Abstract TP243: When Clot Lysis Turns Embolic: Anterior Spinal Cord Infarct after TNK for Vertebral Artery Thrombus

Background: Anterior spinal artery (ASA) infarction is an exceptionally rare condition and is typically associated with trauma, surgery, or profound hypotension. We present an interesting case of ASA infarction caused by thrombus migration after an intravenous tenecteplase (TNK) administration for vertebral artery occlusion, likely due to clot breakdown and distal embolization following thrombolysis. Case: A 69-year-old woman with no major comorbidities developed acute right-sided neck pain, dizziness, dysarthria, and unresponsiveness at home. Emergency services transported her to our comprehensive stroke center where she had mild dysarthria and numbness with a low stroke score of 2. Initial non-contrast computed tomography (CT) of the head was unremarkable, and CT angiography revealed a distal right vertebral artery (V3/V4) thrombus. Considering she had disabling symptoms; she was administered intravenous (IV) TNK. Overnight she developed worsening neurological deficits, ultimately progressing to respiratory failure and quadriplegia. Magnetic Resonance Imaging (MRI) of the brain and cervical spine revealed multifocal acute infarctions most notably in the anterior cervical spinal cord from the cervicomedullary junction to mid-second cervical segment, consistent with ASA territory infarction, along with acute infarctions in the cerebellum, thalamus and medulla. There was no evidence of trauma, dissection, systemic hypotension, or aortic pathology. We hypothesize that TNK-mediated thrombus fragmentation led to distal embolization into the ASA, resulting in spinal cord infarction. Her course was complicated by neurogenic shock, neurogenic bowel and bladder, pneumonia, and prolonged ventilator dependence. Although her initial hospitalization lasted a month and was marked by significant deficits at discharge, she returned from rehabilitation few months later to greet us with remarkable recovery and was walking independently using a walker. Conclusion: This may be one of the first reported cases of ASA infarction as a sequela of IV TNK given for vertebral artery thrombus. While thrombolysis remains the cornerstone of acute ischemic stroke care, this case raises awareness of potential distal embolism to small arteries, including spinal arteries in posterior circulation strokes with vertebral artery pathology. Clinicians should maintain a high index of suspicion for spinal infarcts in patients with atypical or progressive neurologic decline after thrombolysis.