Tenecteplase in Stroke Patients Between 4 and 24 Hours

Inclusion Criteria:

Age >= 18 years

- AIS symptom onset within 4.5 to 24 hours Signs and symptoms consistent with the
diagnosis of an acute anterior circulation ischemic stroke involving occlusion of the
ICA, M1, or M2 vessels

- Functionally independent (mRS 0-2) prior to stroke onset

- Baseline NIHSS >=5 and that remains >=5 immediately prior to randomization

- Neuroimaging: ICA or M1, M2 occlusion (carotid occlusions can be cervical or
intracranial, with or without tandem MCA lesions) by MRA or CTA AND target mismatch
profile on CT perfusion or MRI (ischemic core volume <70 mL, mismatch ratio is >=1.8
and mismatch volume is >15 mL)

- The mismatch volume is determined by FDA-approved imaging software in real time based
on the difference between the ischemic core lesion volume and the Tmax>6s lesion
volume. If both a CT perfusion and a multimodal MRI scan are performed prior to
enrollment, the later of the 2 scans is assessed to determine eligibility. Only an
intracranial MRA is required for patients screened with MRA; cervical MRA is not
required. Cervical and intracranial CTA are typically obtained simultaneously in
patients screened with CTA, but only the intracranial CTA is required for enrollment.

Alternative neuroimaging:

- If CTA (or MRA) is technically inadequate: Tmax>6s perfusion deficit consistent with
an ICA or M1, M2 occlusion AND target mismatch profile (ischemic core volume <70 mL,
mismatch ratio >1.8 and mismatch volume >15 mL as determined by RAPID software)

- If magnetic resonance perfusion (MRP) is technically inadequate: ICA or M1, M2
occlusion (carotid occlusions can be cervical or intracranial; with or without tandem
MCA lesions) by MRA (or CTA, if MRA is technically inadequate and a CTA was performed
within 60 minutes prior to the MRI) AND diffusion-weighted imaging (DWI) lesion volume
<25 mL for an M1 or ICA occlusion and =<15 mL for an M2 occlusion

- If CTP is technically inadequate: patient can be screened with MRI and randomized if
neuroimaging criteria are met.

- Ability to comply with the study protocol, in the investigator's judgment

Exclusion Criteria:

General

- Current participation in another investigational drug or device study

- Active internal bleeding

- Known hypersensitivity or allergy to any ingredients of tenecteplase

- Known bleeding diathesis

- Known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency;
recent oral anticoagulant therapy with INR >1.7

- Use of one of the new oral anticoagulants within the last 48 hours (dabigatran,
rivaroxaban, apixaban)

- Pregnant

- Intracranial neoplasm, arteriovenous malformation, or aneurysm

- Seizures at stroke onset if it precludes obtaining an accurate baseline NIHSS

- Severe, uncontrolled hypertension (systolic blood pressure >180 mmHg or diastolic
blood pressure > 110 mmHg)

- Baseline platelet count <100,000/microL (results must be available prior to treatment)

- Baseline blood glucose >400 mg/dL (22.20 mmol/L)

- Baseline blood glucose <50 mg/dL needs to be normalized prior to randomization

- Clot retrieval attempted using a neurothrombectomy device prior to randomization

- Intracranial or intraspinal surgery or trauma within 2 months

- Treatment with a thrombolytic within the last 3 months prior to randomization

- Other serious, advanced, or terminal illness (investigator judgment) or life
expectancy is less than 6 months

- Pre-existing medical, neurological, or psychiatric disease that would confound the
neurological or functional evaluations

- History of cerebrovascular accident in the last 90 days

- Presumed septic embolus; suspicion of bacterial endocarditis

- Any other condition that, in the opinion of the investigator, precludes an
endovascular procedure or poses a significant hazard to the patient if an endovascular
procedure was to be performed

Imaging

- Unable to undergo a contrast brain perfusion scan with either MRI or CT

- Extensive early ischemic change (hypodensity) on non-contrast CT estimated to be >1/3
MCA territory, or significant hypodensity outside the Tmax>6s perfusion lesion that
invalidates mismatch criteria (if patient is enrolled based on CT perfusion criteria)

- Significant mass effect

- Acute symptomatic arterial occlusions in more than one vascular territory confirmed on
CTA/MRA (e.g., bilateral MCA occlusions, or an MCA and a basilar artery occlusion)

- Evidence of intracranial tumor (except small meningioma) acute intracranial
hemorrhage, neoplasm, or arteriovenous malformation