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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Side-by-side2 compared
Focus
Dimension
Ischemic Stroke
Hemorrhagic Stroke
Pathophysiology
- Clot blocks a cerebral artery
- Most common: ~87% of strokes
- Vessel ruptures, bleeds into brain
- ~13% of strokes, higher mortality
Signs & symptoms
- Often stuttering or on waking (thrombotic)
- Mild or no headache
- Sudden explosive onset
- Severe 'worst ever' headache
- Early ↓ LOC, vomiting
CT scan (acute)
- CT: no blood (may look normal early)
- CT: blood visible immediately
Priority nursing actions
- Activate stroke team
- CT STAT
- Assess tPA eligibility
- Neuro checks q15 min
- Activate stroke team
- CT STAT
- Manage BP & ICP
- Prep for possible surgery
- Neuro checks q15 min
Treatment — opposite!
- ★tPA (alteplase) ≤ 4.5 hr if CT clear
- Thrombectomy up to 24 hr (LVO)
- Antiplatelets, statin
- ★tPA CONTRAINDICATED — worsens bleed
- Reverse anticoagulation
- Nimodipine for SAH vasospasm
BP teaching & prevention
- ★No tPA: permit BP up to 220/120
- After tPA: BP < 180/105
- Adhere to antiplatelets
- Before tPA: BP < 185/110
- ★Lower BP aggressively
- SBP target ~140 (avoid < 130)
- Avoid Valsalva
Red flags — escalate
- Cerebral edema, ↑ ICP (large infarct)
- Post-tPA bleed/neuro change: stop, CT
- ↑ ICP: HOB 30°, head midline
- Rebleed or herniation signs
Complications
- Lower acute seizure risk
- Hemorrhagic conversion after reperfusion
- Higher seizure risk (blood irritant)
- Rebleed, vasospasm (SAH), hydrocephalus
Pathophysiology
Ischemic Stroke
- Clot blocks a cerebral artery
- Most common: ~87% of strokes
Hemorrhagic Stroke
- Vessel ruptures, bleeds into brain
- ~13% of strokes, higher mortality
Signs & symptoms
Ischemic Stroke
- Often stuttering or on waking (thrombotic)
- Mild or no headache
Hemorrhagic Stroke
- Sudden explosive onset
- Severe 'worst ever' headache
- Early ↓ LOC, vomiting
CT scan (acute)
Ischemic Stroke
- CT: no blood (may look normal early)
Hemorrhagic Stroke
- CT: blood visible immediately
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 for possible surgery
- Neuro checks q15 min
Treatment — opposite!
Ischemic Stroke
- ★tPA (alteplase) ≤ 4.5 hr if CT clear
- Thrombectomy up to 24 hr (LVO)
- Antiplatelets, statin
Hemorrhagic Stroke
- ★tPA CONTRAINDICATED — worsens bleed
- Reverse anticoagulation
- Nimodipine for SAH vasospasm
BP teaching & prevention
Ischemic Stroke
- ★No tPA: permit BP up to 220/120
- After tPA: BP < 180/105
- Adhere to antiplatelets
- Before tPA: BP < 185/110
Hemorrhagic Stroke
- ★Lower BP aggressively
- SBP target ~140 (avoid < 130)
- Avoid Valsalva
Red flags — escalate
Ischemic Stroke
- Cerebral edema, ↑ ICP (large infarct)
- Post-tPA bleed/neuro change: stop, CT
Hemorrhagic Stroke
- ↑ ICP: HOB 30°, head midline
- Rebleed or herniation signs
Complications
Ischemic Stroke
- Lower acute seizure risk
- Hemorrhagic conversion after reperfusion
Hemorrhagic Stroke
- Higher seizure risk (blood irritant)
- Rebleed, vasospasm (SAH), hydrocephalus
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Clinical Pearl
No blood on CT → clot → tPA candidate. Blood on CT → bleed → tPA kills.
Component Topics
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Go further
- Commonly confusedIschemic Stroke vs Hemorrhagic StrokeClot vs bleed — the treatment is literally opposite, and getting it wrong is fatal.
- TopicHemorrhagic StrokeA patient's blood pressure is 220/130 and they're seizing — this isn't the stroke you treat with tPA. Giving it would be fatal. Know the difference before it matters.
- TopicIschemic StrokeThe brain loses 1.9 million neurons every minute blood flow is blocked. Recognizing an ischemic stroke and understanding the treatment window separates salvageable brain from…
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