To the Editor: Intravenously administered tissue plasminogen activator (IV-tPA) remains the only approved drug therapy for achieving arterial recanalization in acute ischemic stroke. Timely administration of IV-tPA often results in rapid recanalization and rapid clinical recovery. However, rapid recanalization of an occluded intracranial artery rarely can lead to cerebral hyperperfusion syndrome, with variable presentations. We present a case that showed an excellent early recovery after IV-tPA for severe acute ischemic stroke. However, the patient developed severe suicidal ideation on Day 3. We present clinical and various imaging studies to elucidate the underlying pathophysiological mechanisms.