Confusable diagnoses · PANCE / PANRE

Ischemic Stroke vs Hemorrhagic (Intracerebral) Stroke

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Ischemic Stroke and Hemorrhagic (Intracerebral) Stroke are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Ischemic Stroke vs Hemorrhagic (Intracerebral) Stroke at a glance

  • Ischemic Stroke: Acute focal neurologic deficit from arterial occlusion causing brain infarction.
  • Hemorrhagic (Intracerebral) Stroke: Non-traumatic bleeding into brain parenchyma; higher mortality than ischemic stroke.

Try two board-style questions on Ischemic Stroke vs Hemorrhagic (Intracerebral) Stroke

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Question 1NeurologyEasy
A 65-year-old female has an acute right hemisphere ischemic stroke with left-sided weakness and left-sided neglect. She arrives at the ED 2.5 hours after symptom onset. National Institutes of Health Stroke Scale (NIHSS) is 14. CT shows no hemorrhage and no large territory infarct. She has no contraindications. Which of the following treatments is most appropriate?
  • AIV heparin infusion
  • BAspirin 325 mg orally immediately
  • CIV alteplase 0.9 mg/kg
  • DAspirin plus clopidogrel loading dose
Reveal answer & full explanation
Correct answer: C — IV alteplase 0.9 mg/kg
  • AIV heparin infusion
  • BAspirin 325 mg orally immediately
  • CIV alteplase 0.9 mg/kg✓
  • DAspirin plus clopidogrel loading dose

Why IV alteplase 0.9 mg/kg is correct

  • IV alteplase 0.9 mg/kg given within 4.5 hours of symptom onset reduces 90-day disability (modified Rankin scale) by 30%.
  • This patient arrived at 2.5 hours with no hemorrhage on CT, no large territory infarct, NIHSS of 14, and no stated contraindications — all criteria are met.

Why the others are wrong

  • IV heparin infusion — IV heparin is not indicated for acute ischemic stroke and increases bleeding risk without proven benefit (right-concept-wrong-drug).
  • Aspirin 325 mg orally immediately — aspirin is started 24 hours after tPA, not before, to avoid compounding hemorrhagic risk (wrong-timing).
  • Aspirin plus clopidogrel loading dose — dual antiplatelet therapy is used for high-risk TIA or minor ischemic stroke (POINT/CHANCE trials), not as a substitute for thrombolysis in a patient eligible for alteplase (confused-with minor-stroke protocol).

Additional high-yield points

  • Time is brain: 1.9 million neurons are lost per minute of ischemia.
  • Absolute contraindications to alteplase include hemorrhage on CT, prior intracerebral hemorrhage (ICH), systolic blood pressure (SBP) above 185 or diastolic blood pressure (DBP) above 110, platelets below 100K, anticoagulants with therapeutic INR above 1.7, and active bleeding.
  • Mechanical thrombectomy (MT) is indicated for large vessel occlusion (LVO) involving the internal carotid artery (ICA), M1, or basilar artery, with NIHSS above 6, within 24 hours (extended window with perfusion imaging per DAWN/DEFUSE-3 trials); MT plus tissue plasminogen activator (tPA) is superior to tPA alone for LVO.
  • Tenecteplase 0.25 mg/kg IV bolus is non-inferior to alteplase, simpler to administer as a single bolus, and increasingly used.
Question 2NeurologyMedium
A 64-year-old man is brought to the emergency department 80 minutes after the sudden onset of left-sided weakness that began at rest, with no fall or head trauma. He vomited twice en route and is drowsy but rousable and oriented, with a Glasgow Coma Scale score of 14, dense left hemiparesis, and a left facial droop. He has a 15-year history of hypertension treated with amlodipine that he takes irregularly, and he takes no anticoagulant or antiplatelet medication. Blood pressure is 196/108 mm Hg. Noncontrast head CT shows an acute 18-mL hyperdense hematoma in the right putamen with no intraventricular extension and no midline shift. Which of the following is the most appropriate blood pressure management over the next hour?
  • AStart a titratable IV infusion only if the systolic pressure exceeds 220 mm Hg
  • BStart a titratable IV infusion and target a systolic pressure of 185 mm Hg
  • CStart a titratable IV infusion and target a systolic pressure of 160 mm Hg
  • DStart a titratable IV infusion and target a systolic pressure of 140 mm Hg
Reveal answer & full explanation
Correct answer: D — Start a titratable IV infusion and target a systolic pressure of 140 mm Hg
  • AStart a titratable IV infusion only if the systolic pressure exceeds 220 mm Hg
  • BStart a titratable IV infusion and target a systolic pressure of 185 mm Hg
  • CStart a titratable IV infusion and target a systolic pressure of 160 mm Hg
  • DStart a titratable IV infusion and target a systolic pressure of 140 mm Hg✓

Why Start a titratable IV infusion and target a systolic pressure of 140 mm Hg is correct

  • Sudden focal deficits with vomiting and a falling level of alertness, plus an acute hyperdense putaminal hematoma in a man with long-standing poorly controlled hypertension and no trauma, is spontaneous hypertensive intracerebral hemorrhage.
  • Hematoma expansion over the first several hours is the main driver of early deterioration and is pressure dependent, so acute blood pressure control is the medical intervention that changes the trajectory.
  • The AHA/ASA 2022 guideline addresses spontaneous intracerebral hemorrhage of mild to moderate severity presenting with a systolic pressure of 150-220 mm Hg: lower the systolic pressure to a target of 140 mm Hg and maintain it in the 130-150 mm Hg range, starting treatment within 2 hours of onset and reaching target within 1 hour. This patient meets those bounds - Glasgow Coma Scale score 14, an 18-mL hematoma without intraventricular extension or shift, systolic pressure 196 mm Hg, and 80 minutes from onset.
  • A titratable continuous infusion such as nicardipine or clevidipine is used because smoothness matters as much as the number: wide swings in pressure track with worse outcomes, and the target is reached by controlled taper rather than by the steepest possible drop.

Why the others are wrong

  • Start a titratable IV infusion only if the systolic pressure exceeds 220 mm Hg - that is the permissive-hypertension rule for acute ischemic stroke, where the threatened penumbra survives on perfusion pressure; the logic inverts once CT shows blood, because pressure now drives hematoma growth (the trap is carrying one stroke rule into the other stroke type).
  • Start a titratable IV infusion and target a systolic pressure of 185 mm Hg - 185/110 mm Hg is the eligibility ceiling before IV thrombolysis in ischemic stroke and has no counterpart in the management of a parenchymal hematoma; stopping at 185 mm Hg leaves the hematoma under very nearly the pressure that expands it (the trap is reaching for the most familiar stroke number).
  • Start a titratable IV infusion and target a systolic pressure of 160 mm Hg - a 20 to 25 percent reduction in the first hour is the generic hypertensive-emergency rule that fits most other acute end-organ syndromes, but intracerebral hemorrhage has its own number, and stopping 20 mm Hg above the 130-150 mm Hg band leaves expansion risk on the table (the trap is substituting the general emergency rule for the disease-specific target).

Additional high-yield points

  • Do not overshoot downward either: ATACH-2 randomized patients to an intensive systolic target of 110-139 mm Hg and found no reduction in death or disability against a 140-179 mm Hg target, with more renal adverse events, so 140 mm Hg is a number to reach and hold, not a floor to drive under, and a brain autoregulated to chronic hypertension tolerates a steep fall poorly.
  • Putamen and the rest of the basal ganglia, thalamus, pons, and cerebellum are the classic hypertensive sites because each is fed by small penetrating arteries that undergo lipohyalinosis: lenticulostriate branches to the basal ganglia, thalamoperforating branches of the posterior cerebral artery to the thalamus, paramedian perforators of the basilar artery to the pons, and penetrating cerebellar branches; a lobar hemorrhage in an older normotensive patient points instead to cerebral amyloid angiopathy.
  • The intensive-lowering recommendation is deliberately limited to mild to moderate hemorrhage; its safety and efficacy are not established in large or severe intracerebral hemorrhage or in patients headed for surgical decompression, and above a presenting systolic pressure of 220 mm Hg the benefit of driving to 140 mm Hg is likewise less well established.
  • Anticoagulant reversal runs in parallel with blood pressure control, never after it: 4-factor PCC plus vitamin K for warfarin, 4-factor PCC for apixaban or rivaroxaban (andexanet alfa was withdrawn from the US market in late 2025), idarucizumab for dabigatran.
  • Nicardipine, clevidipine, and labetalol infusions are all acceptable agents; boards test the target and the timing, not the drug.
  • Cerebellar hemorrhage with neurologic deterioration, brainstem compression, obstructive hydrocephalus, or a volume of 15 mL or more warrants immediate surgical evacuation (not an external ventricular drain alone); glucocorticoids and prophylactic antiseizure drugs have no role.
  • Also check platelets and coagulation studies, elevate the head of the bed to 30 degrees, treat fever and hyperglycemia, and repeat CT for any decline in the level of consciousness.
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Side-by-side comparison

FeatureIschemic StrokeHemorrhagic (Intracerebral) Stroke
At a glanceAcute focal neurologic deficit from arterial occlusion causing brain infarction.Non-traumatic bleeding into brain parenchyma; higher mortality than ischemic stroke.
Classic presentationSudden onset focal deficit referable to a single vascular territory; NIHSS quantifies severity (0-42).; Sudden, focal neurologic deficit: unilateral weakness, sensory loss, aphasia, dysarthria, gaze deviation, hemianopia, ataxia, vertigo; Symptoms maximal at onset (contrast with progressive course of tumor); Headache uncommon (more…Hypertensive ICH classically in basal ganglia (putamen most common), thalamus, pons, or cerebellum. ICH score predicts 30-day mortality.; Sudden focal neurologic deficit (similar to ischemic stroke); Headache (more common and severe than ischemic stroke); Nausea/vomiting; Decreased level of consciousness, often progressive over…
Workup / key labsClinical syndrome of acute focal neurologic deficit with hemorrhage excluded on non-contrast CT (often normal in the first hours); infarction is confirmed by MRI DWI restriction or later CT hypodensity, or by a deficit persisting >24 h.; Fingerstick glucose immediately (rule out hypoglycemia); CBC, platelets, PT/INR, PTT, BMP, troponin;…CBC, platelets, PT/INR, PTT — assess coagulopathy; BMP, glucose, troponin; Toxicology screen (cocaine, methamphetamine in young patients); Type and screen
ImagingNon-contrast head CT within 20 min of arrival — excludes hemorrhage (essential before tPA); CT angiography head and neck — identifies large vessel occlusion candidates for thrombectomy; CT perfusion or MR diffusion/perfusion — quantifies core vs penumbra for extended-window thrombectomy (DAWN, DEFUSE-3); MRI with DWI — most sensitive…Non-contrast head CT — high-density acute hematoma; immediately diagnostic; CT angiography — 'spot sign' (contrast extravasation) predicts hematoma expansion; rules out underlying vascular lesion; MRI with susceptibility-weighted imaging — chronic microbleeds suggest cerebral amyloid angiopathy or hypertensive disease; Catheter…
First-line treatmenttPA dosing — alteplase 0.9 mg/kg IV (max 90 mg), 10% as bolus over 1 min, remainder over 60 min, if within 4.5 h of last known well and no contraindications (NINDS, ECASS III); 4.5-9 h from last known well or wake-up stroke only if automated perfusion imaging shows salvageable penumbra (EXTEND; AHA/ASA 2026); mild nondisabling deficits…ABCs, intubation if GCS ≤8 or aspiration risk; BP control: target SBP 130-150 within first hour (INTERACT2, ATACH-2). Agents: IV nicardipine, clevidipine, labetalol; Reverse anticoagulation immediately: warfarin → 4-factor PCC + vitamin K 10 mg IV; dabigatran → idarucizumab 5 g IV; factor Xa inhibitors (apixaban, rivaroxaban) → 4-factor…

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Full outlines

Ischemic Stroke Hemorrhagic (Intracerebral) Stroke All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.