Reference — Critical Care

Stroke Assessment Reference

Quick bedside reference for acute stroke: NIHSS severity, BP targets by stroke type, tPA contraindications, and post-stroke monitoring priorities.

Educational use only. Acute stroke management requires physician-directed decision-making. Follow your institution's stroke protocol for all clinical decisions. 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.

Ischemic vs. Hemorrhagic — Key Differences

Feature	Ischemic	Hemorrhagic
Mechanism	Arterial occlusion (thrombus / embolus)	Vessel rupture — blood compresses brain
Prevalence	~87% of strokes	~13% (higher mortality)
CT scan	No blood initially; ischemia visible later	Hyperdense (bright white) blood immediately
Headache	Less common; mild if present	Severe — 'worst headache of life'
tPA	May be indicated (no contraindications)	ABSOLUTELY CONTRAINDICATED
BP target	Permissive HTN (allow ≤220/120)	Active lowering (SBP <140–160)

NIHSS Score and Severity

Score	Severity	Clinical Action
0	No stroke symptoms	Document baseline; monitor
1–4	Minor stroke	Evaluate for tPA eligibility; close monitoring
5–15	Moderate stroke	Stroke team activation; tPA/LVO evaluation
16–20	Moderate-severe stroke	Likely LVO — thrombectomy evaluation urgent
21–42	Severe stroke	ICU-level care; aggressive neuroprotection

Blood Pressure Targets by Scenario

Scenario	Target	Rationale
Ischemic — no tPA, no intervention	Allow up to 220/120	Permissive HTN preserves penumbral perfusion
Ischemic — tPA given	<180/105	Prevents hemorrhagic transformation
Ischemic — post-thrombectomy	<180/105 (per order)	Reperfusion injury risk reduction
Hemorrhagic (ICH)	SBP <140–160	Reduces hematoma expansion
SAH (pre-clip/coil)	SBP 100–140 (per order)	Balance re-bleed risk vs. vasospasm

tPA Contraindications (Key List)

•Hemorrhagic stroke (any blood on CT)

•BP ≥185/110 that cannot be controlled

•Symptom onset >4.5 hours (or unknown last known well)

•Recent major surgery or head trauma within 14 days

•Active internal bleeding or coagulopathy

•INR >1.7; aPTT elevated with heparin

•Platelet count <100,000

•History of intracranial hemorrhage

•Current anticoagulants (NOAC within 48 hours)

Post-Stroke Monitoring Priorities

Parameter	Frequency	Notes
Neuro checks	Every 1–2 hours	NIHSS trend; GCS; report any worsening
Blood pressure	Every 1 hour or continuous	Maintain per stroke-type protocol
ECG / telemetry	Continuous	Detect atrial fibrillation or arrhythmias
Blood glucose	Per protocol (q2–6h)	Target 140–180 mg/dL; treat hypo- and hyperglycemia
Temperature	Every 4 hours or continuous	Treat fever aggressively; hyperthermia worsens outcomes
Swallow screen	Before any oral intake	NPO until formal swallow screen — aspiration risk high
After tPA: hemorrhagic transformation	Q15–30 min × 2 hours post-infusion	Worsening neuro, new headache, BP spike, altered consciousness

Related Resources

Stroke Nursing Essentials GuideFull conceptual guide: ischemic vs hemorrhagic, NIHSS, reperfusion, and monitoring

Open →

Stroke Comparison ChartIschemic vs. hemorrhagic vs. TIA side-by-side

Open →

Neuro Assessment GuideBedside neuro check and acute deterioration recognition

Open →

Standards & sources

Fact-checked Jun 20, 2026

This page is written to align with Society of Critical Care Medicine (SCCM) · Surviving Sepsis Campaign · American Association of Critical-Care Nurses (AACN). 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 →