The patient should receive intravenous nicardipine in an attempt to lower her blood pressure to the target range. She met no exclusion criteria and was correctly treated with intravenous recombinant tissue plasminogen activator (rtPA) for an acute ischemic stroke within the optimal 3-hour window from onset of symptoms. Her blood pressure before treatment was less than 185/110 mm Hg, as recommended by guidelines. The most serious complication of thrombolysis with intravenous rtPA is intracerebral hemorrhage, which occurs in as many as 6% of patients. The main risk factors for hemorrhage after thrombolysis are a large-volume cerebral infarction, a high National Institutes of Health Stroke Scale score, a cardioembolic origin of the stroke, and protocol violations. The postthrombolysis protocol includes avoiding antiplatelet and anticoagulant agents for 24 hours until a repeat head CT scan shows no hemorrhage, frequent neurologic and vital sign evaluation, and maintenance of the blood pressure at less than 180/105 mm Hg. When the blood pressure exceeds this limit, as in this patient, intravenous labetalol or nicardipine is the best option to reduce the blood pressure and thereby avoid intracerebral hemorrhage.

Oral aspirin and subcutaneous heparin are inappropriate treatments for this patient at this point because antithrombotic medications should not be administered until follow-up CT of the head is obtained 24 hours after rtPA infusion is completed. If the repeat CT scan shows no hemorrhage, and no systemic bleeding complications have occurred, then aspirin should be initiated for secondary stroke prevention and deep venous thrombosis prophylaxis should be started with low-molecular-weight or unfractionated subcutaneous heparin.

Although sublingual nitroglycerin can lower blood pressure, the inability to rapidly titrate the dose to maintain a blood pressure of less than 180/105 mm Hg makes nonintravenous medications a poor choice. Nitrates also have a relative contraindication in the treatment of blood pressure in acute stroke, particularly hemorrhagic stroke, because of the possibility of raising intracranial pressure.