Extending the Time Window for Tenecteplase by Effective Reperfusion in Patients with Large Vessel Occlusion

Inclusion Criteria: * Patients presenting with acute hemispheric ischemic stroke with onset (or the time they last known to be well) within 24 hours. * Patient's age is ≥18 years. * Premorbid mRS \<3, with a concurrent assessment of whether the patient was able, immediately prior to the stroke, to: 1) Drive, or (if never drives) perform own Domestic duties, and 2) Shop for themselves, and 3) Bank/do their own finances (i.e. Drive/Domestic, Bank, Shop = DBS +ve). Need to be DBS +ve to be study eligible. * Presence of a vessel occlusion on CTA or MRA. LVO will be defined as 'potentially retrievable' thrombus at one or more of the following sites: intracranial internal carotid (ICA), middle cerebral artery (MCA) first segment (M1), proximal middle cerebral artery second segment (M2) or isolated/tandem occlusion of the extracranial ICA. Patients with an extracranial ICA stenosis and occlusion are also eligible. * Presence of 'target mismatch' on automated perfusion CT (CTP) or diffusion-perfusion MRI software defined as an ischemic core of \<70mL, penumbra of \>20mL and an ischemic core to perfusion lesion ratio of \>1.8 Exclusion Criteria: * Intracranial hemorrhage (ICH) or other diagnosis (e.g. tumor). * Basilar Artery occlusion. * Extensive early ischemic change (hypodensity on NCCT or high signal on DWI-MRI) or early ischemic change outside the perfusion lesion that invalidates mismatch criteria. * Pre-stroke mRS score of \> 2 (indicating significant previous disability) or DBS -ve. * Any terminal illness such that patient would not be expected to survive more than 1 year * Any condition that, in the judgment of the investigator could impose hazards to the patient if study therapy is initiated or affect the participation of the patient in the study. * Pregnant women. * Other standard contraindications to thrombolysis. * Minor stroke symptoms, or major stroke symptoms rapidly improving * Clinical presentation suggesting subarachnoid haemorrhage * Known bleeding diasthesis and/or platelet count \<100,000 or taking warfarin with INR \> 1.7. * Patients who have received heparin within 48 hours must have normal aPTT. * Major surgery or serious trauma within 14 days, serious head trauma within 3 months. * GI or urinary tract haemorrhage within last 21 days * Arterial puncture at a non-compressible site or lumbar puncture within 7 days * Systolic BP \> 185, diastolic BP \> 110mmHg * Clinical stroke within 3 months or history of ICH * Unable to gain consent from patient or person responsible * Known severe renal impairment (GFR \< 15mls/min)