In a patient with vertebral artery dissection presenting with dizziness who received tenecteplase and has hypertension (BP ~180/105), should tenecteplase be stopped, blood pressure be more tightly controlled, and is endovascular stenting indicated instead of thrombolysis?

Tenecteplase Should NOT Be Stopped; Blood Pressure Management is Critical; Stenting is NOT First-Line for Vertebral Artery Dissection

In a patient with vertebral artery dissection presenting with dizziness who received tenecteplase (TNK), continue the thrombolytic therapy, maintain blood pressure below 180/105 mmHg during and after TNK administration, and reserve endovascular stenting only for cases with recurrent ischemic events despite optimal medical therapy.

Blood Pressure Management During and After Thrombolysis

The blood pressure parameters being used (systolic <180 mmHg, diastolic <105 mmHg) are correct and evidence-based for patients receiving thrombolytic therapy 1. This is not negotiable—these are the FDA-mandated parameters to reduce the risk of symptomatic intracranial hemorrhage 2.

Specific BP monitoring protocol:

• Measure BP every 15 minutes during and for 2 hours after TNK infusion
• Then every 30 minutes for 6 hours
• Then hourly until 24 hours after treatment
• If BP exceeds 180/105 mmHg, administer antihypertensive medications immediately 1

The physician suggesting lower BP parameters is incorrect. In acute ischemic stroke with vertebral artery occlusion or dissection, excessive BP lowering can exacerbate existing ischemia or induce new ischemia 3, 4, 5. The Canadian guidelines explicitly warn against lowering BP more than 15-25% in the first 24 hours, specifically cautioning about vertebral artery occlusion 3, 4.

Tenecteplase Should Continue—Do Not Stop

There is no indication to stop TNK once initiated in this scenario. The patient has:

• Vertebral artery dissection causing ischemic stroke symptoms (dizziness from posterior circulation ischemia)
• Already received TNK appropriately
• BP controlled within acceptable parameters

TNK is appropriate for vertebral artery dissection with acute ischemic stroke. The mechanism of stroke in dissection is primarily thromboembolic 6, making thrombolysis a reasonable acute intervention when presenting within the therapeutic window.

Stenting is NOT Indicated as Primary Treatment

Endovascular stenting for vertebral artery dissection is reserved for specific failure scenarios, not as first-line therapy. The AHA/ASA guidelines are explicit 6:

• Class IIb recommendation (Level C evidence): Stenting may be considered only for patients with stroke/TIA and extracranial vertebral artery dissection who have definite recurrent cerebral ischemic events despite optimal medical therapy

This means stenting is considered only when:

1. The patient has already failed medical management
2. There are documented recurrent ischemic events
3. Optimal antithrombotic therapy has been attempted

Correct Management Algorithm for This Patient

Immediate (Acute Phase - First 24-72 Hours):

1. Continue TNK if infusion ongoing
2. Maintain BP <180/105 mmHg with frequent monitoring as outlined above
3. Avoid precipitous BP drops that could worsen posterior circulation ischemia
4. Monitor for symptomatic intracranial hemorrhage (increased risk with TNK: 2.8% vs 0% with standard care 7)
5. Obtain follow-up CT/MRI at 24 hours before starting antiplatelet or anticoagulation therapy 1

Subacute Management (After Acute Phase):

1. Antithrombotic therapy for 3-6 months is reasonable (Class IIa, Level B) 6
2. The choice between antiplatelet therapy versus anticoagulation is uncertain—both are acceptable 6
3. Most experts use antiplatelet therapy (aspirin 81-325 mg daily, clopidogrel 75 mg daily, or aspirin/dipyridamole combination) 8, 9, 8

Long-term Follow-up:

1. Serial noninvasive imaging (CTA or MRA) to assess dissection healing 8, 9, 8
2. Most dissections heal spontaneously over 3-6 months 6
3. Consider stenting only if recurrent ischemic events occur despite optimal medical therapy 6

Common Pitfalls to Avoid

Do not over-aggressively lower blood pressure. The temptation to achieve "normal" BP parameters can be dangerous in acute stroke with large vessel occlusion or dissection. The brain's autoregulation is impaired, and perfusion depends on adequate systemic pressure, especially with vertebral artery compromise 3, 4, 5.

Do not rush to stenting. The evidence for stenting in vertebral artery dissection is weak (Class IIb, Level C), and most dissections heal with medical management alone 6. Stenting carries procedural risks and should be reserved for medical therapy failures.

Do not confuse anterior circulation guidelines with posterior circulation management. While aggressive BP control may be appropriate in some anterior circulation strokes, posterior circulation strokes—especially with vertebral artery pathology—require more cautious BP management 3, 4.