Can a stroke be either a blood clot (thrombosis), known as an ischemic stroke, or a hemorrhage, in an older adult with a history of hypertension, diabetes, or cardiovascular disease?

Stroke: Blood Clot or Hemorrhage?

A stroke can be either a blood clot (ischemic stroke) or a hemorrhage (hemorrhagic stroke)—these are two fundamentally different disease processes that require opposite treatment approaches. 1, 2

Two Main Types of Stroke

Ischemic Stroke (Blood Clot)

• Accounts for 80-87% of all strokes and results from blocked blood flow to the brain 2, 1
• Caused by thrombosis (clot formation), embolism (traveling clot), or global hypoperfusion 2
• Common mechanisms include:
  • Small vessel arteriolosclerosis (lacunar infarcts) 1
  • Cardioembolism (often from atrial fibrillation) 3, 1
  • Large artery atherothromboembolism 1
  • Extracranial dissection (particularly in younger patients) 1

Hemorrhagic Stroke (Bleeding)

• Accounts for 13-20% of all strokes and results from bleeding into or around the brain 2, 1
• Two subtypes exist:
  • Intracerebral hemorrhage (10% of all strokes): bleeding within brain tissue, typically from hypertensive arteriopathy or cerebral amyloid angiopathy 1, 2
  • Subarachnoid hemorrhage (3% of all strokes): bleeding around the brain surface 2

Critical Clinical Distinction

The first priority in stroke management is rapid brain imaging to differentiate hemorrhage from ischemia, as this determines whether thrombolytic therapy can be safely administered. 4, 3

• Ischemic strokes may benefit from clot-dissolving medications (thrombolytics) within specific time windows 2
• Hemorrhagic strokes are an absolute contraindication to thrombolytics, which would worsen bleeding 3
• CT imaging must be performed immediately to exclude intracranial hemorrhage before considering thrombolytic therapy 2, 4

Risk Factors Overlap

Hypertension is the single most important modifiable risk factor for BOTH ischemic and hemorrhagic stroke, though it contributes differently to each subtype 1, 5

Additional shared risk factors include: 2

• Diabetes mellitus
• Age and race
• Atherosclerosis
• Hyperlipidemia
• Cigarette smoking

Treatment Implications

The distinction between clot and hemorrhage determines completely opposite management strategies:

• For ischemic stroke: antiplatelet therapy, anticoagulation (if cardioembolic), and potentially thrombolysis or thrombectomy 3, 2
• For hemorrhagic stroke: blood pressure control and avoidance of antithrombotic therapy 3, 5

A critical pitfall is assuming all strokes are the same—approximately 15% are hemorrhagic, and giving clot-busting drugs to these patients can be fatal. 1, 3