Teneteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-III

Inclusion Criteria: 1. Age ≥18 years old; 2. Acute ischemic stroke symptom onset between 4.5 to 24 hours prior to enrolment; including wake-up stroke and unwitnessed stroke, onset time refers to "last-seen normal time"; 3. Internal carotid artery, middle cerebral artery M1 or M2 occlusion confirmed by CTA/MRA, internal carotid artery, middle cerebral artery M1 or M2 being responsible for signs and symptoms of acute ischemic stroke; 4. Pre-stroke modified Rankin scale (mRS) score≤1; 5. Baseline National Institutes of Health Stroke Scale (NIHSS) 6-25 (inclusive); 6. Neuroimaging: target mismatch profile on CTP or MRI+MR Perfusion (ischemic core volume \<70 mL, mismatch ratio≥1.8 and mismatch volume≥15 mL; 7. Written informed consent from patients or their legally authorized representatives. Exclusion Criteria: 1. Intended to proceed to endovascular treatment; 2. Allergy to tenecteplase; 3. Rapidly improving symptoms at the discretion of the investigator; 4. NIHSS consciousness score 1a \>2, or epileptic seizure, hemiplegia after seizures ( Todd's palsy ) or other neurological/mental illness such that the patient is not able to cooperate or unwilling to cooperate; 5. Persistent blood pressure elevation (systolic ≥180 mmHg or diastolic ≥100 mmHg), despite blood pressure-lowering treatment; 6. Blood glucose \<2.8 or \>22.2 mmol/L (point of care glucose testing is acceptable ); 7. Active internal bleeding or at high risk of bleeding, e.g., major surgery, trauma or gastrointestinal or urinary tract hemorrhage within the previous 21 days, or arterial puncture at a non-compressible site within the previous 7 days; 8. Any known impairment in coagulation due to comorbid disease or anticoagulant use. If on warfarin, then INR \>1.7 or prothrombin time \>15 seconds; use of any direct thrombin inhibitors or direct factor Xa inhibitors during the last 48 hours unless reversal of effect can be achieved with a reversal agent; any full dose heparin/heparinoid during the last 24 hours or with an elevated aPTT greater than the upper limit of normal; 9. Known defect of platelet function or platelet count below 100,000/mm3 (NB patients taking antiplatelet medication can be included); 10. Ischemic stroke or myocardial infarction in previous 3 months, previous intracranial hemorrhage, severe traumatic brain injury or intracranial or intraspinal operation in previous 3 months, or known intracranial neoplasm, arteriovenous malformation or giant aneurysm; 11. Any terminal illness such that the patient would not be expected to survive more than 1 year; 12. Unable to perform CTP or PWI; 13. Hypodensity in \>1/3 MCA territory on non-contrast CT; 14. Acute or past intracerebral hemorrhage (ICH) identified by CT or MRI; 15. Multiple arterial occlusion (bilateral MCA occlusion, MCA occlusion accompanied with basilar occlusion); 16. Pregnant women, nursing mothers, or reluctant to use effective contraceptive measures during the period of trial; 17. Unlikely to adhere to the trial protocol or follow-up; 18. 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; 19. Participation in other interventional clinical trials within the previous 3 months.