Stroke Types: Ischemic vs. Hemorrhagic and How to Prevent Them

Jonathan Neal

What Are the Two Main Types of Stroke?

There are two main kinds of stroke: ischemic and hemorrhagic. Together, they make up nearly every stroke case in the U.S. About 87% of strokes are ischemic. That means a clot blocks blood flow to part of your brain. The other 13% are hemorrhagic - a blood vessel bursts and bleeds into or around your brain. These aren’t just different in cause. They behave differently, show different symptoms, and need completely different treatments.

If you don’t know which type you’re dealing with, you could get the wrong treatment - and that can be deadly. Giving a clot-busting drug to someone with a bleed can make things worse. That’s why emergency teams use CT scans right away to tell them apart. The faster you get to the hospital, the better your chances.

Ischemic Stroke: The Blockage

Ischemic strokes happen when something blocks an artery feeding your brain. Think of it like a clogged pipe. The clot might form right in your brain (thrombotic stroke), or it might travel from your heart or neck (embolic stroke). About half of all ischemic strokes are thrombotic, often caused by plaque buildup from high cholesterol or smoking. Another 20% are embolic, usually linked to atrial fibrillation - an irregular heartbeat that lets clots form in the heart.

There’s also a third group: cryptogenic strokes. These are ischemic strokes with no clear cause, even after full testing. They make up about 30% of ischemic cases. Doctors are still working to find hidden causes - sometimes it’s a tiny undetected heart rhythm problem or a small hole in the heart.

Symptoms usually come on slowly. You might wake up with numbness in your hand, or your speech might get slurred over 10 or 20 minutes. People often dismiss it as tiredness or a pinched nerve. But if you wait too long, brain cells die. That’s why the FAST acronym matters: Face drooping? Arm weakness? Speech trouble? Time to call 911.

Hemorrhagic Stroke: The Burst

Hemorrhagic strokes are less common but often more violent. Instead of a blockage, a blood vessel ruptures. This causes pressure to build up inside your skull, crushing brain tissue. Two types exist: intracerebral hemorrhage (bleeding inside the brain) and subarachnoid hemorrhage (bleeding on the surface, often from a ruptured aneurysm).

High blood pressure is the #1 cause. Nearly 80% of intracerebral bleeds happen because decades of uncontrolled hypertension have weakened small arteries. The rest come from aneurysms - balloon-like bulges in artery walls that can burst without warning.

The symptoms hit like a lightning strike. People describe it as the “worst headache of my life.” It’s not a migraine. It’s explosive, sudden, and often followed by vomiting, confusion, or loss of consciousness. Other signs include one pupil larger than the other, seizures, or extreme agitation. Unlike ischemic strokes, these symptoms rarely creep in - they explode.

How Symptoms Differ Between Stroke Types

It’s not just about speed. The symptoms themselves can give clues.

• Headache: 92% of hemorrhagic stroke patients report it. Only 19% of ischemic patients do.
• Eye problems: Half of hemorrhagic stroke patients have trouble moving their eyes. Less than 7% of ischemic patients do.
• Pupils: One pupil may be wider than the other in hemorrhagic strokes. That’s rare in ischemic.
• Seizures: Happen in nearly 1 in 6 hemorrhagic cases. Almost never in ischemic.
• Agitation: Nearly 80% of hemorrhagic stroke patients are restless or confused. Only 7% of ischemic patients are.

These differences aren’t perfect - some ischemic strokes can cause headaches, and some hemorrhagic strokes are mild. But when you see a sudden, severe headache with confusion or unequal pupils, treat it like a hemorrhage until proven otherwise.

How Treatment Varies by Stroke Type

There’s no one-size-fits-all fix. Treatment depends entirely on what’s happening inside your brain.

For ischemic strokes, the goal is to dissolve or remove the clot. If you get to the hospital within 4.5 hours, you might get tPA (alteplase) or tenecteplase - drugs that break up clots. For larger clots in major arteries, a mechanical thrombectomy can be done. This is a minimally invasive procedure where a device is threaded through your groin to pull the clot out. Studies show this works even up to 24 hours after symptoms start, if imaging shows salvageable brain tissue.

Hemorrhagic strokes need a different approach. You can’t give clot-busters here - it would make the bleed worse. Instead, doctors focus on stopping the bleeding and reducing pressure. If it’s an aneurysm, they might place tiny coils inside the vessel (coiling) or clamp it shut with a metal clip (clipping). If there’s a large bleed inside the brain, they might use a minimally invasive technique to drain the blood and reduce swelling. In some cases, medications to lower blood pressure are the first line of defense.

One big shift in recent years? Treatment is no longer just about time - it’s about tissue. Advanced imaging can now show which parts of the brain are still alive but starving for blood. That means even if you’re 8 hours in, if the brain tissue is still viable, you might still be a candidate for treatment.

Preventing Ischemic Stroke

If you’ve had an ischemic stroke, your risk of another one is high. Prevention is about managing the root causes.

• Control atrial fibrillation: If you have AFib, your stroke risk goes up fivefold. Blood thinners like apixaban or rivaroxaban reduce that risk by 60-70%. Don’t skip doses.
• Lower cholesterol: Statins aren’t just for your heart. They stabilize plaque in brain arteries, cutting stroke risk by up to 30%.
• Take aspirin or clopidogrel: For people without AFib, daily low-dose aspirin (81 mg) or clopidogrel reduces the chance of a second stroke by 25%.
• Manage diabetes and high blood pressure: Both damage blood vessels over time. Keeping your numbers in range cuts stroke risk significantly.
• Eat the Mediterranean diet: Fruits, vegetables, nuts, olive oil, and fish - this pattern reduced stroke risk by 30% in a major study of over 7,000 people.

And don’t underestimate exercise. Just 150 minutes a week of brisk walking or cycling cuts overall stroke risk by 27%.

Preventing Hemorrhagic Stroke

Hemorrhagic strokes are mostly about pressure. The single most powerful thing you can do? Control your blood pressure.

The SPRINT trial showed that lowering systolic blood pressure to under 120 mmHg - instead of the old goal of 140 - cut hemorrhagic stroke risk by 38%. That’s huge. If you’re on blood pressure meds, take them. Don’t skip them because you feel fine. High blood pressure has no symptoms until it’s too late.

Other key steps:

• Quit smoking: Your stroke risk drops by half within one year of quitting.
• Avoid excessive alcohol: Heavy drinking raises blood pressure and weakens vessel walls.
• Screen for aneurysms if you have a family history: If two close relatives had a ruptured aneurysm, talk to your doctor about an MRI scan.
• Don’t use cocaine or amphetamines: These can cause sudden, catastrophic bleeds even in young, healthy people.

What You Can Do Right Now

You don’t need to wait for a stroke to happen to act. Here’s your practical checklist:

1. Check your blood pressure monthly. If it’s over 130/80, talk to your doctor.
2. If you have AFib, know your medication schedule. Set phone reminders.
3. Get your cholesterol checked every year if you’re over 40.
4. Walk 30 minutes a day, five days a week. No gym needed.
5. Learn FAST. Teach it to your family. Save a life - maybe your own.
6. Don’t ignore a sudden, severe headache. Call 911. Don’t wait to see if it goes away.

Most strokes are preventable. That’s not just a slogan - it’s backed by data. The same lifestyle changes that protect your heart also protect your brain.

What’s Changing in Stroke Care

Technology is speeding up diagnosis. Hospitals in Austin and beyond are using AI tools like Viz.ai that analyze CT scans in seconds. These systems flag possible strokes before the radiologist even looks. That cuts door-to-treatment time by over 50 minutes.

There’s also new hope for bleeding strokes. The MISTIE III trial showed that a minimally invasive surgery using a small tube and clot-dissolving drugs reduced death rates by 10% over a year. And blood tests for GFAP - a protein released when brain cells are damaged - can now tell doctors within 15 minutes whether a stroke is a bleed or a clot. That could change how ambulances treat patients before they even reach the hospital.

Telestroke networks are bringing expert care to rural towns. If you’re in a small community hospital and someone has a stroke, a neurologist in Dallas can connect via video and guide treatment in real time. That’s saved thousands of lives since 2018.

Final Thought: It’s Not Just About Survival

Surviving a stroke isn’t the end goal. The real win is returning to your life - walking, talking, working, laughing with your grandkids. That’s why prevention matters more than ever. The longer you live with high blood pressure, uncontrolled diabetes, or atrial fibrillation, the more damage you’re doing silently.

Stroke doesn’t just hit older people. It’s rising in adults under 55. The reason? Poor diet, inactivity, and ignoring early warning signs. You can change that. Not tomorrow. Not next year. Today. Check your numbers. Take your pills. Move your body. Know the signs.

Your brain doesn’t ask for permission before it fails. But you can ask for help before it’s too late.