Patient description: A 62-year-old African-American man presented with left upper and lower extremity weakness, associated with dark visual spot in right eye, right facial numbness, facial drop and slurred speech. He denied dyspnea, headache, palpitations, chest pain, fever, dizziness, bowel or urinary incontinence, loss of consciousness. His medical history was significant for hypertension, hyperlipidemia and hypothyroidism. He smokes cigarette 1 pack per day for 40 years and alcohol consumption of 5 to 6 beers per week. He is not aware about his family history. He is using Levothyroxine, Atorvastatin and HTCZ. His vital signs were stable in the primary evaluation. Left-sided facial droop, dysarthria, and left-sided hemiplegia were seen in the physical exam. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. Intravenous recombinant tissue plasminogen activator (t-PA) was administered as well as high-dose statin therapy. The patient was admitted to the intensive care unit to be monitored for 24 hours. MRI of the head revealed an acute 1.7-cm infarct of the right periventricular white matter and posterior right basal ganglia.

Clinical trial eligibility criteria: eligible ages (years): 18.0-999.0,  Ischemic Stroke Disabling Ischemic stroke symptoms with onset < 3 hours treated with IV rt-PA by local standards*. * or ≤ 4.5 hours according to local standard of care NIHSS ≥ 10* or any NIHSS with an intracranial clot should be demonstrated on neurovascular imaging (TCD or CTA) in any one of the following areas: distal internal carotid artery (ICA) carotid artery (CA), middle cerebral artery (MCA M1 or M2), posterior cerebral artery (PCA P1 or P2), distal vertebral or basilar artery TCD Thrombolysis in brain ischemia (TIBI) 0, 1, 2 or 3 CT-Angiogram: thrombolysis in myocardial ischemia (TIMI) 0 or 1 * NIHSS ≥ 10, demonstration of clot on neuroimaging is not necessary (i.e., enrollment can proceed with non-contrast head CT alone), but if performed, a clot must be demonstrated For those patients who will undergo repeat CT-Angiogram at 2-3 hours, estimated glomerular filtration rate (eGFR) must be ≥ 60 mL/min/1.73m2 Females of childbearing potential must have a negative serum pregnancy test (HCG) prior to the administration of trial medication Signed (written) informed consent by the patient or the patient's legal representative and/or guardian  Patients whom the treating physician is planning (or could plan) to treat with intra-arterial thrombolysis or other endovascular procedures (i.e., mechanical clot retrieval) aimed at recanalization Evidence of intracranial hemorrhage (ICH) on baseline CT scan or diagnosis of a non-vascular cause of neurologic deficit National institute health stroke scale (NIHSS) Level of Consciousness score (1a) ≥ 2 Pre-existing disability with mRS ≥ 2 CT scan findings of hypoattenuation of the x-ray signal (hypodensity) involving ≥ 1/3 of the MCA territory Any evidence of clinically significant bleeding, or known coagulopathy INR >1.5 Patients with an elevated activated partial thromboplastin time (aPTT) greater than the upper limit of normal Patients currently, or within the previous 24 hours, on an oral direct thrombin inhibitor (i.e., dabigatran) Heparin flush required for an IV line. Line flushes with saline only