Stroke Types: Ischemic vs Hemorrhagic, NIH Stroke Scale, and tPA Eligibility for Nursing Students
A clinical-nursing reference for distinguishing ischemic vs hemorrhagic stroke, applying the NIH Stroke Scale, and recognizing tPA inclusion and exclusion criteria — the framework for the time-critical first hour of stroke care.
Learning Objectives
- Distinguish ischemic from hemorrhagic stroke clinically and on imaging.
- Apply the NIH Stroke Scale (NIHSS) to quantify deficit severity.
- Recognize tPA inclusion and exclusion criteria for time-critical decisions.
1. Direct Answer: Ischemic vs Hemorrhagic Stroke
Stroke = sudden neurologic deficit from cerebral vascular cause. Two categories: ISCHEMIC (87% of strokes) — vessel occlusion blocks blood flow, causing infarction. Subtypes: thrombotic (atherosclerotic plaque rupture), embolic (cardiac source like atrial fibrillation), or lacunar (small vessel disease). HEMORRHAGIC (13%) — vessel rupture causes bleeding into brain parenchyma (intracerebral hemorrhage) or subarachnoid space (subarachnoid hemorrhage from aneurysm rupture). The two cannot be distinguished clinically with high reliability — non-contrast head CT is the immediate test to differentiate (hemorrhage shows as hyperdense on CT). This distinction is time-critical because ischemic stroke can be treated with tPA (thrombolytics) within a narrow window, but tPA is contraindicated in hemorrhagic stroke (would worsen bleeding).
Key Points
- •87% ischemic, 13% hemorrhagic.
- •Non-contrast head CT distinguishes (hemorrhage hyperdense, ischemia initially normal).
- •tPA only for ischemic — contraindicated in hemorrhagic.
- •Differentiation is immediate priority on arrival.
2. Ischemic Stroke Subtypes and Risk Factors
THROMBOTIC: atherosclerosis at vessel bifurcations (carotid, MCA stems), usually associated with hypertension, diabetes, hyperlipidemia, smoking. Often preceded by TIAs. Symptom onset typically gradual or stuttering. EMBOLIC: emboli typically from cardiac source (atrial fibrillation, prosthetic valve, mural thrombus post-MI, endocarditis vegetation). Symptom onset abrupt and at maximum severity initially. LACUNAR: small-vessel hypertensive disease producing small subcortical infarcts in basal ganglia, thalamus, internal capsule, pons. Classic syndromes: pure motor hemiparesis (internal capsule lacune), pure sensory stroke (thalamic), ataxic hemiparesis. Risk-factor management is the foundation of stroke prevention: BP control, statin, glycemic control, smoking cessation, anticoagulation for atrial fibrillation (CHA2DS2-VASc score).
Key Points
- •Thrombotic: atherosclerotic, gradual onset, TIA prodrome.
- •Embolic: cardiac source, abrupt onset at max severity.
- •Lacunar: hypertensive small-vessel disease, classic syndromes.
- •Prevention: BP, statin, glycemic control, anticoagulation for AFib.
3. Hemorrhagic Stroke Categories
INTRACEREBRAL HEMORRHAGE (ICH, 10% of strokes): bleeding into brain parenchyma, usually from hypertensive small-vessel rupture in basal ganglia, thalamus, pons, cerebellum. Symptoms include sudden severe headache, decreased level of consciousness, focal deficits depending on location. SUBARACHNOID HEMORRHAGE (SAH, 3%): bleeding into the subarachnoid space, usually from saccular (berry) aneurysm rupture at circle of Willis. Classic: "worst headache of life" thunderclap onset, photophobia, neck stiffness (meningismus). Diagnosed by non-contrast head CT (hyperdense in basal cisterns); if CT negative but suspicion high, lumbar puncture for xanthochromia. SAH carries high mortality, and survivors face vasospasm risk 3-14 days post-bleed.
Key Points
- •ICH: hypertensive bleed into parenchyma; common in basal ganglia.
- •SAH: aneurysmal bleed into subarachnoid space; thunderclap headache.
- •SAH on CT: hyperdense in basal cisterns.
- •Vasospasm risk 3-14 days post-SAH.
4. NIH Stroke Scale (NIHSS)
11 items scored 0 to maximum total of 42. Higher = worse deficit. Items: level of consciousness (3 sub-items), gaze, visual fields, facial palsy, motor arm (2: left and right), motor leg (2: left and right), limb ataxia, sensory, language, dysarthria, extinction/inattention. NIHSS <5 = minor stroke, 5-15 = moderate, 16-20 = severe, >20 = very severe. NIHSS is used to (1) document baseline deficit, (2) track changes over time, (3) support thrombolysis decisions, and (4) communicate severity in handoffs ("NIHSS of 12"). Memorize the major components even if you don't calculate scores routinely — knowing what to assess is the bedside skill.
Key Points
- •11 items, total 0-42.
- •Higher = worse stroke.
- •Used for triage, tPA decisions, and serial monitoring.
- •Stratification: <5 minor, 5-15 moderate, 16-20 severe, >20 very severe.
5. tPA: Inclusion and Exclusion Criteria
Alteplase and tenecteplase (TNKase) are FDA-approved thrombolytics for acute ischemic stroke. INCLUSION: acute ischemic stroke with a measurable neurologic deficit, symptom onset within 4.5 hours (3 hours is the original FDA window; 3-4.5 hours requires additional criteria), age ≥18. EXCLUSIONS (any one excludes tPA): hemorrhage on CT, history of intracranial hemorrhage, recent stroke within 3 months, recent major surgery within 14 days, BP >185/110 not controlled, INR >1.7 or anticoagulation, platelet count <100,000, blood glucose <50 mg/dL, evidence of active bleeding. The 4.5-hour window is the most consequential nursing knowledge — confirm exact symptom onset time (or last known well time) and document precisely. Under the 2026 AHA/ASA guideline, some patients can be treated later based on brain imaging. Mechanical thrombectomy extends the window to 24 hours for large vessel occlusion meeting imaging criteria (DAWN, DEFUSE 3 trials).
Key Points
- •Window: 4.5 hours from symptom onset (or last known well).
- •Hemorrhage on CT excludes immediately.
- •BP >185/110, INR >1.7, glucose <50 are common exclusions.
- •Mechanical thrombectomy extends window to 24 hours with imaging criteria.
6. Time-Critical Nursing Priorities
First hour priorities: (1) ABC assessment — airway protection if decreased LOC. (2) Vital signs — BP must be measured and addressed before tPA decision. (3) Non-contrast head CT — immediately on arrival (stroke programs track a door-to-CT target). (4) Lab draws — CBC, BMP, PT/INR, glucose, type and screen. (5) IV access — two large-bore. (6) NIHSS — quantify deficit. (7) Time of symptom onset — confirmed with witness or last-known-well. (8) Code Stroke activation — neurology consult. (9) BP management — aim for <185/110 before tPA; labetalol or nicardipine commonly used. (10) After tPA: continuous neuro checks every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every hour for 16 hours. Any deterioration → emergent repeat CT to evaluate for hemorrhagic conversion.
Key Points
- •Door to CT: as fast as possible (facility target).
- •Two large-bore IVs, full labs, NIHSS, time of onset.
- •BP must be <185/110 before tPA.
- •Post-tPA: q15 min × 2 hr neuro checks, q30 min × 6 hr, q1 hr × 16 hr.
7. Studying Stroke Care with NurseIQ
Photograph a stroke practice question from your course or review book, or upload up to 5 PDF pages, and NurseIQ returns the answer with a short rationale. Detailed mode adds the key concept and a study tip, and Detailed and Expert modes also explain why the other options are wrong. Ask the tutor chat to walk through anything still unclear, or build a study guide on stroke care and review it with flashcards. This content is for educational purposes only and does not constitute medical advice.
Key Points
- •Photograph a practice question or upload up to 5 PDF pages
- •Get the answer with a short rationale, plus the key concept and a study tip in Detailed mode
- •Ask the tutor chat follow-up questions
- •Build a study guide and flashcards on stroke care
High-Yield Facts
- 87% ischemic, 13% hemorrhagic; CT differentiates.
- tPA window: 4.5 hours from symptom onset (3 hr classic, 3-4.5 hr with criteria).
- Mechanical thrombectomy window: 24 hours for large vessel occlusion (DAWN/DEFUSE 3).
- NIHSS: 11 items, total 0-42.
- BP must be <185/110 for tPA candidacy.
- SAH: thunderclap headache, basal cistern hyperdensity on CT.
- Lacunar syndromes from small-vessel hypertensive disease.
Practice Questions
1. A patient presents with right-sided weakness, aphasia, and NIHSS of 14. Symptom onset 90 minutes ago. BP 170/95. INR 1.2. Glucose 110. CT shows no hemorrhage. tPA candidate?
2. Same patient but symptom onset 6 hours ago. tPA candidate?
3. A patient has sudden severe headache, photophobia, neck stiffness, and decreased LOC. Most likely diagnosis and next test?
Study with AI
Snap a photo of a practice question for the answer and the rationale, then ask the tutor chat follow-up questions.
FAQs
Common questions about this topic
TIA (transient ischemic attack) is a transient neurologic deficit from cerebral ischemia that resolves within 24 hours (usually within 1 hour) without permanent injury on imaging. A stroke is a deficit lasting longer than 24 hours or showing infarction on imaging. The distinction is increasingly imaging-based: any patient with neurologic symptoms and diffusion restriction on MRI has had a stroke regardless of symptom duration. TIAs signal a high short-term stroke risk and warrant urgent evaluation.
Most stroke patients have elevated BP at presentation (catecholamine surge, autoregulation impairment). Generally BP is NOT aggressively lowered in the first 24-48 hours because cerebral perfusion depends on it. Exceptions: BP >220/120 (or >185/110 for tPA candidates), aortic dissection, hypertensive emergency with end-organ damage. When BP is very high and no reperfusion therapy is given, lowering it by about 15% in the first 24 hours may be reasonable (AHA/ASA).
Endovascular clot retrieval for large vessel occlusion (M1 MCA, ICA, basilar) within 6 hours of symptom onset (extended to 24 hours with favorable imaging on DAWN and DEFUSE 3 criteria). Has dramatically improved outcomes for large vessel occlusion strokes. A thrombolytic may be given first as a bridge to thrombectomy. Time-critical: every minute to reperfusion matters.
Hemorrhagic conversion of ischemic stroke is the most feared complication (about 6% symptomatic within 36 hours in the original NINDS alteplase trial). Systemic bleeding can also occur. Risk increases with higher NIHSS, age, hyperglycemia, and longer time-to-treatment. Post-tPA monitoring: q15 min neuro checks for 2 hours, q30 min for 6 hours, then q1 hr for 16 hours; any deterioration → emergent CT.
Photograph a stroke practice question from your course or review book, and NurseIQ gives the answer with a short rationale. Detailed mode adds the key concept and a study tip, and Detailed and Expert modes also explain why the other options are wrong. You can ask the tutor chat follow-up questions or build a study guide and flashcards on stroke care.