Aim Practitioners are faced with a substantial challenge when considering recombinant tissue plasminogen activator (rt‐PA) therapy for older patients with ischemic stroke. Patients aged over 80 years suffer from the most severe cerebral infarcts. The benefit of rt‐PA treatment compared with single standard care only in stroke units remains to be clearly assessed. Methods We collected data from 321 patients aged over 80 years admitted for acute cerebral infarction to the stroke unit of Nancy University Hospital in France between 1 January 2009 and 31 December 2012. Patients were stratified into two groups: treated or not with rt‐PA. Baseline characteristics and outcome were collected and compared between both groups. Good outcome at 3 months was defined as modified Rankin Scale score ≤2. Results The 55 patients treated with rt‐PA had a higher National Institute of Health Stroke Scale score on admission than those without (15 vs 5; P < 0.001). They were more likely to have intracranial haemorrhage (20 vs 5%; P < 0.001) without an increased mortality rate (28 vs 27%; P = 0.95). Multivariate analysis showed a more favorable outcome (odds ratio 7, 95% confidence interval 3–16.5; P < 0.001). Slightly higher percentages of patients with modified Rankin Scale ≤2 were found after intention‐to‐treat analysis (49 vs 45%) and after exclusion of patients with baseline modified Rankin Scale >2 (57 vs 54 %), but without reaching significance (P > 0.05). Conclusions Rt‐PA therapy would appear to improve prognosis in the elderly with ischemic stroke. This suggests that age alone should no longer be a barrier to rt‐PA therapy. Geriatr Gerontol Int 2016; 16: 843–849.