Reperfusion Therapy in Acute Ischemic Stroke With Unclear Onset (RESTORE)

Consecutive patients with acute ischemic stroke visiting the ER within 6 hours of the detection of stroke symptoms will be screened for this study.

Inclusion Criteria:

1. The patient is male or female and age between 18 and 85 years
2. The patient has unclear onset stroke
3. Treatment of the patient can be initiated within 6 hours after first found abnormal time
4. The patient has imaging-defined penumbra (at least 20%), measured by diffusion- and perfusion-weighted MRI

Exclusion Criteria:

1. The patient has minor neurologic deficits (NIHSS <4, except aphasia or hemianopia).
2. The patient has rapidly resolving neurological symptoms and the rate of improvement is projected to give the patient an NIHSS score <4 at the time of treatment.
3. The patient has a pre-stroke mRS score of >1 (indicating previous disability).
4. The symptoms of stroke are suggestive of subarachnoid hemorrhage.
5. Evidence of infective endocarditis or septic embolism
6. The patient has a history or clinical presentation of ICH, SAH, or AVM.
7. Serious head trauma within 6 weeks
8. Prior ischemic stroke in previous 6 weeks (except small infarct)
9. Myocardial infarction in the previous 3 weeks
10. Gastrointestinal or urinary tract bleeding in previous 21 days
11. Major surgery in the previous 14 days
12. History of biopsy of a parenchymal organ, trauma with internal organ injury or lumbar puncture within 14 days
13. Arterial puncture at a non-compressible site in the previous 7 days
14. Uncontrolled high blood pressure (systolic > 185 mmHg or diastolic > 110 mmHg on 3 separate occasions at least 10 min apart despite appropriate treatment)
15. Evidence of active bleeding or acute trauma (fracture) on examination
16. Current use of oral anticoagulants and a prolonged prothrombin time (INR >1.7)
17. The patient has been treated with heparin in the previous 48 hours with prolonged aPTT, except for low dose subcutaneous LMWH with doses recommended for DVT prophylaxis
18. Baseline platelet count < 100,000 mm3
19. Baseline hematocrit < 25%
20. Blood glucose concentration < 50 mg/dL (2.7 mmol/L) in case of CT screening
21. Seizure at onset with postictal residual neurological impairments in case of CT screening
22. The patient has a terminal illness.
23. The patient is, in the opinion of the investigator, unlikely to comply with the clinical study protocol or is unsuitable for any other reason.
24. The patient has extensive early infarction in any affected area defined as an infarcted core involving > 1/3 of MCA territory or the entire ACA or PCA territory
25. The patient has well-developed parenchymal hyperintensity on FLAIR, T2*, or EPI-T2 images, or marked hypodensity on CT, indicative of subacute infarction, or enhancement with morphologic features suggesting the lesion is more than 6 hours old
26. The patient has a contraindication to the imaging techniques (this means ferromagnetic objects for MRI, contraindications to contrast agent, renal disease with iodinated contrast agent in perfusion CT and CTA, etc.)
27. The patient has imaging evidence of ICH or SAH, AVM, brain tumor (Incidental meningioma and microbleeds are not exclusion criteria. Incidental unruptured aneurysm that is small (< 5mm) is not an exclusion criterion).