A 31-year-old woman presented with sudden onset of vertigo and dysarthria preceded by self-manipulation of the neck. NIHSS score was 3. Head CT scan was normal. CT Angiography (CTA) revealed abrupt caliber change of the left vertebral artery beginning at the distal V2 segment with significant luminal narrowing within the V3 segment and reconstitution of a normal caliber at the distal V3 segment, all suggestive of dissection. She was considered eligible for and received IV r-tPA. Within minutes into r-tPA infusion, she reported worsening severe cervico-occipital headache and diplopia. Infusion was stopped immediately. Exam showed left facial hypoesthesia, Horner’s syndrome as well as left hemi-ataxia. Repeat CTA showed expansion of left vertebral artery dissection, which now included the V4 segment and caused complete occlusion of the vertebral and left posterior inferior cerebellar arteries.

Our case proves IVT can cause expansion of intramural hematoma and associated neurological deterioration in symptomatic CCAD, especially of the vertebral arteries. Although IVT is the standard of care, supported by major rtPA clinical trials, which included patients with CCAD, our case points that there is need for a dedicated study to assess the safety and efficacy of IVT in this specific patient population.