Guidelines for the Management of Acute Ischemic Stroke Published

Updated clinical practice guidelines from the American Heart Association and American Stroke Association (AHA/ASA) provide a comprehensive revision of evidence-based recommendations for the early management of adults with acute ischemic stroke (AIS), incorporating advances in thrombolysis, endovascular thrombectomy (EVT), blood pressure management, and systems of stroke care. Published in Stroke, the 2026 guidelines replace the 2018 guidelines and their 2019 update, emphasizing rapid reperfusion, streamlined imaging, and avoidance of interventions shown to provide no benefit or cause harm.

The guidelines were developed by a multidisciplinary writing group convened by the AHA/ASA Stroke Council and included experts in neurology, emergency medicine, neurointervention, nursing, and patient representation. The panel conducted systematic literature searches across MEDLINE, PubMed, and the Cochrane Library for studies published since 2018, with additional high-impact evidence incorporated through March 2025. Recommendations were assigned a class of recommendation and level of evidence and underwent external peer review. The published guidelines were endorsed by the American Association of Neurological Surgeons/Congress of Neurological Surgeons, the Neurocritical Care Society, the Society for Academic Emergency Medicine, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology, with the American Academy of Neurology affirming its value as an educational tool for neurologists.

Key guideline updates and recommendations include the following:

• Intravenous thrombolysis should be initiated as quickly as possible within 4.5 hours of symptom onset in eligible patients without delays for advanced imaging, using either Activase (alteplase; Genentech, South San Francisco, CA) or TNKase (tenecteplase; Genentech, South San Francisco, CA).
• Extended-window IV thrombolysis (4.5 to 9 hours) may be reasonable in selected patients with stroke of unknown onset who have salvageable ischemic penumbra detected on automated perfusion imaging.
• Endovascular thrombectomy (EVT) is recommended for patients with anterior circulation large-vessel occlusion presenting within 6 hours and is now strongly recommended for select patients with basilar artery occlusion presenting within 24 hours and National Institutes of Health Stroke Scale (NIHSS) scores of ≥10.
• Intensive systolic blood pressure lowering to <140 mm Hg after thrombolysis or thrombectomy is not recommended, with evidence of harm after successful EVT and no improvement in functional outcome after IVT.
• Dual antiplatelet therapy is preferred over thrombolysis within 4.5 hours of symptom onset in patients with non-disabling deficits.
• For the first time, the guideline includes recommendations addressing acute interventional management in pediatric AIS.

Source: Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online January 26, 2026. doi:10.1161/STR.0000000000000513