2026 AHA/ASA Acute Ischemic Stroke Guideline Summary

This is a condensed summary of the 2026 Guideline for the Early Management of Patients with Acute Ischemic Stroke (Prabhakaran et al.), replacing the 2018 guideline and 2019 update. Recommendations are listed by Class of Recommendation (COR) and Level of Evidence (LOE) where clinically impactful.

1. Stroke Systems of Care & Prehospital Management

Stroke Awareness

• Implement public educational programs on stroke recognition and calling 9-1-1 (COR 1, LOE B-R)
• Design programs to reach diverse communities and populations (COR 1, LOE B-NR)
• Sustain educational programs over time (COR 1, LOE B-NR)

EMS Destination Management

• Prioritize transport to closest appropriate stroke center (ASRH, PSC, TSC, or CSC) over non-stroke hospital (COR 1, LOE B-NR)
• Direct transport of suspected LVO to TSC can be beneficial where locally available (COR 2a, LOE B-NR)
• In areas without well-coordinated systems, direct transport to closest TSC may be reasonable if it won't disqualify patient from IVT (COR 2b, LOE B-NR)
• In areas with well-coordinated systems and proficient local PSCs, bypassing to distant TSC (~45–60 min) does NOT improve outcomes (COR 3: No Benefit, LOE B-R)
• Establish agreements/protocols to reduce DIDO times for interhospital transfers (COR 1, LOE B-NR)
• Target DIDO time: ≤120 minutes (median in US registry: 174 min)

Mobile Stroke Units

• Use MSUs over conventional EMS where available for thrombolytic-eligible patients (COR 1, LOE A)
• MSUs must be equipped to diagnose and treat with IVT (COR 1, LOE A)
• MSU care with streamlined protocols and neurological expertise (in-person or telemedicine) is beneficial (COR 1, LOE B-R)
• MSUs can be beneficial to identify and triage EVT-eligible patients (COR 2a, LOE B-NR)

Hospital Capabilities

• Stroke center certification improves thrombolysis rates and outcomes
• TSC/CSC hospitals should track key time metrics (door-to-puncture, reperfusion rates) and long-term outcomes (COR 1)
• Credential neurointerventionalists using established training and certification standards (COR 1)

2. Imaging

Initial Imaging

• Emergent brain imaging (CT or MRI) is required before IVT to exclude hemorrhage (COR 1, LOE A)
• Do NOT delay IVT for additional multimodal imaging (CTA/MRA, perfusion) in eligible patients within 4.5 hours (COR 1)
• CT/CTA is the most generalizable first-line modality
• Do NOT delay CTA for renal function testing

Advanced Imaging for EVT Selection

• For suspected LVO within 24 hours: emergent brain + vascular imaging (CT/CTA or MRI/MRA) (COR 1, LOE A)
• CTP or MR DWI-PWI with automated software can be useful for extended window (6–24 h) EVT selection (COR 2a, LOE A)
• For wake-up or unknown onset 4.5–24 h: CTP or MR DWI-PWI selection can be useful for extended window IVT (COR 2a, LOE B-R)

Direct-to-Angio Suite (DTAS)

• For suspected LVO eligible for EVT (e.g., RACE >4), DTAS for flat-panel CT may be considered (COR 2b, LOE B-R)
• For transfer patients with confirmed LVO, DTAS may be considered without repeat imaging (unless clinical change or transfer delay) (COR 2b, LOE B-NR)

Other Diagnostic Tests

• Baseline ECG is recommended but should NOT delay IVT/EVT (COR 1, LOE C-LD)
• Baseline troponin is recommended but should NOT delay IVT/EVT (COR 1, LOE B-NR)
• Only glucose testing is required before IVT

3. Intravenous Thrombolysis (IVT)

Thrombolysis Decision-Making

• In eligible patients within 4.5 hours, initiate treatment as quickly as possible (COR 1)
• Do NOT delay IVT for advanced imaging in the standard window
• Treat disabling deficits regardless of NIHSS score within 4.5 hours without advanced imaging selection

Choice of Thrombolytic Agent

• Tenecteplase 0.25 mg/kg (max 25 mg) OR alteplase 0.9 mg/kg (max 90 mg) — both recommended (COR 1, LOE A)
• Tenecteplase 0.4 mg/kg is NOT recommended — no additional benefit, potential harm (COR 3: No Benefit, LOE A)
• TNK advantages: single bolus, easier administration, may reduce DTN times

Extended Time Windows for IVT

• Unknown onset within 4.5 h of symptom recognition + DWI lesion <⅓ MCA territory + no FLAIR hyperintensity: IVT can be beneficial (COR 2a, LOE B-R)
• Wake-up stroke within 9 h from midpoint of sleep OR 4.5–9 h from LKW + salvageable penumbra on perfusion imaging: IVT may be reasonable (COR 2a, LOE B-R)
• LVO with salvageable penumbra, 4.5–24 h, who cannot receive EVT: IVT may be beneficial if directed by thrombolysis experts (COR 2b, LOE B-R)

Other IV Fibrinolytics

• IV reteplase (instead of alteplase) may be considered within 4.5 h if not undergoing EVT (COR 2b, LOE B-R)
• IV mutant prourokinase (instead of alteplase) may be considered (COR 2b, LOE B-R)
• IV desmoteplase: NOT recommended (COR 3: No Benefit)
• IV streptokinase: Should NOT be administered — causes harm (COR 3: Harm, LOE A)
• Sonothrombolysis as adjunct to IVT: NOT recommended (COR 3: No Benefit, LOE A)

IVT + EVT

• In patients eligible for both, IVT is safe and recommended (COR 1, LOE A)
• IVT should be administered rapidly WITHOUT observation to assess clinical response or delay EVT (COR 1, LOE A)
• Do NOT skip IVT to facilitate EVT — "drip-and-ship" remains appropriate

Non-Disabling Deficits

• For non-disabling deficits (e.g., isolated sensory syndrome) within 4.5 h, trials failed to show benefit
• DAPT preferred in this population

4. Endovascular Thrombectomy (EVT)

Anterior Circulation — Standard Window (0–6 hours)

• ICA or M1 occlusion, NIHSS ≥6, pre-stroke mRS 0–1, ASPECTS 3–10: EVT recommended (COR 1, LOE A)
• Age <80, NIHSS ≥6, pre-stroke mRS 0–1, ASPECTS 0–2, no significant mass effect: EVT is reasonable (COR 2a, LOE B-R)
• Pre-stroke mRS 2: EVT is reasonable to reduce accumulated disability (COR 2a)

Anterior Circulation — Extended Window (6–24 hours)

• ICA or M1 occlusion, NIHSS ≥6, pre-stroke mRS 0–1, ASPECTS ≥6: EVT recommended (COR 1, LOE A)
• Age <80, NIHSS ≥6, pre-stroke mRS 0–1, ASPECTS 3–5, no significant mass effect: EVT recommended (COR 1, LOE A)

Posterior Circulation (Basilar Artery)

• Basilar occlusion, pre-stroke mRS 0–1, NIHSS ≥10, PC-ASPECTS ≥6, within 24 hours: EVT recommended (COR 1, LOE A)

Medium/Distal Vessel Occlusions

• Dominant proximal M2 division: EVT is reasonable, but benefit is uncertain (COR 2a, LOE B-NR)
• Nondominant/codominant proximal M2, distal MCA, ACA, or PCA: EVT is NOT recommended (COR 3: No Benefit, LOE A)

Endovascular Techniques

• Stent retrievers, contact aspiration, or combination techniques are recommended (COR 1, LOE A)
• Target reperfusion: eTICI 2b/2c/3 as early as possible (COR 1, LOE A)
• General anesthesia or procedural sedation are both acceptable (COR 1, LOE B-R)
• Tandem lesions: acute extracranial stenting may be reasonable (COR 2b, LOE B-NR)
• Rescue intracranial angioplasty/stenting for failed EVT: uncertain benefit (COR 2b)
• Adjunctive IA thrombolytics (urokinase, alteplase, TNK) post-mTICI 2b+ may be reasonable (COR 2b, LOE B-R)
• Preoperative tirofiban before EVT: NOT useful (COR 3: No Benefit)

5. Blood Pressure Management

General

• Correct hypotension and hypovolemia to maintain systemic perfusion (COR 1, LOE C-LD)
• Treat hypertension if required by comorbid conditions (ACS, heart failure, aortic dissection, sICH, preeclampsia) (COR 1, LOE C-EO)
• BP ≥220/120 without IVT/EVT and no urgent indication: benefit of treatment within 48–72 h is uncertain (COR 2b)
• BP <220/120 without IVT/EVT and no urgent indication: treatment within 48–72 h is NOT effective (COR 3: No Benefit, LOE A)

Before Reperfusion

• Lower BP to <185/110 mmHg before IVT (COR 1, LOE B-NR)
• Maintain BP ≤185/110 mmHg before EVT (COR 2a, LOE B-NR)

After IVT

• Maintain BP <180/105 mmHg for at least 24 hours (COR 1, LOE B-R)
• Intensive SBP <140 mmHg (vs <180) is NOT recommended — no improvement in functional outcome (COR 3: No Benefit, LOE B-R)

After EVT

• Maintain BP ≤180/105 mmHg during and for 24 hours after EVT (COR 2a, LOE B-NR)
• Intensive SBP <140 mmHg after successful EVT (mTICI 2b/2c/3) is HARMFUL — causes worse outcomes, higher mortality (COR 3: Harm, LOE A)

6. Blood Glucose Management

• Treat hypoglycemia (<60 mg/dL) (COR 1, LOE C-LD)
• Treat hyperglycemia to achieve levels of 140–180 mg/dL (COR 2a, LOE C-LD)
• Intensive glucose control (80–130 mg/dL) is NOT recommended — does not improve outcomes, increases severe hypoglycemia (COR 3: No Benefit)

7. Temperature Management

• Target normothermia in patients with hyperthermia, including nurse-initiated protocols (COR 1, LOE B-R)
• Identify and treat sources of hyperthermia (e.g., infection) (COR 1, LOE C-EO)
• Induced hypothermia: NOT recommended (COR 3: No Benefit, LOE B-R)

8. Antiplatelet Treatment

• Aspirin within 24–48 h of AIS onset is recommended (COR 1, LOE A)
• Delay aspirin for 24 h after IVT (COR 1)
• Minor non-cardioembolic AIS (NIHSS ≤5) or high-risk TIA (ABCD2 ≥4), 24–72 h from onset, with presumed atherosclerotic cause (≥50% stenosis): DAPT × 21 days then SAPT is reasonable (COR 2a)

9. Anticoagulation

Acute Phase

• Urgent anticoagulation to prevent early recurrence is NOT recommended for most patients (COR 3: No Benefit)
• Urgent anticoagulation to prevent DVT is NOT recommended if at risk for hemorrhagic conversion (COR 3: Harm)

Atrial Fibrillation

• In carefully selected (milder severity) patients with AIS and AF: early oral anticoagulation is low risk and reasonable vs delayed strategy (COR 2a)
• Efficacy of early anticoagulation for preventing early recurrent stroke is not established
• CATALYST meta-analysis: Early DOAC (≤4 days) reduced recurrent ischemic stroke at 30 days vs later (≥5 days) without increased sICH

Adjunctive Anticoagulation with IVT

• Argatroban or eptifibatide with IVT: NOT recommended (COR 3: No Benefit)

10. In-Hospital Management

Stroke Units

• Admit to stroke unit for coordinated multidisciplinary care (COR 1, LOE A)

Dysphagia

• Dysphagia screening before oral intake is recommended (COR 1, LOE B-NR)
• Pharyngeal electrical stimulation (PES) can be beneficial to reduce dysphagia severity and aspiration risk (COR 2a)

Nutrition

• Enteral feeding within 7 days of admission is reasonable (COR 2a)
• NGT vs PEG: no clear superiority in early phase

DVT Prophylaxis

• Intermittent pneumatic compression (IPC) for immobile patients (COR 1, LOE B-R)
• Prophylactic-dose subcutaneous heparin or LMWH may be considered (COR 2b)
• Elastic compression stockings alone: NOT recommended (COR 3: No Benefit)

Depression

• Screen for depression (COR 1, LOE B-NR)
• Treat depression when identified (COR 1, LOE B-R)

11. Acute Complications

Cerebral Edema — Medical Management

• Osmotic therapy (mannitol, hypertonic saline) is reasonable for deterioration from edema (COR 2a, LOE C-LD)
• Brief hyperventilation is reasonable for acute herniation (COR 2a, LOE C-EO)
• IV glibenclamide for large hemispheric infarction: NOT recommended (COR 3: No Benefit)
• Corticosteroids for ischemic brain edema: NOT recommended (COR 3: No Benefit)

Supratentorial Infarction — Surgical Management

• Decreased LOC attributed to brain swelling is a reasonable trigger for decompressive craniectomy selection (COR 2a, LOE B-NR)
• Age ≤60 years, unilateral MCA infarction, neurological deterioration within 48 h despite medical therapy: decompressive craniectomy with dural expansion is beneficial (COR 1, LOE A)
• Age >60 years: decompressive craniectomy may be considered to reduce mortality (but functional outcomes remain poor) (COR 2b, LOE B-R)
• Post-IVT malignant edema: early decompressive craniectomy within 48 h may still be considered without additional safety concerns (COR 2b, LOE B-NR)

Cerebellar Infarction — Surgical Management

• Obstructive hydrocephalus: ventriculostomy is recommended (COR 1, LOE C-LD)
• Neurological deterioration from brainstem compression or volume ≥35 mL: decompressive suboccipital craniectomy with dural expansion should be performed (COR 1, LOE B-NR)

Seizures

• Unprovoked seizure after AIS: antiseizure medication is recommended (COR 1, LOE C-LD)
• Prophylactic antiseizure medication: NOT recommended (COR 3: No Benefit)

12. Pediatric Stroke (New Section)

Prehospital

• Common adult stroke screening tools perform poorly in children (COR 2b)
• Newer pediatric stroke screening tools show good interrater reliability but require validation

Imaging

• MRI/MRA is reasonable for suspected AIS to identify LVO and differentiate from hemorrhage or mimics (COR 2a)
• CT/CTA is reasonable if MRI not available within 25 minutes (COR 2a)

Thrombolysis

• Pediatric patients (28 days–18 years) with confirmed AIS within 4.5 h and disabling deficits: IVT with alteplase may be considered — safe but efficacy uncertain (COR 2b)
• TNK appears safe in limited pediatric data (n=11)

Endovascular Thrombectomy

• Age ≥6 years, LVO, within 6 h: EVT can be effective if performed by experienced neurointerventionalists (COR 2a)
• Age ≥6 years, LVO, 6–24 h with salvageable tissue: EVT can be effective (COR 2a)
• Age 28 days–6 years, LVO including first-time seizure, within 24 h with salvageable tissue: EVT may be reasonable by neurointerventionalists with pediatric experience (COR 2b)

Reference

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. 2026;57:e00–e00. doi: 10.1161/STR.0000000000000513