Stroke: Ischemic vs. Hemorrhagic — Recognition, Treatment, and Nursing Care

Stroke is a time-critical neurologic emergency where every minute of delayed recognition or treatment costs brain tissue. This guide compares ischemic and hemorrhagic stroke side-by-side, focusing on the recognition, treatment windows, blood pressure rules, and nursing priorities most often tested on the NCLEX.

Stroke Definition

A stroke is a sudden interruption of blood flow to the brain caused by either a blocked artery (ischemic) or bleeding in the brain (hemorrhagic), leading to rapid loss of brain function.

Recognition: BEFAST Mnemonic

• B – Balance: sudden loss of balance or coordination
• E – Eyes: sudden vision changes or loss in one or both eyes
• F – Face: facial drooping
• A – Arm: arm weakness or drift
• S – Speech: speech difficulty or slurring
• T – Time: call 911 immediately

Any one sign requires immediate emergency evaluation.

Ischemic Stroke

Pathophysiology

• Caused by a blocked artery supplying blood to the brain.
• Two types:
  • Thrombotic: clot forms locally in a cerebral artery.
  • Embolic: clot travels from elsewhere — most commonly the heart due to atrial fibrillation.
• Hypertension is the single most important modifiable risk factor.
• Other major risks: atrial fibrillation, diabetes, high cholesterol, and smoking.

Signs and Symptoms

• Sudden numbness or weakness of face, arm, or leg on one side.
• Sudden confusion, trouble speaking, or trouble understanding.
• Sudden trouble walking, dizziness, or loss of balance.
• Onset can be gradual or occur during sleep.
• Headache is usually mild or absent.

Diagnostics and Immediate Actions

• Maintain ABCs and oxygen saturation above 94%.
• Non-contrast CT scan is the first test — must rule out hemorrhage before any treatment.

IV Thrombolysis (tPA / Alteplase)

• Given within 3 to 4.5 hours of symptom onset.
• Door-to-needle time should be < 60 minutes.
• Dissolves the clot and restores blood flow.
• Strict BP criteria: must be < 185/110 before administration.

Absolute contraindications for tPA:

• Symptoms beyond 3 to 4.5 hours
• Current anticoagulant use with elevated INR
• Recent major surgery or trauma within 14 days
• Uncontrolled hypertension above 185/110
• History of intracranial hemorrhage

Mechanical Thrombectomy

• A catheter is used to remove the clot from a large vessel occlusion.
• Performed within 6 hours (up to 24 hours with advanced imaging).
• Standard of care for eligible large vessel occlusions.

Blood Pressure Management in Acute Ischemic Stroke

• Receiving tPA: maintain BP < 185/110 before treatment and < 180/105 for 24 hours after.
• Thrombectomy patients: keep BP ≤ 180/105 during and for 24 hours after the procedure.
• No reperfusion therapy: do NOT lower BP unless SBP > 220 or DBP > 120.
• If BP is severely elevated (> 220/120), reduce gradually by about 15% in the first 24 hours.
• Exam trick: Do not lower BP aggressively in acute ischemic stroke — cerebral autoregulation is impaired, and lowering BP can worsen ischemia.

Nursing Interventions

• Position head of bed at 30 degrees to reduce ICP.
• Maintain oxygen saturation > 94%.
• Keep patient NPO until swallowing assessment is complete.
• Administer tPA within the window if no contraindications exist.
• Monitor for bleeding during and after tPA infusion.
• Do not lower BP unless directed and BP exceeds 220/120.

Hemorrhagic Stroke

Definition and Pathophysiology

• Caused by bleeding into brain tissue or surrounding spaces.
• Blood irritates brain tissue and increases intracranial pressure.
• Two types:
  • Intracerebral hemorrhage: bleeding into brain tissue.
  • Subarachnoid hemorrhage: bleeding around the brain.
• Uncontrolled hypertension is the most common cause of intracerebral hemorrhage.
• Ruptured aneurysm causes most subarachnoid hemorrhages.

Signs and Symptoms

• Severe headache described as "worst headache of life" is classic.
• Nausea and vomiting are common due to increased ICP.
• Decreased level of consciousness occurs early and may progress rapidly.
• Neck stiffness occurs in subarachnoid hemorrhage.

Diagnostics and Treatment

• Maintain ABCs and secure the airway.
• Non-contrast CT scan shows blood immediately.
• Lower SBP to 130–140 mmHg (for patients with SBP 150–220 mmHg).
• Lower BP gradually to avoid cerebral hypoperfusion.
• Avoid SBP below 130 mmHg (Class 3 recommendation).
• Reverse anticoagulation immediately if patient is on blood thinners.
• Surgical evacuation may be needed for large bleeds (typically > 30 mL).
• Aneurysm clipping or coiling prevents rebleeding.

Reversal of Anticoagulation

• Warfarin: reversed with vitamin K and fresh frozen plasma.
• DOACs (apixaban, rivaroxaban): reversed with specific reversal agents.

Exam trick: Unlike ischemic stroke, lower BP aggressively in hemorrhagic stroke to prevent hematoma expansion.

Nursing Interventions

• Position head of bed at 30 degrees to reduce ICP.
• Lower BP gradually to target levels.
• Reverse anticoagulation immediately.
• Prepare for possible surgical intervention.
• Monitor for signs of increased ICP: worsening headache, decreasing consciousness, pupillary changes.
• Maintain a quiet, calm environment to prevent rebleeding.

Ischemic vs. Hemorrhagic: Side-by-Side Comparison

• Cause: blocked artery vs. bleeding in brain
• Headache: mild or none vs. severe, "worst of life"
• Consciousness: often preserved vs. decreased early
• Onset: can be gradual vs. sudden, often during activity
• CT scan: normal early vs. shows blood immediately
• BP management: do not lower unless > 220/120 vs. lower aggressively to 130–140
• Treatment: tPA or thrombectomy vs. BP control and surgery

Common NCLEX Traps

• tPA is only for ischemic stroke and is contraindicated in hemorrhagic stroke.
• Do not lower BP in ischemic stroke unless very high (> 220/120).
• Lower BP aggressively in hemorrhagic stroke to 130–140 mmHg.
• Non-contrast CT is the first test — must rule out hemorrhage before any treatment.
• Door-to-needle time for tPA should be < 60 minutes.
• Hemorrhagic conversion can occur after tPA for ischemic stroke.
• Rapid BP lowering in ischemic stroke can worsen outcomes — "lower is not always better."
• Patients with atrial fibrillation stopping anticoagulation are at high risk for embolic stroke.

Key Takeaways

• Ischemic stroke (≈87%) is a blocked artery; hemorrhagic stroke (≈13%) is bleeding in the brain but accounts for ≈40% of stroke deaths.
• Use BEFAST for rapid recognition and obtain a non-contrast CT first to differentiate the two types.
• Treat ischemic stroke with tPA within 3–4.5 hours or thrombectomy for large vessel occlusions (up to 24 hours with imaging).
• Treat hemorrhagic stroke with BP control to 130–140 mmHg and immediate anticoagulation reversal.
• BP rules are opposite: do NOT lower BP in ischemic stroke unless > 220/120; lower aggressively in hemorrhagic stroke.
• Nursing priorities: airway, HOB at 30°, NPO until swallow screen, monitor for bleeding/ICP changes, and rapid neuro reassessment.