Reversal of ischemic cortical blindness with tenecteplase

Tenecteplase (TNK) is a bioengineered variant of alteplase that has a longer half-life, a higher fibrin binding specificity, and a lower effect on systemic fibrinolytic activity. We reported a case of reversible bilateral vision loss to homonymous hemianopsia after TNK administration.

A 56-year-old African American male presented with acute onset of visual loss to no light perception (NLP) in both eyes (OU), left hemiparesis, decreased sensation, and dysarthria. Brain MRI revealed acute infarct involving the right posterior cerebral artery distribution without evidence of hemorrhagic transformation. CTA showed 4mm long segmental occlusion on the right P2 PCA. After the patient was given intravenous 23mg TNK after two and half hours since symptom onset, he recovered vision from NLP OU to 20/25 OU, but he had a residual left homonymous hemianopsia (HH), in addition to hemiparesis and decreased sensation on the left. The patient was eventually discharged to rehabilitation and outpatient follow up.At the two-month follow up, patient only had residual left HH.

Clinicians should be aware of the various treatment options in acute ischemia related cortical visual loss such as TNK. Future providers should also add comprehensive ophthalmological exam before and after patient receiving TNK to determine if our case is generalizable.