Hemiparesis Progressing to Hemiplegia After Tenecteplase
Immediately obtain an emergency non-contrast CT head to rule out intracranial hemorrhage (ICH), as neurological deterioration after tenecteplase administration is a symptomatic ICH until proven otherwise. 1
Immediate Recognition and Action
Stop tenecteplase immediately upon recognition of neurological deterioration—do not wait for imaging confirmation before discontinuing the infusion. 1 The key clinical indicators that should trigger immediate action include:
- Change in level of consciousness 1
- Sudden elevation of blood pressure 1
- Deterioration in motor examination or increase in NIHSS score ≥4 1
- New-onset headache, nausea, or vomiting 1
The progression from hemiparesis to hemiplegia represents a significant worsening (likely NIHSS increase ≥4) and mandates immediate hemorrhage evaluation. 1
Emergency Diagnostic Workup
Obtain the following laboratory studies simultaneously with CT imaging:
- Prothrombin time/INR 1
- Activated partial thromboplastin time (aPTT) 1
- Fibrinogen level 1
- Complete blood count with platelets 1
- Type and cross-match 1
Emergency CT imaging should be performed immediately to assess the extent of hemorrhage and guide further management. 1
If ICH is Confirmed: Pharmacologic Reversal
Do not delay supportive care waiting for a "reversal agent"—none exists for tenecteplase, and time is critical. 1 However, immediately administer the following to mitigate ongoing bleeding:
- Cryoprecipitate: 6-10 units IV to replace fibrinogen and factor VIII 1
- Fresh frozen plasma: 2-4 units IV to replace clotting factors 1
- Tranexamic acid: 1 gram IV over 10 minutes as an antifibrinolytic agent to inhibit plasminogen activation 1
- Platelet transfusion: 6-8 units if thrombocytopenia is present or the patient was on antiplatelet therapy 1
Blood Pressure Management
Target systolic blood pressure <140-160 mmHg to prevent hematoma expansion, though specific targets should be guided by neurosurgical consultation. 1 Aggressive blood pressure control is critical in ICH to prevent further bleeding. 1
Neurosurgical Consultation
Contact neurosurgery immediately for potential surgical intervention, particularly if there is:
- Large parenchymal hematoma with mass effect 1
- Deteriorating neurological status despite medical management 1
- Hydrocephalus from intraventricular hemorrhage 1
If ICH is Excluded: Alternative Diagnoses
If CT head is negative for hemorrhage, consider:
- Stroke progression/extension: The patient may have failed reperfusion or reocclusion of the initially treated vessel 2
- Immediate transfer to PCI-capable center: If this was tenecteplase given for STEMI (not stroke), signs of failed reperfusion mandate immediate coronary angiography and rescue PCI 2
- Repeat vascular imaging: If this was stroke treatment, obtain CT angiography or MR angiography to assess vessel patency and consider mechanical thrombectomy if large vessel occlusion persists 3
Monitoring Protocol
Implement intensive neurological monitoring:
- Neurological assessments every 15 minutes until stabilized 1
- Complete NIHSS assessment with any change in status 1
- Repeat CT imaging at 24 hours or sooner if clinical deterioration 1
Critical Context
The incidence of symptomatic ICH after tenecteplase is approximately 0.9-1.0% in STEMI patients and 3.0% in ischemic stroke patients. 1 Independent predictors of ICH include advanced age (especially >75 years), lower body weight, female gender, prior cerebrovascular disease, elevated blood pressure at presentation, and higher baseline NIHSS score. 1
Do not confuse tenecteplase with streptokinase—tenecteplase does not cause antibodies or hypotension requiring different management. 1