Efficacy and Safety of Tenecteplase Among acutE Ischemic Stroke Patients With Recent Ingestion of Direct Oral Anticoagulant

Inclusion Criteria: * Adults (18 years or older) with a suspected acute ischemic stroke and clearly disabling deficits * Presenting within 4.5 hours of last known well * Able to initiate intravenous thrombolysis within 4.5 hours of last known well * On recent DOAC therapy (dabigatran, apixaban, rivaroxaban, edoxaban) and known last dose taken within 48 hours from thrombolysis. Exclusion Criteria: * Current or history of intracerebral hemorrhage * Non-disabling deficits * Bleeding disorder (e.g. hemophilia) or advanced liver disease or known INR \> 1.7 within 6 hours * Use of therapeutic low molecular weight heparin or therapeutic dose heparin with elevated PTT * ASPECTS \< 6 or clear hypodensity on CT suggestive of completed infarct * Advanced kidney disease (eGFR \< 30 ml/min) * Known or suspected aortic dissection * Known or high suspicion for infective endocarditis * Surgery within 2 weeks * Intracranial or intraspinal surgery within 3 months * Active internal bleeding or gastrointestinal or urinary tract hemorrhage within 3 weeks * Intracranial neoplasm, arterio-venous malformation, or cavernous malformation * Major head trauma or ischemic stroke within 3 months * Known thrombocytopenia (platelets \< 100,000) * Planned endovascular treatment within 30 minutes of study drug administration (i.e., consent, randomization and administration of study drug must occur at least 30 minutes prior to groin puncture; standard care is not to be delayed and patients in whom endovascular therapy will start sooner will not be enrolled) * Comorbid condition with life expectancy of less than 3 months * Any condition that precludes thrombolytic therapy as determined by site principal investigator * Pregnancy