Can a patient with cavernoma treat a stroke with tenecteplase (TNK)?

Tenecteplase (TNK) is Absolutely Contraindicated in Patients with Cavernoma

A patient with a known cavernoma should NOT receive tenecteplase (TNK) or any thrombolytic therapy for acute ischemic stroke due to the unacceptably high risk of catastrophic intracranial hemorrhage. This represents an absolute contraindication based on FDA labeling and established stroke guidelines.

Absolute Contraindication Based on FDA Labeling

The FDA explicitly lists intracranial arteriovenous malformation as an absolute contraindication to TNKase administration 1. While cavernomas are technically distinct from AVMs, they fall under the broader category of intracranial vascular malformations with hemorrhagic potential and are treated identically in clinical practice regarding thrombolytic contraindications 1.

Why Cavernomas Preclude Thrombolytic Use

Inherent Hemorrhage Risk

• Cavernous malformations are thin-walled vascular lesions with sinusoidal spaces that have an annual hemorrhage rate of 4.5% even without provocation 2
• Hemorrhage is the most serious complication of cavernomas, with deeper lesions carrying even higher bleeding risk than superficial ones 2
• These lesions frequently increase in size over time due to repeated hemorrhage episodes with subsequent fibrosis and calcification 2

Thrombolytic-Induced Hemorrhage Risk

• Tenecteplase carries a 2% risk of hemorrhagic stroke in patients WITHOUT underlying vascular malformations 2
• The presence of an intracranial vascular malformation exponentially increases this baseline hemorrhagic risk when exposed to thrombolytic agents 1
• Both tenecteplase and alteplase share identical contraindications, including intracranial vascular abnormalities 3, 4

Clinical Decision Algorithm

If acute ischemic stroke is suspected in a patient with known cavernoma:

1. Immediately exclude thrombolytic therapy - Document cavernoma as absolute contraindication 1
2. Proceed directly to imaging - Obtain CT/CTA to confirm ischemic stroke and evaluate for large vessel occlusion 2
3. Consider mechanical thrombectomy - If large vessel occlusion is present and patient meets criteria, endovascular intervention does NOT carry the same hemorrhagic contraindication as systemic thrombolysis 3
4. Initiate standard stroke care - Antiplatelet therapy, blood pressure management, and supportive measures remain appropriate 2

Critical Pitfall to Avoid

Do not rationalize thrombolytic use based on cavernoma location or size. Even small or superficial cavernomas represent an absolute contraindication 1. The risk-benefit calculation is never favorable when a known hemorrhage-prone vascular lesion exists, as the mortality from thrombolytic-induced hemorrhage into a cavernoma would be catastrophic 2.

Alternative Stroke Management

• Mechanical thrombectomy remains a viable option for large vessel occlusions in patients with cavernomas, as it does not involve systemic fibrinolysis 3
• Standard antiplatelet therapy for secondary stroke prevention may be considered, though this requires careful multidisciplinary discussion given the cavernoma's hemorrhage risk 5
• MRI with gradient-echo or susceptibility-weighted imaging should be performed to identify any additional occult cavernomas, as 13-50% of patients have multiple lesions 2