The 2019 AHA/ASA updated Guidelines for the Early Management of Patients with Acute Ischemic Stroke mention Tenecteplase (TNK) as a reasonable therapy in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy. 

A 61-year-old male with history of HTN and cardiomyopathy . Presented with sudden onset right sided weakness, aphasia and left gaze. Presenting NIHSS was 28. CT head with hyperdense left MCA sign and ASPECTS score of 10. CTA confirmed proximal left MCA M1 segment occlusion. IV TNK was given within 01:23 hours of symptoms onset. Subsequently, patient underwent emergent mechanical thrombectomy for disabling large vessel occlusion stroke. Spontaneous near complete recanalization of left MCA occlusion was noted on initial angiography run. Post procedure CT head was negative for any intracranial hemorrhage. Patient’s exam was noted to improve to NIHSS of 2. Approximately 6 hours after the TNK administration, patient became acutely unresponsive with NIHSS of 26. CT head revealed bilateral cerebellar intraparenchymal hemorrhages, extensive subarachnoid hemorrhage in basal cisterns and within the sulci in bilateral frontotemporal regions, as well as subdural hemorrhages along the falx and tentorial dural folds. Tranexamic acid was given as emergent reversal. Despite aggressive medical management and over following 24 hours, exam worsened with loss of pupillary reflexes. Patient was terminally extubated 2 days after initial presentation in accordance with his advance directives.

Patient's multicompartmental intracranial hemorrhages unrelated to area of infraction were unusual in the absence of any vascular lesions to predispose hemorrhage based on CT and conventional angiography. Further observational studies are warranted to evaluate similar complications of Tenecteplase administration and their occurrence rates.