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Apex Nursing

Chart — Neurology

Stroke Comparison Chart

Ischemic stroke, hemorrhagic stroke (ICH), TIA, and subarachnoid hemorrhage (SAH) compared by cause, key findings, CT appearance, tPA eligibility, BP management, and initial priority.

Data Source: AHA/ASA Stroke Guidelines / ACLS Stroke Protocol

CT head without contrast MUST be performed before tPA — hemorrhagic stroke is an absolute contraindication. Do not administer tPA without imaging.

Educational use only. Stroke care is time-critical and physician-directed; treatment decisions require imaging confirmation and institutional stroke protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Quick Comparison

TypePrevalenceHallmark FindingCT AppearancetPA?First Priority
Ischemic~87%Focal deficit — no headacheNormal or subtle (early)YES (if criteria met)CODE STROKE — CT now
Hemorrhagic (ICH)~10%Severe HA + rapid decline + HTNBright/white on non-contrast CTNEVERNo tPA — reverse anticoag, neuro
TIAVariableStroke symptoms that RESOLVEUsually normalNot indicatedUrgent neuro — high recurrent-stroke risk
SAH~3%Thunderclap HA — worst of lifeBlood in subarachnoid cisternsNEVERNeuro/neuroSurg — BP control, ICU

Stroke Type Detail

Ischemic Stroke

~87% of strokes

Cause: Thrombotic: clot forms in situ in cerebral artery (atherosclerosis, plaque rupture). Embolic: clot travels from heart (Afib, valvular disease), aortic arch, or proximal vessel.

Onset: Variable — may evolve over minutes to hours; often maximal at onset with embolic

Key Findings

  • Focal neurological deficit: hemiplegia, aphasia, visual field cut, facial droop, neglect
  • Usually NO headache (unlike hemorrhagic)
  • Usually awake at onset (unlike subarachnoid which may lose consciousness)
  • Symptoms consistent with a vascular territory

CT: Normal or early subtle ischemic changes (loss of gray-white differentiation, dense MCA sign). CANNOT diagnose on CT alone — MRI DWI is definitive.

tPA: YES — absolute indication if criteria met

BP management: Permissive: allow up to 220/120 if NOT tPA candidate. <185/110 required BEFORE tPA administration.

Priority: ACTIVATE CODE STROKE. CT STAT. tPA within 3–4.5 hours. Thrombectomy if LVO.

Hemorrhagic Stroke (ICH)

~10% of strokes

Cause: Hypertensive vasculopathy (most common), amyloid angiopathy (lobar hemorrhage in elderly), AVM, coagulopathy, anticoagulant use.

Onset: Often during activity; progressive worsening — NOT maximal at onset

Key Findings

  • Severe headache, nausea/vomiting
  • Rapid LOC decline and progression
  • Hypertension (often severely elevated)
  • Focal deficit that worsens over time (expanding hematoma)
  • Seizure at onset possible

CT: BRIGHT (hyperdense/white) on non-contrast CT — blood is hyperdense. Definitive diagnosis.

tPA: ABSOLUTELY CONTRAINDICATED — tPA will expand the bleed

BP management: Aggressive BP lowering: target SBP <140–160 mmHg (per current guidelines). Reverse anticoagulation urgently.

Priority: NO tPA. Reverse anticoagulation. Neurosurgical consult. ICU monitoring. Strict BP control.

TIA (Transient Ischemic Attack)

~15% have stroke within 3 months

Cause: Same mechanism as ischemic stroke — transient arterial occlusion that spontaneously resolves before permanent infarction occurs.

Onset: Sudden onset, same deficits as stroke, but RESOLVES completely within 24 hours (usually within 1 hour)

Key Findings

  • IDENTICAL to ischemic stroke symptoms — but resolves
  • Patient may appear 'normal' by the time they arrive
  • High stroke risk immediately after TIA: 10–15% in 90 days; highest in first 48 hours
  • ABCD2 score assesses short-term stroke risk

CT: Usually normal. MRI DWI may show small acute infarcts (technically making it a minor stroke, not TIA).

tPA: Not indicated (symptoms resolved), but treat as stroke equivalent

BP management: Lower BP once stroke is excluded. Manage risk factors aggressively.

Priority: URGENT evaluation — treat as stroke equivalent. Urgent neurology/TIA clinic. Antiplatelet or anticoagulation per etiology. Risk factor control.

Subarachnoid Hemorrhage (SAH)

~3% of strokes

Cause: Ruptured intracranial aneurysm (80%), AVM, trauma.

Onset: Sudden — often described as INSTANTANEOUS maximum-intensity headache (“thunderclap”)

Key Findings

  • Worst headache of life — thunderclap onset ('I've never had a headache like this')
  • Nausea, vomiting, photophobia
  • Meningismus (neck stiffness)
  • Rapid LOC loss at onset (syncope or coma)
  • Fundoscopy: subhyaloid hemorrhages (Terson syndrome)

CT: Bright blood in subarachnoid space — cisterns, sulci (stellate/star pattern). Sensitivity decreases after 12 hours. LP for xanthochromia if CT negative but high suspicion.

tPA: ABSOLUTELY CONTRAINDICATED

BP management: SBP <160 mmHg to reduce rebleeding risk while maintaining cerebral perfusion.

Priority: EMERGENT neurosurgical consultation. Secure airway if LOC impaired. Prevent re-rupture (BP control, avoid Valsalva). Nimodipine for vasospasm prophylaxis. ICU monitoring.

NCLEX Pearls

  • ✦CT head WITHOUT contrast comes before ANY decision about tPA — always.
  • ✦Hemorrhagic stroke: bright (white/hyperdense) on CT. Ischemic: dark (hypodense) or normal early.
  • ✦tPA is contraindicated in hemorrhagic stroke and SAH — giving tPA in these conditions is catastrophic.
  • ✦TIA symptoms resolve by definition — but the stroke risk in the next 48–90 hours is extremely high. Treat urgently.
  • ✦SAH: thunderclap headache (sudden, worst-of-life) + normal CT → lumbar puncture for xanthochromia.
  • ✦Ischemic stroke BP: do NOT lower aggressively if not giving tPA. The elevated BP is helping perfuse the penumbra.
  • ✦Hemorrhagic stroke: aggressively lower BP (target SBP <140–160) to reduce hematoma expansion.

Related Resources

Stroke Recognition and Initial ManagementFAST/BE-FAST, last known well, NIHSS, treatment windows, and nursing priorities
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Stroke Syndromes ReferenceLeft/right hemisphere, brainstem, cerebellar, and lacunar stroke findings
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Increased Intracranial PressureICP management for hemorrhagic stroke complications
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Neurological Assessment FundamentalsBedside neuro exam to identify and track stroke deficits
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Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with AHA/ASA Stroke Guidelines / ACLS Stroke Protocol. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →