Ischemic stroke affects up to 3% of the US population and is the leading cause of disability nationwide. This article outlines the evidence to support the use of intravenous thrombolytic, including tenecteplase, in the setting of acute ischemic stroke, along with thrombectomy for up to 24 hours, even in those patients with a large ischemic core and in those with an acute basilar artery occlusion. A clinical case of a patient with large ischemic core who received thrombectomy is included, along with images.