Background and purpose: barriers within the patient pathway can prevent early administration of thrombolytic therapy in patients admitted with acute stroke. This systematic review aimed to identify such barriers that have been reported in the medical literature. Methods: we searched MEDLINE and EMBASE for prospective and retrospective observational studies that assessed the nature of barriers to delivery of thrombolysis for acute stroke. Results: we identified 54 eligible studies (including a total of 39,030 patients). The reported barriers included: (i) the patient or family did not recognise symptoms of stroke or seek urgent help, (ii) the general practitioner (rather than an ambulance) was called first, (iii) the paramedics and emergency department staff triaged stroke as non-urgent, (iv) delays in neuroimaging (v) inefficient process of in-hospital emergency stroke care, (vi) difficulties in obtaining consent for thrombolysis, and (vii) physicians’ uncertainty about administering thrombolysis. Conclusions: we identified important pre-hospital and in-hospital barriers that should be overcome if thrombolysis is to be administered to stroke patients efficiently and equitably.