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BACKGROUND Tenecteplase (TNK), a recombinant tissue plasminogen activator administered as a single intravenous bolus, is increasingly used in acute ischemic stroke (AIS) thrombolysis owing to its ease of administration and comparable efficacy to alteplase. Patients with AIS often have cardiovascular comorbidities, including coronary atherosclerosis and aortic disease, which can predispose to abdominal aortic aneurysm (AAA). This report presents the case of a 77-year-old man treated with TNK fibrinolysis for AIS, in whom an incidental AAA was later identified, highlighting its potential impact on hemorrhagic risk. CASE REPORT A 77-year-old man presented 4 h after onset of acute left-sided weakness, with a National Institutes of Health Stroke Scale score of 12. Initial head computed tomography (CT) excluded hemorrhage, and intravenous TNK (0.25 mg/kg, 21.25 mg) was administered, resulting in partial neurological improvement. Several hours later, he developed groin pain, diaphoresis, and hemodynamic instability. Aortic CT angiography revealed an infrarenal AAA measuring 41 mm, with mural thrombus and penetrating ulceration. The AAA had been previously noted as measuring 34 mm on imaging 5 years earlier. That evening, he experienced sudden neurological deterioration, and follow-up CT demonstrated thalamic and cerebellar hemorrhages. Laboratory findings showed systemic inflammation and coagulopathy. Although TNK reversal strategies were proposed, the family declined further aggressive interventions, and the patient died within hours. CONCLUSIONS This case highlights that undisclosed AAA can increase hemorrhagic risk following TNK thrombolysis in AIS. Careful vascular history-taking, individualized risk assessment, and early recognition of vascular warning signs are essential to optimize safety and clinical outcomes.