Post-thrombectomy Intra-arterial Tenecteplase for Acute manaGement of Non-retrievable Thrombus and No-reflow in Emergent Stroke

Inclusion Criteria:

• Adult participants (age≥18 years) presenting with ischemic stroke with arterial LVOon CT/MR Angiogram of the intracranial internal carotid or middle cerebral artery (MCA) first segment (M1) or proximal second segment (M2) committed to thrombectomyusing standard criteria within 24 hours of onset:

• For 0-6 hours of symptom onset: Presence of arterial occlusion as defined above andASPECTS≥3 on NCCT

• For 6-24 hours of symptom onset: Additional imaging criteria on CTP or MRI perfusionof core volume <100ml.

• Qualifying CT/MR within 4hrs of randomisation (repeat CT for transferredparticipants required if >4hr)

• Pre-stroke Modified Rankin Scale (mRS) score of ≤2 (mild pre-existing disabilitypermitted)

• Local legal requirements for consent have been satisfied.

Exclusion Criteria:

• Intracranial hemorrhage identified by CT or MRI

• ASPECTS 0-2 on NCCT

• CTP or MRI perfusion ischemic core volume >100ml if presenting within 6-24 hoursfrom symptoms onset

• Anticipated endovascular stenting required for intracranial or extracranialatherosclerotic stenosis/occlusion.

• More than six retrieval attempts in the same vessel

• Alteplase being infused within 30 minutes (~5x half-life) of anticipated trial drugadministration

• Contraindication to imaging with contrast agents

• Any condition (eg.mid-arterial phase early venous filling) that in the judgment ofinvestigators could impose hazards if study therapy is initiated

• Pregnant women.

• Current participation in another intervention research study that includesexperimental interventions beyond standard-of-care.

• Anticoagulation. INR ≤1.7 if on warfarin, and dabigatran reversal by idarucizumabare permitted.

• Other standard contraindications to thrombolysis apart from time window.

• Known terminal illness such that the participants would not be expected to survive ayear.

• Planned withdrawal of care or comfort care measures.