side by side comparison

Stroke Types: Ischemic vs Hemorrhagic — Treatment Is Opposite

Giving tPA to a hemorrhagic stroke patient accelerates fatal bleeding. Giving nothing to an ischemic stroke patient lets brain tissue die. The CT scan result flips your entire plan — choosing wrong is catastrophic, and the NCLEX knows it.

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Comparison

Side-by-side2 compared
Dimension
Ischemic Stroke
Hemorrhagic Stroke
Pathophysiology
  • Clot blocks a cerebral artery
  • ~87% of all strokes
  • Vessel ruptures, bleeds into brain
  • ~13% of all strokes
Signs & symptoms
  • Gradual/stuttering onset
  • mild or no headache
  • Sudden explosive onset
  • thunderclap headache
CT scan (acute)
  • CT negative for blood (rules out bleed pre-tPA)
  • Blood visible immediately on CT
Priority nursing actions
  • Activate stroke team
  • CT STAT
  • Assess tPA eligibility
  • neuro checks q15 min
  • Activate stroke team
  • CT STAT
  • Manage BP & ICP
  • prep surgery
  • neuro q15 min
Treatment — opposite!
  • ★tPA/alteplase if within 4.5 hr + CT clear
  • Thrombectomy ≤24 hr
  • antiplatelets, statin
  • ★tPA CONTRAINDICATED — worsens bleed
  • Reverse anticoagulation
  • nimodipine for SAH
BP teaching & prevention
  • ★Permissive HTN pre-tPA ≤220/120
  • <180/105 after
  • Adhere to antiplatelets
  • control risk factors
  • ★Lower BP aggressively
  • SBP < 140
  • Avoid Valsalva
  • manage HTN long-term
Red flags — escalate
  • Cerebral edema then ↑ ICP after large infarct
  • Bleeding signs post-tPA then hold, CT
  • High ICP expected — elevate HOB 30°
  • Head midline
  • rebleed/herniation signs
Complications
  • Lower acute seizure risk
  • Hemorrhagic conversion after reperfusion
  • Higher seizure risk — blood irritates cortex
  • Rebleed, vasospasm (SAH), hydrocephalus
Pathophysiology

Ischemic Stroke

  • Clot blocks a cerebral artery
  • ~87% of all strokes

Hemorrhagic Stroke

  • Vessel ruptures, bleeds into brain
  • ~13% of all strokes
Signs & symptoms

Ischemic Stroke

  • Gradual/stuttering onset
  • mild or no headache

Hemorrhagic Stroke

  • Sudden explosive onset
  • thunderclap headache
CT scan (acute)

Ischemic Stroke

  • CT negative for blood (rules out bleed pre-tPA)

Hemorrhagic Stroke

  • Blood visible immediately on CT
Priority nursing actions

Ischemic Stroke

  • Activate stroke team
  • CT STAT
  • Assess tPA eligibility
  • neuro checks q15 min

Hemorrhagic Stroke

  • Activate stroke team
  • CT STAT
  • Manage BP & ICP
  • prep surgery
  • neuro q15 min
Treatment — opposite!

Ischemic Stroke

  • ★tPA/alteplase if within 4.5 hr + CT clear
  • Thrombectomy ≤24 hr
  • antiplatelets, statin

Hemorrhagic Stroke

  • ★tPA CONTRAINDICATED — worsens bleed
  • Reverse anticoagulation
  • nimodipine for SAH
BP teaching & prevention

Ischemic Stroke

  • ★Permissive HTN pre-tPA ≤220/120
  • <180/105 after
  • Adhere to antiplatelets
  • control risk factors

Hemorrhagic Stroke

  • ★Lower BP aggressively
  • SBP < 140
  • Avoid Valsalva
  • manage HTN long-term
Red flags — escalate

Ischemic Stroke

  • Cerebral edema then ↑ ICP after large infarct
  • Bleeding signs post-tPA then hold, CT

Hemorrhagic Stroke

  • High ICP expected — elevate HOB 30°
  • Head midline
  • rebleed/herniation signs
Complications

Ischemic Stroke

  • Lower acute seizure risk
  • Hemorrhagic conversion after reperfusion

Hemorrhagic Stroke

  • Higher seizure risk — blood irritates cortex
  • Rebleed, vasospasm (SAH), hydrocephalus

★ marks the fact that sets a column apart.

Clinical Pearl

No blood on CT → clot → tPA candidate. Blood on CT → bleed → tPA kills.

Component Topics

Hemorrhagic StrokeIschemic Stroke

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