Contents
Two Types of Stroke
- Ischemic (~87%): clot blocks a cerebral artery (thrombotic or embolic)
- Hemorrhagic: vessel rupture — intracerebral or subarachnoid bleed
- Management diverges sharply — you MUST image before treating
- Time is brain: rapid recognition and CT are critical
Recognition: FAST & Symptoms
- FAST: Face droop, Arm drift, Speech difficulty, Time to call
- Sudden unilateral weakness/numbness, aphasia, visual loss, severe headache
- Establish last known well time — it drives treatment eligibility
- Subarachnoid: "worst headache of my life," meningismus
Initial Workup
- Non-contrast head CT FIRST — rules out hemorrhage before any thrombolytic
- Check glucose (hypoglycemia mimics stroke), labs, coagulation studies
- NIH Stroke Scale (NIHSS) quantifies severity
- Keep the patient NPO until swallow screen passed (aspiration risk)
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Start Free Practice →Ischemic Stroke: Reperfusion
- IV thrombolytics (alteplase/tenecteplase): within 3–4.5 hr of last known well, if eligible
- Mechanical thrombectomy: large-vessel occlusion, often up to 24 hr in selected patients
- Screen for thrombolytic contraindications (recent surgery, bleeding, recent stroke, etc.)
- Sooner is better — outcomes degrade with every minute of delay
Blood Pressure — the high-yield distinction
- Ischemic + getting tPA: BP must be <185/110 before, and <180/105 after
- Ischemic NOT getting tPA: permissive hypertension — treat only if >220/120
- Hemorrhagic: lower BP (commonly target SBP ~140–160) to limit hematoma expansion
- Lowering BP too aggressively in ischemic stroke worsens penumbral perfusion
Hemorrhagic Stroke Management
- Reverse anticoagulation; control BP to reduce bleed expansion
- Manage increased ICP (HOB ~30°, osmotherapy, neuro checks)
- Neurosurgical consult (evacuation, EVD, aneurysm securing for SAH)
- SAH: watch for vasospasm (often days 3–14) — nimodipine
Post-tPA Care
- Frequent neuro checks and BP monitoring per protocol
- Watch for bleeding — especially intracranial hemorrhage (sudden ↓LOC, new headache, vomiting)
- Avoid antiplatelets/anticoagulants and invasive lines for ~24 hr
- No NG tubes/foley/arterial sticks unless necessary in the immediate window
Complications
- Cerebral edema and increased ICP / herniation
- Hemorrhagic transformation of an ischemic stroke
- Seizures, aspiration pneumonia, DVT
- Vasospasm (SAH), hydrocephalus
Nursing Priorities
- Rapid triage: CT, glucose, NIHSS, last-known-well time
- Strict BP targets based on stroke type and treatment
- Dysphagia screen before anything by mouth; aspiration precautions
- Serial neuro assessments; escalate any new deficit immediately
Prevention & Education
- Control hypertension, diabetes, AFib (anticoagulation), and hyperlipidemia
- Smoking cessation and lifestyle modification
- Recognize FAST symptoms and act fast
- Medication adherence and follow-up
Can you answer these 3 CCRN questions?
Here are 3 questions in the style of our premium bank. The full rationale explains exactly why the right answer is right — and why the distractors trap most test-takers.
Premium Practice Question
A patient with an acute ischemic stroke is a candidate for IV thrombolytics. The BP is 196/114. The nurse anticipates:
- Giving tPA immediately at this BP
- Lowering BP to below 185/110 before tPA
- Withholding all BP treatment (permissive hypertension)
- Targeting an SBP of 220
Rationale: Before IV thrombolytics for ischemic stroke, blood pressure must be lowered to below 185/110, then maintained below 180/105 afterward....
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Premium Practice Question
Which diagnostic test must be completed FIRST in suspected acute stroke?
- MRI with contrast
- Non-contrast head CT
- Carotid ultrasound
- Lumbar puncture
Rationale: A non-contrast head CT is obtained first to rule out hemorrhage, because thrombolytics are contraindicated in hemorrhagic stroke....
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Premium Practice Question
For an ischemic stroke patient who is NOT a thrombolytic candidate, blood pressure is generally treated only when it exceeds:
- 140/90
- 160/100
- 185/110
- 220/120
Rationale: In ischemic stroke without thrombolysis, permissive hypertension is allowed and BP is typically treated only above 220/120 to preserve perfusion to the ischemic penumbra....
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Related CCRN Guides
Frequently Asked Questions
What is the difference between ischemic and hemorrhagic stroke?
Ischemic stroke (about 87%) is caused by a clot blocking a cerebral artery, while hemorrhagic stroke is caused by a ruptured vessel bleeding into or around the brain. A non-contrast head CT is required to distinguish them before treatment because management differs sharply.
What is the time window for IV thrombolytics in stroke?
IV thrombolytics such as alteplase or tenecteplase are given within 3 to 4.5 hours of the last known well time in eligible patients. Mechanical thrombectomy for large-vessel occlusion can be performed later, in selected patients up to 24 hours.
How is blood pressure managed differently in ischemic versus hemorrhagic stroke?
In ischemic stroke receiving thrombolytics, BP must be below 185/110 before and below 180/105 after. In ischemic stroke not receiving thrombolytics, permissive hypertension is allowed and BP is treated only above 220/120. In hemorrhagic stroke, BP is lowered (often to a systolic around 140–160) to limit hematoma expansion.
Why must blood pressure not be lowered too aggressively in ischemic stroke?
The ischemic penumbra (at-risk but salvageable brain tissue) depends on collateral perfusion. Aggressively lowering blood pressure reduces that perfusion and can enlarge the infarct.
What is a key complication to watch for after subarachnoid hemorrhage?
Cerebral vasospasm, which typically occurs between days 3 and 14, can cause delayed ischemia. Nimodipine is given to reduce this risk.
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