Despite advances in treatment of acute ischemic strokes (AIS) with development of multimodal thrombolytic therapies, there are no clear guidelines for early recurrent stroke management. We present a patient with recurrent ischemic stroke that received off-label repeated dose of intravenous (IV) alteplase less than 48 hours after first administration, with good outcome.

There is little data on repeated administration of IV alteplase within 90 days of the index event, and the shortest safe time-lapse for a second dose is yet to be determined. Previous metanalyses suggest that functional outcome and spontaneous intracerebral hemorrhage (ICH) rate is similar to data for first time stroke administration. It is hypothesized that due to pharmacodynamic properties of IV alteplase with rapid clearance and short half-life, repeated use shouldn’t reinforce fibrinolytic effect of first infusion.

This case supports existing anecdotal data for repeated IV thrombolysis in cases of recurrent AIS within 90 days after initial small size infarcts. For safety reasons, we recommend following current guidelines for IV alteplase administration, however more studies are needed to investigate value of early repeated thrombolytic therapy.