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Results: all had minor stroke and elevated admission blood pressure; antihypertensive treatment reduced BP before thrombolysis, yet all died despite rapid brain protection. Conclusion: fatal brainstem hemorrhage may occur even in minor stroke, emphasizing careful risk assessment and aggressive blood pressure control in patients with poorly controlled 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Insights From Three Clinical Cases  \nLei Shen 1,* 􀀁, Niao Yang2,*, Dong Sun3, Bin Mei3 and Nao Yan3  \nJournal of Central Nervous System Disease Volume 18: 1-6 © The Author(s) 2026 Article reuse guidelines:  \n[sagepub.com/journals-permissions](sagepub.com/journals-permissions)  \n[DOI: 10.1177/11795735251409050](DOI: 10.1177/11795735251409050)  \n[journals.sagepub.com/home/cns](journals.sagepub.com/home/cns)  \nAbstract  \nObjective: To report three cases of immediate brainstem hemorrhage following intravenous thrombolysis with tenecteplase (TNK) in patients with minor ischemic stroke, resulting in poor outcomes and death.  \nMethods: We describe the clinical characteristics, imaging findings, and outcomes of three patients who developed brainstem parenchymal hemorrhage immediately after TNK thrombolysis.  \nResults: All three patients had minor ischemic stroke (National Institute of Health stroke scale score ≤5) and presented with elevated blood pressure on admission. Blood pressure was lowered to guideline-recommended levels (\u003C180 mmHg) using intravenous antihypertensives before thrombolysis. Despite rapid brain protection measures, including hematoma evacuation or external ventricular drainage in two cases and conservative management in one, all patients died due to brainstem hemorrhage. Conclusion: These cases suggest that fatal brainstem hemorrhage may occur after TNK thrombolysis in minor stroke. For patients with a history of poorly controlled hypertension, careful risk assessment and aggressive blood pressure management are critical if thrombolysis is considered.  \nPlain Language Summary  \nIntravenous thrombolysis is commonly used to treat acute ischemic stroke and is generally considered safe in patients with mild symptoms. In this report, we describe three patients with minor ischemic stroke who developed severe bleeding in the brainstem immediately after receiving tenecteplase. All three patients had a history of high blood pressure, and their blood pressure was lowered to recommended levels before treatment. Despite prompt medical and surgical interventions, the bleeding rapidly worsened and resulted in death in all cases. These cases highlight that life-threatening brainstem hemorrhage can occur even after thrombolysis for minor stroke. Our findings suggest that patients with long-standing or poorly controlled hypertension may be at particularly high risk. Careful patient selection and strict blood pressure control are essential when considering thrombolytic therapy in this population.  \nKeywords  \nbrainstem hemorrhage, case report, ischemic stroke, tenecteplase, thrombolysis  \nReceived: June 14, 2025; accepted: November 24, 2025  \n1 Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China  \n2Department of Cardiology, Hanyang Hospital, Wuhan University of Science & Technology, Wuhan, China 3Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China  \n*Shen and Yang contributed equally to this study.  \nCorresponding Authors:  \nNao Yan, Department of Neurology, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, Hubei, China.  \nEmail: [yannao@whu.edu.cn](yannao@whu.edu.cn)  \nBin Mei, Department of Neurology, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, Hubei, China.  \nEmail: [neuromei20@163.com](neuromei20@163.com)  \nDong Sun, Department of Neurology, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, Hubei, China.  \nEmail: [dongsun128@sina.com](dongsun128@sina.com)  \nCreative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons  \nAttribution-NonCommercial 4.0 License ([https://creativecommons.org/licenses/by-nc/4.0/](https://creativecommons.org/licenses/by-nc/4.0/)) which permits non-commercial use,  \nreproduction and distribution of the work without further permission pr","cbCairmtiKrM9XAl","https://ap.wps.com/l/cbCairmtiKrM9XAl","pdf",858372,"English","# Abstract\n## Objective\n## Methods\n## Results\n## Conclusion\n# Plain Language Summary\n# Keywords\n# Introduction\n# Case Presentations\n## Case 1","[{\"question\":\"What does the study report about thrombolysis safety in minor ischemic stroke?\",\"answer\":\"It reports three fatal cases of immediate brainstem parenchymal hemorrhage after intravenous tenecteplase (TNK) in patients with minor ischemic stroke.\"},{\"question\":\"How were blood pressure levels managed before thrombolysis in the cases?\",\"answer\":\"All patients had elevated blood pressure on admission, and clinicians lowered it to guideline-recommended levels (\\u003c180 mmHg) using intravenous antihypertensives before thrombolysis.\"},{\"question\":\"What were the clinical outcomes after the brainstem hemorrhage developed?\",\"answer\":\"Despite rapid brain protection measures, including hematoma evacuation or external ventricular drainage in some cases and conservative management in another, all three patients died due to the brainstem hemorrhage.\"}]","Immediate Brainstem Hemorrhage after Thrombolysis in Ischemic Stroke With Poorly Controlled Hypertension - Insights From Three Clinical Cases | PDF",1790653477,15]