What are the key updates in the 2026 acute ischemic stroke guideline?

2026 Acute Ischemic Stroke Guidelines: Key Updates

Critical New Evidence on Thrombolytic Selection

The 2026 AHA/ASA guidelines now incorporate new evidence on thrombolytic choice, moving beyond the traditional alteplase-only approach. 1 This represents a significant shift from the 2018 guidelines, with tenecteplase emerging as an alternative cornerstone therapy alongside alteplase. 2

Expanded Thrombolysis Eligibility Criteria

The 2026 guidelines have modified the approach to thrombolysis contraindications, expanding treatment eligibility for patients previously excluded. 1 Key changes include:

• Revised contraindication framework that allows more patients to receive life-saving reperfusion therapy 1
• The boundaries for intravenous thrombolysis have been extended beyond the traditional 3-hour window in carefully selected patients 2
• Treatment decisions now incorporate advanced imaging to identify salvageable brain tissue rather than relying solely on time-based criteria 1

Enhanced Endovascular Thrombectomy Selection

New evidence has refined the determination of eligibility for endovascular thrombectomy, allowing treatment in broader patient populations. 1 The 2026 guidelines now address:

• Expanded time windows for mechanical thrombectomy based on advanced imaging selection 2
• Both anterior and posterior circulation large vessel occlusions are now standard indications for endovascular treatment 2
• More precise criteria for patient selection using perfusion imaging and collateral assessment 1

Hyperglycemia Management Protocol

The 2026 guidelines provide specific new recommendations for managing hyperglycemia in acute stroke patients. 1 This addresses a critical gap from previous guidelines:

• Hyperglycemia requires prompt measurement and correction, as it can worsen stroke outcomes 3
• Specific glucose targets and management protocols are now defined (though the exact thresholds should be referenced in the full guideline) 1

Dysphagia Screening and Management

New evidence-based protocols for dysphagia assessment and management are incorporated. 1 Key points include:

• Mandatory swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 4, 3
• Early screening by speech-language pathologists is now a formal recommendation 3
• Specific timing and protocols for dysphagia screening are defined 1

Pediatric Stroke Considerations

For the first time, the 2026 guidelines include a focused consideration of the pediatric population with acute ischemic stroke. 1 This represents a major expansion:

• Previously, pediatric stroke management relied on extrapolation from adult data 1
• Age-specific dosing and safety considerations are now addressed 1
• Recognition that stroke in children requires specialized protocols 1

Imaging and Diagnostic Updates

Advanced imaging modalities are now integrated into treatment algorithms rather than being optional. 1 Specific updates include:

• CT perfusion and MRI perfusion/diffusion imaging are recommended for patient selection beyond traditional time windows 5
• Noninvasive intracranial vascular imaging (CTA or MRA) is strongly recommended when endovascular therapy is contemplated 5
• Brain imaging must be interpreted within 45 minutes of ED arrival by an expert 5

Blood Pressure Management Refinements

The 2026 guidelines maintain but clarify blood pressure targets:

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving reperfusion therapy 6, 4
• For thrombolysis candidates: BP must be <185/110 mmHg before treatment and maintained ≤180/105 mmHg for 24 hours after 6, 4
• Permissive hypertension allows cerebral perfusion through collaterals 6, 4

Stroke Unit Care Standards

All stroke patients must be admitted to geographically defined stroke units with specialized interdisciplinary teams. 6, 4, 3 This remains a Class I recommendation:

• The multidisciplinary team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 4, 3
• Specialized nursing staff with stroke expertise is mandatory 6

Antiplatelet Therapy Timing

Clear protocols for antiplatelet administration:

• Aspirin 325 mg should be given within 24-48 hours after stroke onset for patients NOT receiving thrombolysis 6, 4
• Absolute prohibition of aspirin or antiplatelet agents within 24 hours of IV thrombolysis 6, 4

Critical Pitfalls Explicitly Addressed

The 2026 guidelines explicitly state what NOT to do:

• Do NOT use volume expansion, vasodilators, or induced hypertension — decades of research show no benefit 6, 4
• Do NOT use neuroprotective agents — none have demonstrated efficacy 6, 4, 3
• Do NOT delay transfer to comprehensive stroke center if neurosurgical evaluation is needed 6
• Do NOT delay emergency treatment to obtain multimodal imaging studies 5

Time-Critical Performance Metrics

Every 30-minute delay in treatment reduces probability of favorable outcome by approximately 10.6%. 6, 4 This emphasizes:

• Door-to-needle time must be minimized at all costs 6
• Groin puncture for thrombectomy should be initiated within 6 hours when criteria are met 6
• Prehospital notification of receiving hospitals is mandatory 5

Secondary Prevention Initiation

Early workup requirements include:

• Transthoracic echocardiography to assess for cardioembolic sources 6, 4
• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are revascularization candidates 6, 4, 3
• Continuation of statin therapy during acute period for patients already on statins 3

Quality Improvement Mandates

The 2026 guidelines emphasize systematic quality monitoring:

• In-hospital stroke performance data must be examined and used for quality improvement 3
• Metrics include stroke alert numbers, response times, imaging times, treatment rates, and outcomes 3
• Reporting to stroke registries is recommended for monitoring true incidence 3