Balancing Ischemia and Hemorrhage After Tenecteplase in Wake-Up Stroke.

BACKGROUND: Contemporary stroke management assumes discrete clinical scenarios with clear separation between ischemic and hemorrhagic risks. When these processes coexist, guideline recommendations may be insufficient or conflicting. CASE SUMMARY: A 74-year-old woman with a wake-up stroke received computed tomography perfusion-guided thrombolysis. She developed hemorrhagic transformation, followed by intermediate-risk pulmonary embolism (PE) requiring anticoagulation. Despite treatment, recurrent intracranial large-vessel occlusion occurred; mechanical thrombectomy achieved complete reperfusion. Transesophageal echocardiography revealed a thrombus traversing a patent foramen ovale, confirming paradoxical embolism. WHY BEYOND THE GUIDELINES?: Management required balancing competing thrombotic and hemorrhagic risks: anticoagulation for PE after hemorrhagic transformation and thrombectomy in a recently thrombolyzed brain. DISCUSSION: Overlapping thrombotic and hemorrhagic conditions require individualized decision-making guided by continuous risk reassessment and multidisciplinary collaboration. TAKE-HOME MESSAGES: Concurrent stroke, PE, and hemorrhagic transformation create conflicting recommendations requiring dynamic decision-making. A thrombus crossing a patent foramen ovale confirms paradoxical embolism and justifies aggressive intervention.