CHinese ischEmic Stroke Beyond 4.5 Hours With TeNecteplase Under Optimized Non-Contrast CT Selection

Prior treatment

• Treatment with a full dosage of low-molecular weighted heparin in the last 24 hours
• Recent participation in another investigational drug or device study or registry in the past 30 days before enrollment.

Other illness

• Obvious hypodensity on NCCT deemed related with the current stroke event, with no expected benefit from thrombolysis as assessed by the investigators
• Allergy to the test drug and its ingredients
• Any sign of an acute intracranial hemorrhage or subarachnoid hemorrhage identified on baseline NCCT
• History of any intracranial hemorrhage
• History of ischemic stroke or major head trauma within the last 3 months
• History of intracranial/intraspinal surgery during the last 3 months
• Gastrointestinal malignancy or gastrointestinal bleeding within 21 days
• Clinical presentation or imaging profile consistent with Moyamoya disease/syndrome.
• Any terminal illness such that the patient would not be expected to survive more than three months.
• Other conditions in which investigators believe that participating in this study may be harmful to the patient.

Lab values

• Known bleeding diatheses; platelets count \< 100000/mm3, international normalized ratio \> 1.7, prothrombin time \> 15 s, or activated partial thromboplastin clotting time \> 40 s
• Treatment with direct thrombin inhibitors or direct factor Xa inhibitors within the previous 48 hours unless the laboratory test of coagulation function is normal
• Initial glucose levels \<2.8 or 22.22 mmol/L

Other

• Endovascular thrombectomy (EVT) planned at the time of randomization
• Rapidly improving symptoms at the discretion of the investigator
• Initial systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥100 mmHg
• Known or suspected aortic arch dissection
  • In addition to:
• Pregnancy or breastfeeding.

• Suspected acute ischemic stroke of anterior cerebral circulation.
• Last known well time \>4.5 hours.
• Age ≥18 years old.
• Baseline NIHSS (National Institutes of Health Stroke Scale) score \>5.
• Premorbid modified Rankin Scale (mRS) ≤1.
• Imaging criteria: Automated infarct segmentation by NCCT post-processing model indicates infarct core volume \<50 mL with no visible hypodensity in \>1/3 of the MCA territory.
• Informed consent signed by the patient or the patient's legally authorized representative.