# Situation: A 64-year-old woman is brought to a stroke-ready hospital with sudden right-sided weakness and slurred speech that began 90 minutes ago. She weighs 104 kg. Noncontrast computed tomography (CT) shows no hemorrhage, and the team plans intravenous (IV) alteplase for acute ischemic stroke. Forty minutes into the alteplase infusion, she reports a sudden severe headache and vomits. Her blood pressure is 198/112 mmHg, and she is harder to rouse. What is the MOST likely cause?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630135  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 64-year-old woman is brought to a stroke-ready hospital with sudden right-sided weakness and slurred speech that began 90 minutes ago. She weighs 104 kg. Noncontrast computed tomography (CT) shows no hemorrhage, and the team plans intravenous (IV) alteplase for acute ischemic stroke.

Forty minutes into the alteplase infusion, she reports a sudden severe headache and vomits. Her blood pressure is 198/112 mmHg, and she is harder to rouse. What is the MOST likely cause?

## 보기

1. Intracranial hemorrhage from the thrombolytic **✔ 정답**
2. Expected headache as the clot is dissolved
3. Malignant cerebral edema from a large infarct
4. Extension of the original ischemic infarct

**정답: 1**

## 해설

A sudden severe headache, vomiting, a rise in blood pressure, and a falling level of consciousness during thrombolysis point to symptomatic intracranial hemorrhage. The nurse stops the infusion and notifies the provider at once, and emergency CT follows.

## 심화 해설

What the question is testing

This item asks you to recognize the most feared complication of IV alteplase for acute ischemic stroke: symptomatic intracranial hemorrhage. The clinical picture is deliberately classic, and the timing during the infusion is the key clue.

Why intracranial hemorrhage is the answer

Alteplase is a recombinant tissue plasminogen activator that converts plasminogen to plasmin, leading to systemic fibrinolysis. In the brain, this lytic state can disrupt the blood–brain barrier and weaken already injured vessels in the ischemic penumbra, allowing blood to extravasate into brain tissue. The result is hemorrhagic transformation, which becomes clinically apparent as symptomatic intracranial hemorrhage when it causes neurologic deterioration.

The patient’s findings fit that process precisely. A sudden severe headache, vomiting, acute hypertension, and a declining level of consciousness during alteplase infusion are the hallmark signs of sICH. The blood pressure of 198/112 mmHg is especially concerning because extreme hypertension during thrombolysis both reflects rising intracranial pressure and worsens ongoing bleeding. The change in arousal indicates that the hemorrhage is now producing a mass effect or direct brainstem compression.

Watch out! Do not call this an “expected” headache. A mild headache can occur during thrombolysis, but a sudden, severe headache with vomiting and neurologic worsening is never expected and must be treated as sICH until proven otherwise.

Why the other options are less likely

| Option | Why it is not the best answer |
| --- | --- |
| 2. Expected headache as the clot is dissolved | Clot dissolution itself does not produce a sudden severe headache, vomiting, or a falling level of consciousness. These are neurologic emergency signs, not normal treatment effects. |
| 3. Malignant cerebral edema from a large infarct | Malignant edema typically develops over 24–72 hours after a large infarct, not within 40 minutes of starting alteplase. The abrupt onset during infusion points to hemorrhage rather than gradual edema. |
| 4. Extension of the original ischemic infarct | Ischemic extension can worsen deficits, but the combination of sudden severe headache, vomiting, and marked hypertension is far more specific for hemorrhagic conversion. In addition, alteplase is actively lysing clot, which makes hemorrhage more biologically plausible than new large-vessel occlusion at this moment. |

Pathophysiology of hemorrhagic transformation

Ischemic stroke damages the endothelium and basal lamina of cerebral vessels. When alteplase is given, plasmin activation degrades fibrin and other extracellular matrix components, including laminin and fibronectin in the vessel wall. This weakens the blood–brain barrier. Reperfusion into damaged capillaries then leads to leakage or frank rupture, producing petechial hemorrhage or a larger parenchymal hematoma. The more severe the ischemic injury and the longer the vessel has been occluded, the higher the risk of hemorrhagic conversion.

Key point! The risk of intracranial hemorrhage is higher with thrombolysis for acute ischemic stroke than with thrombolysis for myocardial infarction or pulmonary embolism. In stroke thrombolysis, reported intracranial hemorrhage rates range from about 6.4% to 20%, whereas thrombolysis for acute MI or PE carries a cerebral hemorrhage risk of less than 2%. This difference reflects the underlying cerebral vascular injury that is already present in stroke.

Immediate nursing and team actions

The priority is to stop the alteplase infusion immediately and notify the provider. Emergency noncontrast CT is obtained to confirm hemorrhage and assess its size and location. Blood pressure must be controlled aggressively, because ongoing hypertension worsens hematoma expansion. Coagulation studies, including fibrinogen, PT/INR, and aPTT, are drawn to guide reversal. If hemorrhage is confirmed, cryoprecipitate or antifibrinolytic agents such as tranexamic acid may be considered, although the evidence for specific reversal strategies remains limited and is based largely on expert opinion and small case series.

Why this matters for the licensure exam

This scenario tests your ability to recognize a time-critical adverse event during thrombolytic therapy. The exam will expect you to know that any sudden neurologic worsening, severe headache, vomiting, or acute blood pressure elevation during alteplase infusion means stop the infusion and obtain emergency imaging. Do not wait for the infusion to finish, and do not attribute these findings to anxiety, positioning, or normal clot lysis. The correct nursing response is always to suspect sICH first and act immediately.

## 임상 시나리오

Recognizing sICH During Alteplase InfusionAct immediately when neurologic status worsens during thrombolysis
The most feared complication of IV alteplase for acute ischemic stroke is symptomatic intracranial hemorrhage. Classic signs include sudden severe headache, vomiting, acute hypertension, and a falling level of consciousness.

A blood pressure of 198/112 mmHg during thrombolysis is a red flag. Extreme hypertension both reflects rising intracranial pressure and worsens ongoing bleeding.

CautionStop the alteplase infusion immediately, notify the provider, and prepare for emergency CT. Never dismiss these findings as an expected headache or simple infarct extension.

## 핵심 개념

- **symptomatic intracranial hemorrhage** — Bleeding into brain tissue during or after thrombolysis that causes neurologic deterioration, the most feared complication of IV alteplase.
- **alteplase** — Recombinant tissue plasminogen activator that converts plasminogen to plasmin, producing systemic fibrinolysis and increasing bleeding risk.
- **hemorrhagic transformation** — Bleeding into an ischemic area due to disrupted blood-brain barrier and weakened vessels in the ischemic penumbra.
- **Cushing response** — Hypertension, bradycardia, and irregular respirations reflecting rising intracranial pressure; acute severe hypertension during thrombolysis is a red flag.

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