Rapid spontaneous regression of a massive post-thrombolysis intracerebral hemorrhage: A case report

Background: Symptomatic intracerebral hemorrhage is a feared complication of intravenous thrombolysis for acute ischemic stroke and is typically associated with hematoma expansion and poor clinical outcomes. The management of such hematomas represents a significant neurosurgical challenge, particularly in the setting of thrombolysis-induced hypocoagulability. Rapid spontaneous regression of large intracerebral hematomas remains an exceptionally rare phenomenon. Case Description: We report the case of a 57-year-old woman who presented with an acute ischemic stroke due to left middle cerebral artery occlusion. Following intravenous thrombolysis with tenecteplase, the patient experienced neurological deterioration, and imaging revealed a massive left intra-parenchymal hematoma associated with significant mass effect and herniation. Despite the severity of the initial presentation, follow-up imaging performed 24 h later demonstrated a marked spontaneous reduction in hematoma volume, with substantial improvement in mass effect and complete resolution of uncal herniation. Conclusion: This case highlights an unusual evolution of post-thrombolysis intracerebral hemorrhage and suggests that, in acute hypocoagulable states, hematoma dynamics may differ from the classical course. Potential mechanisms include early redistribution of blood and impaired clot stabilization. These findings, in line with recent observations in similar contexts, may have implications for understanding hematoma evolution and guiding clinical decision-making.