This report highlights the outcome of intravenous alteplase in a patient with acute ischemic stroke subsequent to purulent meningitis. This type of meningitis has not been defined in the guideline for early treatment of acute ischemic stroke. A 58-year-old woman with purulent meningitis developed a sudden stroke and was admitted to our emergency department. She received 0.6 mg/kg of alteplase intravenously 90 minutes after stroke onset. At 1 hour after thrombolysis, the patient's National Institute of Health Stroke Scale score improved from 9 to 4. At 2 hours, she developed a sudden severe headache that progressed to coma, and her National Institute Health Stroke Scale score rapidly deteriorated to 20. Cranial computed tomography revealed subarachnoid hemorrhage and multiple bilateral lobar brain hemorrhages. She died of a cerebellar tonsillar hernia. Intravenous alteplase might be hazardous in patients with acute ischemic stroke subsequent to purulent meningitis.Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.