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): 18.0-80.0,  Ischemic Stroke Age 18 to 80 years 2. Acute neurologic deficit with an NIHSS ≥ 4 3. Non-enhanced computed tomography (NECT) of the head showing no hemorrhage 4. Acute ischemic stroke symptoms with onset, or time last known well, clearly defined between 3 and 4.5 hours 5. Treatment can be initiated within 3 to 4.5 hours from symptom onset  Evidence of intracranial hemorrhage on NECT 2. Clinical suspicion of subarachnoid hemorrhage even with normal NECT 3. NECT shows hypo-density greater than 1/3 cerebral hemisphere) 4. History of intracranial hemorrhage/stroke 5. Uncontrolled HTN: At time treatment begins SBP remains >185 mmHg or DBP remains >110 mmHg despite repeated measurements 6. Known arteriovenous malformation, neoplasm, or aneurysm 7. Witnessed seizure at stroke onset 8. Acute bleeding tendencies 9. Platelet count <100,000/mm3 10. Heparin received in prior 48 hours with elevated aPTT 11. Current use of an anticoagulant (Coumadin/Warfarin) irrespective of INR 12. Prior use (within 48 hours) of direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban) 13. Within prior 3 months: intracranial or spinal surgery, head trauma, or previous stroke 14. Arterial puncture at non-compressible site within last 7 days 15. Woman of child bearing age who has a positive pregnancy test 16. NIH stroke scale >25 (severe deficit) or <4 and no dysphasia (mild deficit) or rapidly improving 17. Symptoms spontaneously clearing 18. 14 days post-operative or post major trauma 19. Recent gastrointestinal or urinary tract hemorrhage within the past 21 days 20. Recent acute MI within the past 3 months 21. Serum glucose <50 mg/dl or >400 mg/dL 22. Age >80 or less than 18 23. History of ischemic stroke AND diabetes mellitus 24. Unable to obtain consent from patient or power of attorney 25. Baseline mRS > 2 26. Consent not obtained by 20 minutes prior to closure of the therapeutic window. 27. The subject has been treated with a thrombolytic agent within the past 72 hours 28. The subject is a pregnant woman (positive serum βHCG pregnancy test, positive urine pregnancy test or clinically evident pregnancy) 29. The subject is, in the opinion of the investigator, unlikely to comply with the clinical study protocol or is unsuitable for any other reason