Ischemic stroke vs Hemorrhagic stroke
How to tell Ischemic stroke and Hemorrhagic stroke apart when a board question makes them look alike.
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Immediate noncontrast head CT evidence of intracranial blood separates hemorrhagic from ischemic stroke.
Side by side
Sudden focal neurologic deficit with noncontrast head CT showing no acute blood indicates likely ischemic stroke.
Acute focal deficit with severe headache, vomiting, reduced consciousness, or CT-visible intracranial blood indicates hemorrhagic stroke.
Ischemic stroke is caused by arterial occlusion with downstream cerebral infarction.
Hemorrhagic stroke results from ruptured intracranial vessels causing parenchymal or subarachnoid bleeding.
Initial noncontrast head CT is often normal or shows early ischemic change; if eligible, thrombolysis window is within 4.5 hours and alteplase dosing is 0.9 mg/kg IV (max 90 mg) with 10% bolus then remainder over 60 minutes.
Noncontrast CT shows acute hyperdense blood; management includes blood pressure control (often target systolic around 140 to 160 depending scenario), reversal of anticoagulation, and neurosurgical evaluation.
The trap
Clinicians may anchor on focal deficits and give antithrombotics or thrombolysis before imaging. History and exam cannot safely exclude hemorrhage, so CT must come first in every acute stroke code.
The repair move
Next best step: obtain immediate noncontrast head CT before thrombolytics or antiplatelets, then if no bleed and within 4.5 hours give IV alteplase 0.9 mg/kg (maximum 90 mg), with 10% as bolus and remainder over 60 minutes after blood pressure is below 185/110 mm Hg. If hemorrhage is present, reverse anticoagulation and control blood pressure with ICU or neurosurgical pathway.
Try a free question
CoreA 71-year-old man develops left arm weakness and dysarthria 2 hours ago. BP 172/98 mm Hg, HR 86/min, temp 36.7 C. Noncontrast head CT shows no acute hemorrhage. What is the most likely diagnosis?
Show answer and explanation
Answer: B. Ischemic stroke. Acute focal deficits with negative initial CT for blood in the correct clinical context are most consistent with ischemic stroke.
Why the other choices are tempting
- A. Hemorrhagic stroke is less likely because CT does not show intracranial blood.
- C. Hypoglycemia is less likely with normal glucose and persistent focal exam findings.
- D. Complex migraine can mimic stroke but usually has migrainous history and less focal persistent deficit in this scenario.
- E. Todd paralysis follows seizure activity, which is not described here.
Flashcards
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What mandatory test must precede alteplase in acute focal neurologic deficit?
Noncontrast head CT is mandatory to exclude intracranial hemorrhage before alteplase.
Which clinical features more strongly suggest hemorrhagic stroke?
Severe headache, vomiting, and depressed consciousness increase suspicion for hemorrhagic stroke.
Quick answers
What is the fastest way to tell Ischemic stroke from Hemorrhagic stroke?
Immediate noncontrast head CT evidence of intracranial blood separates hemorrhagic from ischemic stroke.
What is the key clue for Ischemic stroke?
Sudden focal neurologic deficit with noncontrast head CT showing no acute blood indicates likely ischemic stroke.
What is the key clue for Hemorrhagic stroke?
Acute focal deficit with severe headache, vomiting, reduced consciousness, or CT-visible intracranial blood indicates hemorrhagic stroke.
What is the common trap with Ischemic stroke vs Hemorrhagic stroke?
Clinicians may anchor on focal deficits and give antithrombotics or thrombolysis before imaging. History and exam cannot safely exclude hemorrhage, so CT must come first in every acute stroke code.