To illustrate the significance of thrombus migration in the posterior circulation post-tPA administration as well as the importance of adequate access to thrombectomy in the event of clinical neurological deterioration.

We searched the Quality Improvement and Clinical Research (QuICR) database from April 2015 – March 2018 to identify cases of isolated vertebral occlusion. This database collects data for all ischemic stroke patients treated with alteplase (tPA and TNK) or endovascular treatment in the province of Alberta.

From all the patients to have received alteplase or endovascular therapy from April 2015 – March 2018 in the province of Alberta, Canada, we identified 7 cases of isolated intra or extracranial vertebral occlusion treated with tPA. Of these 7 cases, 2 cases went on to receive endovascular therapy following tPA administration due to worsening clinical status of the patient and imaging revealing migration of the thrombus.

Strokes that initially present as a thrombus originating in the vertebral arteries may evolve post tPA administration to more distal and serious vascular territories through thrombus migration. Transferring the patient to a tertiary stroke center with rapid access to endovascular therapy options is key in attempting to treat patients that experience rapid deterioration secondary to thrombus migration.