolysis with TCTS guidance seems to be feasible and safe, and needs to be tested in large sample-sized studies.