Repeat Intravenous Tenecteplase for Posterior Circulation Stroke Without Completed Infarction

Intravenous thrombolysis is traditionally avoided in patients with early recurrent acute ischemic stroke due to concerns for increased hemorrhagic risk. Although emerging evidence suggests that repeat intravenous thrombolysis may be safe in selected patients, nearly all published cases involve alteplase, with limited data on repeated use of tenecteplase.

A 39-year-old woman with no prior medical history presented with acute posterior circulation stroke symptoms following cervical chiropractic manipulation and was found to have a right vertebral artery dissection. She received intravenous tenecteplase with rapid neurologic improvement and no evidence of completed infarction on magnetic resonance imaging. Five days later, she re-presented with sudden-onset diplopia, obtundation, and signs concerning for brainstem ischemia. Imaging demonstrated diminished basilar artery flow concerning for occlusion. Given disabling symptoms and absence of established infarction, repeat intravenous tenecteplase was administered approximately 140 h after the initial dose, resulting in rapid neurologic recovery and restoration of posterior circulation flow. She experienced no thrombolysis-related complications and was discharged neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recurrent stroke presents a diagnostic and therapeutic challenge in the emergency department, particularly in patients with posterior circulation symptoms and recent thrombolytic exposure. This case demonstrates that, in carefully selected patients with disabling symptoms and no completed infarction, repeat intravenous tenecteplase may be a viable treatment option, highlighting the importance of timely neurologic assessment, vascular imaging, and multidisciplinary decision-making.