Situation: A 45-year-old woman comes to the emergency room (ER) with sudden shortness of breath and right-sided pleuritic chest pain that began 2 hours ago, the day after a 14-hour bus trip. She takes a combined estrogen–progestin oral contraceptive. Her right calf is swollen and tender. She weighs 70 kg and has no known drug allergies. Despite heparin and a 500 mL fluid bolus, her blood pressure stays at 78/48 mmHg, and the team plans systemic thrombolysis with alteplase. While reviewing her history, which finding should the nurse report to the provider as an absolute contraindication?

Systemic thrombolysis is used for pulmonary embolism with persistent hypotension. Absolute contraindications include any prior intracranial hemorrhage, ischemic stroke within the past 3 to 6 months (depending on the guideline), recent head trauma or brain or spinal surgery, intracranial tumor, and active internal bleeding. A hemorrhage inside the skull 6 years ago still counts, whereas an ischemic stroke 8 months ago lies outside that window.

Clinical context This patient has a high-risk (massive) pulmonary embolism. The combination of sudden dyspnea, pleuritic chest pain after prolonged immobilization, a swollen tender calf suggesting deep vein thrombosis, and persistent hypotension despite heparin and fluids defines hemodynamic instability. In this situation, systemic thrombolysis is indicated to rapidly dissolve the clot and reduce right ventricular afterload.

Why option 1 is the answer A history of any prior intracranial hemorrhage is an absolute contraindication to systemic thrombolysis, regardless of how long ago it occurred or how complete the recovery was. The risk of catastrophic rebleeding into the brain is unacceptably high because alteplase is a systemic fibrinolytic that dissolves protective hemostatic plugs throughout the body, not just the pulmonary clot. The 6 years since the bleed does not reduce this risk to an acceptable level.

Why the other options are not absolute contraindications

Option	Classification	Reasoning
2. Menstrual period that began yesterday	Not a contraindication	Normal menstrual flow is not active internal bleeding in a critical location. It may increase blood loss slightly but does not pose a life-threatening risk.
3. Heparin infusion running for 2 hours	Expected, not a contraindication	Heparin is standard initial therapy for PE. Thrombolysis is added on top of heparin in massive PE; the infusion does not preclude alteplase.
4. Ischemic stroke 8 months ago	Relative or outside window	Ischemic stroke within the past 3 to 6 months is an absolute contraindication. At 8 months, the risk has decreased enough that thrombolysis may be considered if the benefit outweighs the risk.

Pathophysiology of the contraindication Alteplase converts plasminogen to plasmin, which degrades fibrin clots and also fibrinogen. In a patient with a prior intracranial hemorrhage, the cerebral vasculature may have residual structural weakness, microaneurysms, or areas of impaired autoregulation. When systemic fibrinolysis is introduced, any subclinical or healed bleeding site in the brain can rupture again, leading to a potentially fatal hemorrhagic stroke. This is why the contraindication is permanent, not time-limited.

Nursing priority Before alteplase is administered, the nurse must complete a thorough screening for contraindications and Key point! report any history of intracranial bleeding, recent ischemic stroke, major surgery, or active bleeding immediately to the provider. The decision to proceed with thrombolysis in a patient with a relative contraindication requires a careful risk-benefit discussion, but an absolute contraindication such as prior intracranial hemorrhage removes thrombolysis as an option entirely.

Distinguishing the two neurologic histories The critical distinction is between hemorrhagic and ischemic events. An ischemic stroke leaves a time-limited window of risk because the infarcted brain tissue is most vulnerable to hemorrhagic transformation in the first weeks to months. A prior hemorrhage, however, indicates a structural or hemostatic predisposition that does not resolve with time. Watch out! Do not confuse the two: ischemic stroke has a time window (3–6 months), while intracranial hemorrhage has no time window and remains an absolute contraindication permanently.