What are the updated 2026 guidelines for managing acute ischemic stroke in patients, including treatment options and secondary prevention measures?

Updated 2025-2026 Stroke Management Guidelines

Acute Ischemic Stroke: Intravenous Thrombolysis

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 3 hours of clearly defined symptom onset, with 10% given as bolus over 1 minute and 90% infused over 60 minutes. 1, 2, 3

Time Windows for Thrombolysis

• 0-3 hours: Strong recommendation for IV alteplase in all eligible patients 4, 1, 5
• 3-4.5 hours: IV alteplase is recommended for selected patients with additional exclusion criteria: age >80 years, oral anticoagulant use regardless of INR, baseline NIHSS >25, imaging showing >1/3 MCA territory involvement, or history of both diabetes and prior stroke 4, 3
• >4.5 hours: IV alteplase is not recommended 5

Critical Time Targets

Achieve door-to-needle time <60 minutes in 90% of treated patients—every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%, and every 30-minute delay reduces probability of favorable outcome by approximately 10.6%. 4, 1, 3

Blood Pressure Management for Thrombolysis

• Before rtPA: BP must be reduced to <185/110 mmHg 4, 1, 2, 3
• During and 24 hours after rtPA: Maintain BP ≤180/105 mmHg 4, 1, 2, 3
• Monitor BP every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours post-treatment 4, 3

Absolute Contraindications to rtPA

• Significant head trauma or prior stroke in previous 3 months 4
• Symptoms suggesting subarachnoid hemorrhage 4
• History of intracranial hemorrhage 4
• Intracranial neoplasm, arteriovenous malformation, or aneurysm 4
• Arterial puncture at non-compressible site in previous 7 days 4

Post-Thrombolysis Monitoring

• Delay antiplatelet agents and anticoagulants for 24 hours after rtPA due to increased bleeding risk 3, 5
• Obtain follow-up CT at 24 hours before starting antithrombotics 4, 3
• Symptomatic intracranial hemorrhage occurs in approximately 6.4% of rtPA-treated patients 3

Endovascular Thrombectomy (EVT)

Proceed with mechanical thrombectomy using stent retriever devices for patients with large vessel occlusions (internal carotid, middle cerebral, or basilar artery) who meet ALL criteria: prestroke mRS 0-1, NIHSS ≥6, ASPECTS ≥6, and groin puncture can be initiated within 6 hours of symptom onset. 1, 3

• Obtain CT angiography immediately to identify large vessel occlusions, but do not delay thrombolysis for this imaging 2, 3
• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers based on recent trial data 3
• Do not delay IV alteplase even if EVT is planned—both therapies are complementary 3

Blood Pressure Management in Non-Thrombolysis Candidates

Ischemic Stroke Without Thrombolysis

• For BP <220/120 mmHg: Withhold antihypertensive medications 1, 2
• For BP >220/120 mmHg: Reduce BP by approximately 15% (not more than 25%) over the first 24 hours 2, 3
• Avoid aggressive BP lowering as this may exacerbate ischemia 2

Hemorrhagic Stroke

• Target systolic BP 140-160 mmHg with more aggressive lowering than in ischemic stroke 2
• In ICH patients with hypertension history, maintain mean arterial pressure <130 mmHg 3

Antiplatelet Therapy

Acute Phase

• For patients NOT receiving thrombolysis: Administer oral aspirin 160-325 mg within 24-48 hours of stroke onset 1, 2, 5
• For patients receiving rtPA: Do not administer aspirin within 24 hours of treatment; wait for 24-hour CT to exclude hemorrhage 2, 3

Minor Stroke or High-Risk TIA

For patients with minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), initiate dual antiplatelet therapy (DAPT) with aspirin 81 mg daily plus clopidogrel 75 mg daily as early as possible, ideally within 12-24 hours after excluding intracranial hemorrhage on neuroimaging. 4

• Give loading doses: aspirin 160-325 mg and clopidogrel 300-600 mg 4
• Continue DAPT for 21 days, then transition to single antiplatelet therapy 4
• Alternative regimen: aspirin 75-100 mg daily plus ticagrelor 90 mg twice daily for 30 days 4

Long-Term Secondary Prevention

• Recommended single antiplatelet agents: aspirin 50-100 mg daily, aspirin/extended-release dipyridamole 25/200 mg twice daily, or clopidogrel 75 mg daily 4, 5
• Avoid long-term combination of aspirin plus clopidogrel due to increased bleeding risk without additional benefit 5

Supportive Care

Temperature Management

• Monitor temperature routinely and treat if >37.5-38°C 1, 2
• Identify and treat sources of hyperthermia 1

Oxygen and Airway

• Provide supplemental oxygen only to maintain saturation >94% 1, 2
• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1

Glucose Management

• Treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia 1, 2
• Treat hyperglycemia to achieve blood glucose 140-180 mg/dL 1, 2

Fluid Management

• Correct hypovolemia with intravenous normal saline 1

Stroke Unit Care and Rehabilitation

Admit all stroke patients to a geographically defined stroke unit with specialized nursing staff—this reduces mortality and disability across all stroke types, ages, and severities. 1, 3

• Begin frequent brief mobilization within 24 hours if no contraindications 3
• Initiate comprehensive rehabilitation as early as medically possible 1, 2

Secondary Prevention

Cardiac Evaluation

• Perform ECG on all patients, but do not delay thrombolysis assessment 1, 2
• Obtain transthoracic echocardiography to assess for cardioembolic sources 3
• For suspected cardioembolic stroke without initial atrial fibrillation evidence, perform prolonged ECG monitoring up to 30 days 2

Risk Factor Management

• Initiate statin therapy for lipid lowering regardless of baseline levels 3
• Begin antihypertensive therapy for long-term BP control before discharge 3
• For intracranial atherosclerotic stenosis (50-99%): target systolic BP <140 mmHg, use high-dose statin therapy, and recommend at least moderate physical activity 4

Anticoagulation for Atrial Fibrillation

• For patients with atrial fibrillation and recent stroke/TIA, initiate long-term oral anticoagulation (target INR 2.5, range 2.0-3.0) 5

Critical Pitfalls to Avoid

• Never delay thrombolysis for advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 3
• Do not use full-dose anticoagulation (IV or subcutaneous heparin) in acute ischemic stroke as it increases hemorrhage risk without improving outcomes 3
• Do not delay nasogastric tubes, bladder catheters, or arterial lines can be delayed if patient can be safely managed without them during the first 24 hours post-rtPA 4
• Do not assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis—they may reflect the stroke pathology itself 3