Stroke (Ischemic and Hemorrhagic)
3-4.5 hrs
tPA Window
Alteplase from symptom onset
<185/110
Pre-tPA BP
Must be below before administration
<140
Hemorrhagic SBP
Target for hemorrhagic stroke
Ischemic vs Hemorrhagic Stroke
Ischemic stroke accounts for 87% of all strokes. Treatment includes tPA within 3-4.5 hours and mechanical thrombectomy up to 24 hours with favorable imaging. Hemorrhagic stroke includes intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).
BP management is OPPOSITE between ischemic and hemorrhagic stroke. The NIH Stroke Scale quantifies deficit severity and guides intervention decisions.
Ischemic (87%)
Clot blocking blood flow
- BP Goal Permissive hypertension (up to 220/120 if no tPA)
- Treatment tPA, thrombectomy, antiplatelet
- Rationale Pressure perfuses penumbra around infarct
Hemorrhagic (13%)
Vessel rupture and bleeding
- BP GoalSBP <140 mmHg aggressively
- Treatment BP reduction, reversal of anticoagulation, surgical evacuation if large
- Rationale Pressure worsens hematoma expansion
SAH and Vasospasm Prevention
SAH typically presents with a thunderclap headache described as the worst of the patient's life. Vasospasm peaks at days 4-14 post-bleed. Nimodipine 60 mg every 4 hours for 21 days is the standard. Triple-H therapy (hypertension, hypervolemia, hemodilution) may be used for symptomatic vasospasm.
Key Values to Memorize
tPA window 3-4.5 hrs
Pre-tPA BP <185/110
Hemorrhagic SBP <140
Thrombectomy up to 24h
Nimodipine 21 days
Vasospasm peaks day 4-14
stroke BP management trips up even experienced nurses
Practice CCRN exam-style questions with instant feedback
Practice CCRN QuestionsExam Traps
Permissive hypertension in ischemic, aggressive lowering in hemorrhagic
Ischemic stroke needs perfusion pressure to push blood past the clot into the penumbra. Lowering BP too aggressively in ischemic stroke can extend the infarct. In hemorrhagic stroke, elevated BP worsens bleeding and hematoma expansion. The management is OPPOSITE.
BP must be below 185/110 before tPA administration
If BP exceeds 185/110, tPA cannot be given. The risk of hemorrhagic conversion is too high. Labetalol or nicardipine can be used to bring BP into range, but if it cannot be controlled, tPA is contraindicated.
Nimodipine prevents vasospasm, it does NOT control BP
In subarachnoid hemorrhage, nimodipine is given for 21 days to prevent cerebral vasospasm. It is a calcium channel blocker but its benefit in SAH is neuroprotective, not antihypertensive. Do not confuse its purpose.
Time of symptom onset drives every decision
The tPA window is 3-4.5 hours from symptom onset, not from arrival. If onset is unknown (wake-up stroke), advanced imaging (CT perfusion, MRI DWI-FLAIR mismatch) may extend the window. Mechanical thrombectomy can go up to 24 hours with favorable imaging.
BP Direction Rule
Ischemic = let BP ride (perfusion). Hemorrhagic = bring it down (stop bleeding). They are polar opposites.
Nimodipine Clarification
Nimodipine in SAH = vasospasm prevention. Not a BP drug here. 21 days. Every 4 hours. Do not skip doses.
A clot is blocking the pipe. The tissue downstream is dying. You need water pressure (BP) to push through or around the blockage. Dropping the pressure means less water reaches the dying area. That is why we allow permissive hypertension.
The pipe has burst and water is flooding everywhere. Higher pressure means more water pouring out through the hole. You MUST reduce the pressure to slow the leak. That is why we aggressively lower BP in hemorrhagic stroke.
Alteplase is like chemical drain cleaner for the blocked pipe. But it only works if used within the window, and you cannot use it if there is already a burst somewhere (hemorrhagic). And the pressure must be safe before you pour it in.
After a subarachnoid hemorrhage, the blood vessels around the brain can spasm shut (vasospasm). Nimodipine keeps those vessels relaxed so they do not clamp down and cause secondary ischemic damage.
Ready to test your CCRN knowledge?
1,200+ practice questions written by certified professionals.
Start Practicing CCRN