TWISTTenecteplase in Wake-up Ischaemic Stroke Trial (TWIST). A Randomised-controlled Trial of Thrombolytic Treatment With Tenecteplase for Acute Ischaemic Stroke Upon Awakening

Study start date: June 12, 2017

Inclusion Criteria: * Stroke symptoms on awakening that were not present before sleep * Clinical diagnosis of stroke with limb weakness with NIHSS score \>=3, or dysphasia * Treatment with tenecteplase is possible within 4.5 hours of awakening * Written consent from the patient, non-written consent from the patient (witnessed by non-participating health care personnel), or written consent from the nearest family member Exclusion Criteria: * Age \<18 years * NIHSS score \>25 or NIHSS consciousness score \>2, or seizures during stroke onset * Findings on plain CT that indicate that the patient is unlikely to benefit from treatment: * Infarction comprising more than \>1/3 of the middle cerebral artery territory on plain CT or CT perfusion * Intracranial haemorrhage, structural brain lesions which can mimic stroke (e.g cerebral tumour) * Active internal bleeding of high risk of bleeding, e.g.: * Major surgery, trauma or gastrointestinal or urinary tract haemorrhage within the previous 21 days, or arterial puncture at a non-compressible site within the previous 7 days * Any known defect in coagulation, e.g. current use of vitamin K antagonist with an INR \>1.7 or prothrombin time \>15 seconds, or use of direct thrombin inhibitors or direct factor Xa inhibitors during the last 24 hours (unless reversal of effect can be achieved by agents such as idarucizumab) or with elevated sensitive laboratory tests (such as activated partial thromboplastin time (aPTT), international normalized ratio (INR), platelet count, ecarin clotting time, thrombin time (TT), or appropriate factor Xa activity assays), or heparins during the last 24 hours or with an elevated aPTT greater than the upper limit of normal * Known defect of clotting or platelet function or platelet count below 100,000/mm3 (but patients on antiplatelet agents can be included) * Ischaemic stroke or myocardial infarction in previous 3 months, previous intracranial haemorrhage, severe traumatic brain injury or intracranial or intraspinal operation in previous 3 months, or known intracranial neoplasm, arteriovenous malformation or aneurysm * Contraindications to tenecteplase, e.g., acute bacterial endocarditis or pericarditis; acute pancreatitis; severe hepatic dysfunction, including hepatic failure, cirrhosis, portal hypertension; active hepatitis; systemic cancer with increased bleeding risk; haemostatic defect including secondary to severe hepatic, renal disease; organ biopsy; prolonged cardiopulmonary resuscitation \> 2 min (within 2 weeks) * Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg), despite blood pressure lowering treatment * Blood glucose \<2.7 or \>20.0 mmol/L (use of finger-stick measurement devices is acceptable) * Pregnancy, positive pregnancy test, childbirth during last 10 days, or breastfeeding. In any woman of childbearing potential, a pregnancy test must be performed and the result assessed before trial entry * Other serious or life-threatening disease before the stroke: severe mental or physical disability (e.g. Mini Mental Status score \<20, or mRS score ≥3), or life expectancy less than 12 months * Patient unavailability for follow-up (e.g. no fixed address)