Tenecteplase Before Interhospital Transfer for EVT in Acute Anterior Circulation LVO at 4.5-24 Hours

Inclusion Criteria: * Age of 18 years or older; * AIS symptom onset within 4.5 to 24 hours, stroke onset is defined as the time the patient was last known to be well (including wake-up stroke and unwitnessed stroke); * Signs and symptoms consistent with the diagnosis of an acute anterior circulation ischemic stroke involving occlusion of the internal carotid artery (ICA), MCA (M1 or M2) vessels; * Functionally independent (mRS 0-2) prior to stroke onset; * Baseline National Institute of Health Stroke Scale (NIHSS) of 6-25; * Intended to transfer to ECCs for EVT; * Written informed consent from patients or legally authorized representatives; * Neuroimaging: * ICA or M1, M2 occlusion by magnetic resonance angiography (MRA) or computed tomography angiography (CTA) and ANY of the following: 1. if CT perfusion (CTP) or MR perfusion (MRP) is performed, target mismatch is defined as ischemic core volume \<70mL, mismatch volume ≥15mL and mismatch ratio ≥1.8; 2. if CTP or MRP is technically inadequate, an ASPECTS score should be of 7 or more evidenced by CT or MRI scan; Exclusion Criteria: * Known hypersensitivity or allergy to any ingredients of Tenecteplase; * Rapidly improving symptoms with NIHSS score \<6 before randomization; * Any contra-indication for IVT except for the time criterion; * Known hereditary or acquired hemorrhagic diathesis; * Impairment in coagulation due to comorbid disease or anticoagulant use. If on warfarin, INR \>1.7 or prothrombin time \>15s; if use of any direct oral anticoagulant within the last 48 hours; if on any full dose heparin/heparinoid within the last 24 hours; * Ischemic stroke or myocardial infarction in previous 3 months * Previous intracranial hemorrhage, active internal bleeding (gastrointestinal or urinary tract hemorrhage) in previous 3 months; * Severe, uncontrolled hypertension (systolic blood pressure \>180 mmHg or diastolic blood pressure \>110 mmHg); * Other serious, advanced or terminal illness with life expectancy less than 6 months; * Baseline blood glucose \<50mg/dl or \>400mg/dl; * Contraindication to imaging with contrast agents; * Acute symptomatic arterial occlusions in more than one vascular territory confirmed on CTA or MRA (e.g. bilateral MCA occlusions, or an MCA and a basilar artery occlusion); * Extensive early ischemic change on non-contrast CT estimated to be \>1/3 MCA territory, or significant hypodensity outside the Tmax\>6s perfusion lesion that invalidates mismatch criteria; * Evidence of intracranial tumor (mass effect), acute intracranial hemorrhage, or arteriovenous malformation; * Current participation in another investigational drug or device study; * Suspected endocarditis; * 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;