What are the initial management steps for a patient presenting with acute stroke according to the American Heart Association (AHA) 2026 guidelines?

AHA 2026 Acute Stroke Guidelines: Initial Management

Critical Note on Available Evidence

The evidence provided consists of 2013 AHA/ASA guidelines and 2010 CPR guidelines—there are no actual 2026 AHA guidelines available in the literature at this time. The most recent comprehensive guidance comes from 2025 Praxis Medical Insights summaries, which synthesize current AHA/ASA recommendations. 1, 2, 3

Immediate Prehospital Management

Activate 911/EMS immediately when stroke symptoms are recognized—this is the single most important action that determines whether patients receive treatment within the critical therapeutic window. 1

EMS Personnel Actions:

• Assess and stabilize airway, breathing, and circulation (ABCs) first 4
• Initiate cardiac monitoring immediately 4
• Provide supplemental oxygen to maintain O₂ saturation >94% 4
• Establish IV access per local protocol 4
• Determine blood glucose and treat if abnormal (hypoglycemia is a common stroke mimic) 4
• Determine exact time of symptom onset or last known normal—this is the single most critical piece of information for treatment decisions 4, 3
• Obtain family contact information, preferably cell phone 4
• Triage and rapidly transport to nearest certified stroke center (bypass non-stroke hospitals) 4, 1
• Notify receiving hospital before arrival—this facilitates rapid ED response 4

Critical Prehospital Prohibitions:

• Do NOT initiate antihypertensive interventions unless directed by medical command 4
• Do NOT administer excessive IV fluids 4
• Do NOT give dextrose-containing fluids in non-hypoglycemic patients 4
• Do NOT administer anything by mouth (maintain NPO status) 4
• Do NOT delay transport for prehospital interventions 4

Emergency Department Evaluation

Triage stroke patients with the same priority as acute myocardial infarction or serious trauma, regardless of severity of neurological deficits. 4, 3

Immediate Actions (Within Minutes):

• Stabilize ABCs while simultaneously beginning stroke evaluation protocol 3
• Assess neurological deficits using NIHSS (National Institutes of Health Stroke Scale) 3
• Obtain non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and determine thrombolysis eligibility 1, 3
• Interpret CT within 45 minutes of arrival for thrombolysis candidates 3

Essential Laboratory Tests:

• Complete blood count, electrolytes, renal function tests 1, 3
• Blood glucose (critical—hypoglycemia mimics stroke) 3
• PT/INR and aPTT (coagulation studies) 1, 3
• 12-lead ECG (high incidence of cardiac disease in stroke patients) 3

Advanced Imaging (Selected Cases):

• Consider CT angiography and CT perfusion to evaluate vessel status and cerebral blood flow for mechanical thrombectomy candidates 3

Acute Reperfusion Therapy

IV Thrombolysis (tPA/Alteplase):

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if patient presents within 3 hours of clearly defined symptom onset—10% given as bolus, remainder infused over 60 minutes. 1, 3

Blood pressure MUST be reduced to <185/110 mmHg BEFORE alteplase administration and maintained ≤180/105 mmHg during and for 24 hours after treatment. 1, 2

Mechanical Thrombectomy:

Proceed with mechanical thrombectomy using stent retriever devices if ALL criteria met: 1

• Prestroke modified Rankin Scale (mRS) 0-1
• Large vessel occlusion confirmed on CTA
• Age ≥18 years
• NIHSS ≥6
• ASPECTS (Alberta Stroke Program Early CT Score) ≥6
• Groin puncture can be initiated within 6 hours

Every 30-minute delay reduces probability of favorable outcome by approximately 10.6%—time is absolutely critical. 1

Hospital Admission and Monitoring

Admit ALL acute stroke patients to a specialized stroke unit with continuous monitoring capabilities—this intervention provides mortality and morbidity benefits comparable to IV thrombolysis itself. 4, 2

Stroke Unit Requirements:

• Geographically defined facility 2
• Specialized interdisciplinary staff (physicians, nurses, rehabilitation personnel) 2
• Regular communication and coordinated care 2

Neurological Monitoring:

• NIHSS every 15 minutes during thrombolysis 2
• Hourly for 6 hours post-thrombolysis 2
• Every 2 hours for 18 hours thereafter 2

Vital Signs Management:

For patients who received IV tPA: maintain BP <180/105 mmHg for at least 24 hours post-thrombolysis. 2

For patients who did NOT receive thrombolysis: only treat BP if systolic >220 mmHg or diastolic >120 mmHg—permissive hypertension maintains cerebral perfusion through collaterals. 1, 2

Monitor temperature every 4 hours for first 48 hours and treat fever aggressively if temperature exceeds 37.5°C (99.5°F) with acetaminophen and cooling measures—hyperthermia worsens neurological damage. 2

Swallowing Assessment and Nutrition

Keep patient NPO until formal swallowing assessment completed. 2

Perform bedside swallowing screen (water swallow test) within 24 hours before allowing any oral intake. 2

High-risk patients for aspiration: brainstem infarctions, multiple strokes, major hemispheric lesions, depressed consciousness, dysphonia, cranial nerve palsies, high NIHSS scores. 2

Maintain euvolemia with IV normal saline at maintenance rate (75-100 mL/hr) until swallowing cleared—dehydration increases DVT risk. 2

If swallowing impaired beyond 24-48 hours, consider nasogastric tube or early PEG placement. 2

Antiplatelet Therapy

Administer aspirin 325 mg orally within 24-48 hours after stroke onset for patients NOT receiving thrombolysis. 1

Do NOT give aspirin or other antiplatelet agents within 24 hours of IV thrombolysis—wait for 24-hour repeat head CT to exclude hemorrhage. 1, 2

Venous Thromboembolism Prophylaxis

Apply intermittent pneumatic compression devices to both legs within 24 hours. 2

Consider subcutaneous heparin 5000 units every 8-12 hours or enoxaparin 40 mg daily after 24 hours if no hemorrhagic transformation on repeat imaging. 2

Do NOT use subcutaneous heparin in first 24 hours after thrombolysis due to bleeding risk. 2

Mobilization and Rehabilitation

Begin early mobilization within 24 hours if patient stable—initial bed rest with head of bed flat or at 30 degrees (avoid extreme head elevation which may reduce cerebral perfusion). 2

Physical therapy, occupational therapy, and speech therapy consultations within 24 hours—early rehabilitation lessens complications including pneumonia, DVT, pulmonary embolism, pressure sores, contractures, and orthopedic complications. 2

Glucose Management

Check fingerstick glucose every 6 hours for first 24 hours. 2

Maintain glucose 140-180 mg/dL; treat if >180 mg/dL with sliding scale insulin. 2

Secondary Prevention Initiation

Start high-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg daily) regardless of baseline LDL. 2

Obtain transthoracic echocardiography to assess for cardioembolic sources. 1

Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates. 1

Repeat Imaging

Repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation, especially if thrombolysis given. 2

Critical Pitfalls to Avoid

Do NOT aggressively lower blood pressure in acute stroke unless specific criteria met—permissive hypertension allows cerebral perfusion to penumbra. 2

Do NOT give oral medications, food, or water before swallowing assessment—aspiration pneumonia significantly worsens outcomes. 2

Do NOT use volume expansion, vasodilators, or induced hypertension—these have been studied for decades without proven benefit. 1

Do NOT use neuroprotective agents—none have demonstrated efficacy in improving outcomes. 1

Do NOT delay mobilization beyond 24 hours unless contraindicated—prolonged immobility increases complications. 2

Do NOT delay transfer to comprehensive stroke center if patient requires neurosurgical evaluation. 1

Stroke Mimics to Consider

Common conditions that mimic stroke include: 4

• Seizures (postictal period)
• Hypoglycemia (check glucose immediately)
• Migraine with aura (complicated migraine)
• Hypertensive encephalopathy
• CNS abscess (fever, drug abuse history)
• CNS tumor (gradual progression)
• Drug toxicity (lithium, phenytoin, carbamazepine)