Hemorrhagic Stroke

A 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.

Hemorrhagic stroke occurs when a blood vessel ruptures within or around the brain, causing bleeding that compresses neural tissue. The two main types are intracerebral hemorrhage (ICH), where bleeding occurs within brain parenchyma, and subarachnoid hemorrhage (SAH), where bleeding fills the space between the arachnoid and pia mater — classically from a ruptured cerebral aneurysm. SAH presents with a sudden, explosive 'worst headache of my life,' nuchal rigidity, photophobia, and possibly loss of consciousness. ICH presents more like ischemic stroke but with faster deterioration, vomiting, and severely elevated blood pressure. Diagnosis requires CT scan without contrast — hemorrhagic stroke appears bright white (hyperdense) immediately. Blood pressure management is critical: the target for ICH is typically systolic below 140 mmHg using IV antihypertensives like nicardipine or labetalol. Anticoagulants and antiplatelets are contraindicated and must be reversed immediately if the patient is on them. Surgical intervention (craniotomy, aneurysm clipping, or coiling) may be needed. Nurses monitor neurological status using the Glasgow Coma Scale every 1-2 hours, watch for signs of increased intracranial pressure (ICP) — widening pulse pressure, bradycardia, irregular respirations (Cushing's triad) — and maintain the head of bed at 30 degrees to promote venous drainage.

Key Distinctions

Don't confuse hemorrhagic stroke management with ischemic stroke management — tPA and anticoagulants treat ischemic stroke but worsen hemorrhagic stroke and are absolutely contraindicated. Students mix up SAH ('worst headache of my life,' meningeal signs) with ICH (focal deficits, rapid decline, severe hypertension). Cushing's triad signals rising ICP, not improving status — bradycardia here is ominous, not benign.

Clinical Pearl

Bright white on CT, bright red alert: no tPA, no anticoagulants, reverse what's on board, and control that blood pressure before the bleed expands.