2026 AHA/ASA Acute Ischemic Stroke Guidelines

Mobile Stroke Units (MSU)

• MSUs enable rapid identification and treatment of thrombolytic-eligible patients
• Recent evidence supports MSU implementation over conventional EMS when available
• Class I MSUs offer safety and benefit in appropriate systems

Transport Destination

• Consider local system characteristics when determining transport destination
• Direct transport to EVT-capable hospital when rapid interhospital transfer is not available
• System design affects choice between thrombolytic-capable vs. thrombectomy-capable facilities

Thrombolytic Choice: Alteplase vs. Tenecteplase

• Class I Both alteplase and tenecteplase are recommended for AIS within 4.5 hours
• Multiple international trials show non-inferiority of tenecteplase (TNK) vs. alteplase (tPA)
• Tenecteplase may have advantages: single bolus, potentially lower intracranial hemorrhage risk

Rapid Treatment in Disabling Deficits

• Class I Administer thrombolysis within 4.5 hours for patients with disabling deficits
• Do NOT delay treatment for advanced imaging in clearly disabling strokes
• Emphasize rapid door-to-needle (DTN) times

Extended Window Thrombolysis (4.5–9 hours)

• Class I Extended window IVT for select patients with imaging criteria (DWI/FLAIR mismatch)
• Appropriate for stroke of unknown onset or delayed presentation
• Requires advanced imaging selection (perfusion or DWI mismatch)

Endovascular Thrombectomy (EVT)

• Class I EVT is standard treatment for large vessel occlusion (LVO)
• Recent evidence supports expanding EVT to larger ischemic cores previously considered ineligible
• Class I Strong recommendation for basilar artery occlusion with NIHSS ≥10 within 24 hours

Pediatric Acute Ischemic Stroke

• First time guideline includes recommendations for pediatric AIS intervention
• Expert consensus supports safety and potential benefit of endovascular interventions in select pediatric patients
• Future work needed to adapt prehospital and hospital protocols for children

Glucose Management

• Class III Intensive glucose control (80–130 mg/dL) is NOT recommended to improve outcomes
• Intensive control increases risk of severe hypoglycemia
• Maintain normoglycemia but avoid aggressive lowering

Blood Pressure Management Post-Reperfusion

• Class III Intensive systolic BP lowering to <140 mm Hg is NOT recommended after IVT or EVT
• Intensive BP reduction does not improve outcomes and may cause harm
• Avoid aggressive antihypertensive therapy in the acute phase

IVT Recommendations

• Class I Administer IV thrombolysis to eligible patients presenting within 4.5 hours of AIS symptom onset
• Class I Both alteplase and tenecteplase are recommended; choice depends on institutional protocols and clinical judgment
• Class I Rapid thrombolysis in patients with disabling deficits without advanced imaging delays
• Class I Extended window (4.5–9 hours) for patients with DWI/FLAIR mismatch or perfusion criteria

EVT Indications

• Class I EVT is standard care for patients with AIS with large vessel occlusion (LVO) presenting within established time windows
• Class I EVT is beneficial within 24 hours of symptom onset with imaging evidence of favorable perfusion or salvageable tissue
• Class I Perform EVT concomitantly with IVT in eligible patients; do NOT delay IVT waiting for EVT if patient presents to non-EVT center
• Class I Strong recommendation for basilar artery occlusion: perform EVT within 24 hours for NIHSS ≥10
• Class I Expand EVT candidacy to patients with larger ischemic cores previously deemed ineligible (based on RAPID, DEFUSE 3, DISCLe trials)

EVT in Pediatric Patients

• Expert consensus supports safety and potential benefit of EVT in select pediatric AIS patients
• Evidence remains limited; protocols require adaptation for pediatric anatomy and physiology
• Involve pediatric neurovascular expertise and informed family consent

• Class I Use mechanical thrombectomy devices (stent retrievers or aspiration) as first-line technique
• Class I Perform angiography to document reperfusion success (mTICI 2b or 3 preferred)
• Aspiration thrombectomy or combined stent/aspiration techniques are acceptable alternatives
• Local protocols and operator expertise guide specific device selection

• Class I Non-contrast head CT to exclude intracranial hemorrhage and other mimics
• Class I Perform rapidly; do NOT delay thrombolysis in clearly disabling strokes
• CTA of head and neck to identify large vessel occlusion in EVT-eligible patients

BP Management Approach

• Permissive hypertension in acute phase (allow SBP up to 180–185 mm Hg)
• Initiate antihypertensive therapy only if SBP >220 or DBP >120 mm Hg
• Target modest reduction (10–15% in first 24 hours) if treatment necessary

• Class I Identify and treat fever >38.5°C
• Class III Induced hypothermia is NOT recommended to improve neurological outcome

• Class I Identify hyperglycemia and provide glucose-lowering therapy to maintain normoglycemia (140–180 mg/dL target)
• Avoid hypoglycemia (<70 mg/dL) as it worsens outcomes
• Monitor frequently in first 24 hours

• Class I Aspirin (325 mg loading, then daily dosing) within 24–48 hours after non-thrombolyzed AIS
• Class I For minor non-disabling AIS or TIA (non-cardioembolic): dual antiplatelet therapy (clopidogrel + aspirin) preferred over single agent or thrombolysis

• Consider anticoagulation for cardioembolic sources (AF, cardiac thrombus) after hemorrhage exclusion
• Timing depends on stroke severity, imaging findings, and hemorrhage risk

Recommended Stroke Unit Characteristics

• Class I Organized inpatient stroke unit with dedicated multidisciplinary team
• Nursing staff trained in stroke assessment and monitoring
• Protocols for early mobilization, dysphagia screening, and DVT prophylaxis
• Access to neuroimaging and neurovascular intervention
• Quality improvement infrastructure with outcome tracking

• Class I Perform formal dysphagia screening before oral intake
• Class I Nothing by mouth until swallowing evaluated
• Class IIa Pharyngeal electrical stimulation may reduce dysphagia severity and aspiration risk in appropriate patients

• Class I Provide mechanical DVT prophylaxis (sequential compression devices) for immobilized patients
• Class IIa Consider pharmacologic prophylaxis (LMWH) in high-risk patients after hemorrhage exclusion

Medical Management

• Class I Head of bed elevated 30 degrees
• Class I Head midline positioning
• Class I Maintain normothermia and normoxia
• Class IIa Osmotic therapy (mannitol or hypertonic saline) for symptomatic elevations in ICP

• Class I Neurosurgical consultation for posterior fossa infarction with edema and brainstem compression
• Class I Consider decompressive suboccipital craniectomy for deterioration

• Monitor closely for clinical deterioration in first 24 hours
• Repeat imaging if neurological decline occurs
• Manage elevated ICP medically or surgically as indicated
• Continue supportive care and rehabilitation planning