Intra-Arterial Tenecteplase to Improve the Microvascular Hemodynamics After Mechanical Thrombectomy

This is a prospective, single-arm, open-label study to evaluate the efficacy of intra-arterial tenecteplase in improving microvascular reperfusion following successful large vessel recanalization. Acute ischemic stroke patients with large anterior circulation large vessel occlusion will receive a single weight-based dose of intra-arterial tenecteplase after achieving successful large vessel recanalization (defined as TICI ≥ 2b) via standard of care mechanical thrombectomy. Microvascular flow will be assessed by quantitative angiography before and after the intra-arterial drug administration in order to quantify the impact of targeted thrombolysis on microvascular reperfusion. Reperfusion will be secondarily assessed with 24-hour imaging, final infarct volume will be quantified 72 hours following treatment, and functional outcome will be assessed in the short-term by the NIHSS and in the long-term by the 90-day modified Rankin Scale.

Inclusion Criteria: * Patient/legally authorized representative has signed the Informed Consent Form * At least 18 years of age * Ability to comply with the study protocol, in the investigator's judgment * Acute ischemic stroke attributed to anterior circulation large vessel occlusion (of the internal carotid artery or first segment of the middle cerebral artery based on CTA, MRA, or catheter angiogram) being treated with mechanical thrombectomy * NIHSS ≥ 6 at the initiation of endovascular therapy (arterial puncture) * Time from stroke onset to IA-TNK administration \< 24 hours. Stroke onset is defined as the time the patient was last known to be at their neurologic baseline * ASPECTS ≥ 6 on pre-MT CT imaging * If treated \> 6 hours from stroke onset, CTP imaging must demonstrates favorable mismatch profile (based on RAPID processing: infarct core \185 mmHg or diastolic BP \>110 mmHg, refractory to treatment * Suspicion of aortic dissection * Known allergy to iodine or iodinated contrast * Subject who requires hemodialysis or peritoneal dialysis, or who have a contraindication to an angiogram * Renal failure as defined by a serum creatinine \> 3.0 mg/dl or GFR \< 30 * Known intracranial neoplasm * GI bleeding within the past 21 days * Pre-existing medical or neurological disease that will confound the neurological or functional evaluations * Premorbid (prior to the index stroke) modified Rankin Scale (mRS) score ≥ 3 Additional neuroimaging exclusion criteria: * ASPECTS \