Background Immediate reperfusion is vital to treating an acute ischemic stroke (AIS). Tenecteplase can be used for thrombolysis. However, there is a chance of early recurrence of ischemia which can affect the high cervical spinal cord (HCSC) which often gives a bad prognosis but with appropriate management, a good clinical outcome can still be expected.

Case Presentation A 69-year-old female with no known comorbidities suffered an HCSC infarct after treatment with tenecteplase for an acute ischemic stroke.

She presented with sudden pain in the right neck with nausea, diaphoresis, and dizziness. Neurologic examination was significant only for a left facial droop. CT angiogram showed an occlusion of the right vertebral artery at V3-V4 segment. She was given IV Tenecteplase within 4.5 hours of onset.

Few hours later, she developed difficulty breathing. She had bilateral diaphragmatic paralysis resulting in respiratory acidosis requiring mechanical ventilation. Additionally, she developed quadriplegia. MRI brain showed an HCSC infarction. She was on ventilatory support for 2 months due to diaphragmatic compromise. She underwent a tracheostomy and percutaneous endoscopic gastrostomy. Multiple bronchoscopies were done to manage mucous plugs and retained secretions, and she received antibiotics for ventilator-associated pneumonia.

Despite all complications, she was weaned to a speaking valve and eventually was able to communicate. Modified barium swallow showed tolerance to oral intake. Tracheostomy was successfully decannulated thereafter.

She was eventually discharged with a motor exam of 2-3/5 in all extremities with no other focal neurologic deficits.

Discussion The patient suffered from a mild ischemic stroke. Alteplase is the only approved thrombolytic drug by the Food and Drug Administration (FDA) for the treatment of AIS. If given within 3-4.5 hours of onset, it can prevent further disability.

Coming in during the therapeutic window for thrombolysis, she was given tenecteplase, a modified variant of alteplase. Tenecteplase is FDA-approved for thrombolysis in acute myocardial infarction but has found off-label use for AIS.

Early recurrence of ischemic stroke has been reported after alteplase. For tenecteplase, there are instances of expansion of the original infarct after thrombolysis but no documented report of an HCSC infarct as of this writing. Nevertheless, due to the similar pharmacokinetic properties of tenecteplase to alteplase, such a phenomenon of ischemic stroke recurrence may occur.

Acute spinal cord infarct is a rare occurrence and usually involves non-cervical territory. It may be associated with episodes of hypotension and may present with quadriplegia and diaphragmatic paralysis which were all found in this patient.