What is the recommended acute management for an adult presenting in 2026 with an acute ischemic stroke?

Acute Ischemic Stroke Management in 2026

For adults presenting with acute ischemic stroke in 2026, immediately administer IV tenecteplase (preferred over alteplase) within 3-4.5 hours of symptom onset for eligible patients, and perform endovascular thrombectomy for large vessel occlusions up to 24 hours using perfusion imaging selection in extended windows. 1, 2

Immediate Assessment (First 10 Minutes)

• Stabilize airway, breathing, and circulation while simultaneously beginning stroke evaluation 3, 4
• Provide supplemental oxygen only if SpO2 < 94%—avoid routine oxygen therapy in non-hypoxic patients 5, 4
• Establish IV access and draw blood for: complete blood count, PT/INR, aPTT, metabolic panel, glucose, and cardiac biomarkers 3, 4
• Perform 12-lead ECG to detect atrial fibrillation or acute MI as stroke sources 3, 4
• Determine exact time last known well—this is when the patient was last at baseline, not when symptoms were discovered 3, 4
• Assess stroke severity using the NIHSS score to guide treatment decisions 3

Neuroimaging Protocol

• Obtain non-contrast head CT within 25 minutes of arrival and interpret within 45 minutes 3, 4
• The CT must exclude intracranial hemorrhage before thrombolysis 3, 4
• Do not delay IV thrombolysis to obtain CT angiography or perfusion imaging in patients presenting within 3-4.5 hours 4
• Early ischemic changes involving >1/3 cerebral hemisphere do not preclude rtPA when treatment starts within 3 hours 4
• Obtain CT angiography to identify large vessel occlusions for potential thrombectomy, but only if it does not delay IV thrombolysis 4, 1
• Use perfusion imaging (CT perfusion or multimodal MRI) for patient selection in the 6-24 hour window to identify salvageable tissue 1, 6

Blood Pressure Management

For Thrombolysis Candidates:

• Blood pressure must be < 185/110 mmHg before initiating thrombolysis 5, 4
• If BP is 185-230 systolic or 105-120 diastolic, use IV labetalol 10-20 mg (repeat once) or IV nicardipine starting at 5 mg/h, titrating by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h 4
• Do not give thrombolysis if BP cannot be reduced to < 185/110 mmHg 4
• After thrombolysis, maintain BP < 180/105 mmHg for at least 24 hours 5
• Monitor BP every 15 minutes for first 2 hours, then every 30 minutes for next 6 hours, then hourly until 24 hours 4

For Non-Thrombolysis Patients:

• Practice permissive hypertension for 48-72 hours—only treat if BP > 220/120 mmHg 5, 4
• When treatment is indicated, reduce BP by 15-25% within the first 24 hours 4
• Never use sublingual nifedipine—it causes uncontrollable precipitous drops that compromise cerebral perfusion 5

Thrombolytic Therapy

Current Standard (2026):

• Tenecteplase is now superior to alteplase based on recent meta-analyses and should be the preferred agent 1, 2
• Administer IV thrombolysis within 3-4.5 hours of symptom onset for eligible patients 3, 5, 4
• Dosing: 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute, remainder over 60 minutes 7
• Thrombolysis is now beneficial up to 24 hours in patients selected using perfusion imaging 1

Absolute Contraindications:

• Recent (≤3 months) head trauma or prior stroke 4
• History of intracranial hemorrhage 4
• Clinical features suggesting subarachnoid hemorrhage 4
• Arterial puncture at non-compressible site within past 7 days 4
• Uncontrolled BP > 185/110 mmHg despite treatment 4
• Active bleeding, platelet count < 100,000/mm³, INR > 1.7, PT > 15 seconds, or recent heparin with elevated aPTT 7, 4

Special Considerations:

• Do not withhold thrombolysis solely because NIHSS ≥ 25—severe stroke patients may still benefit within 4.5 hours 4
• If symptoms are rapidly improving and patient is approaching baseline function, thrombolysis may be withheld, but this requires clinical judgment that the patient is near normal, not merely mildly improved 4
• Seizures at presentation do not preclude thrombolysis if residual deficits are due to ischemia rather than postictal state 7

Endovascular Thrombectomy

• Perform thrombectomy for anterior and posterior circulation large vessel occlusions up to 24 hours 1, 2
• CT angiography identifies medium-large vessel occlusions that trigger thrombectomy consideration 6
• In the 6-24 hour window, use perfusion imaging to identify salvageable brain tissue and select patients likely to benefit 1, 6
• Imaging parameters are prognostic but do not modify relative treatment benefit—deciding who not to treat requires careful integration of clinical, imaging, and patient preference considerations 1
• Ongoing trials are testing more distal occlusions, mild presentations, and >24 hour windows 1

Glucose Management

• Target blood glucose 140-180 mg/dL 5
• Treat hyperglycemia > 140-185 mg/dL with insulin—persistent hyperglycemia during first 24 hours is associated with poor outcomes and increased infarct volume 5
• Treat hypoglycemia immediately to achieve normoglycemia 7

Hospital Care and Monitoring

• Admit to dedicated stroke unit with monitored beds for at least 24 hours 3
• Maintain NPO status until swallow assessment is complete to prevent aspiration 5, 4
• Perform neurological assessments every 15 minutes during thrombolysis infusion, every 30 minutes for next 6 hours, then hourly until 24 hours 7
• Begin venous thromboembolism prophylaxis with intermittent pneumatic compression devices within 24 hours for immobile patients 3
• Initiate early mobilization within 24 hours if no contraindications 3
• Treat fever aggressively as it worsens neurological damage 3

Antiplatelet Therapy

• Delay antiplatelet agents for 24 hours after thrombolysis 7
• For patients not receiving thrombolysis, aspirin initiated within 48 hours provides modest benefit primarily through prevention of recurrent events 7
• The role of clopidogrel or combination antiplatelet therapy in acute stroke has not been established 7

Basilar Artery Occlusion (Special Population)

• For BAO presenting within 4.5 hours without extensive posterior circulation ischemic changes, expert consensus suggests IV thrombolysis 7
• Single-arm data show up to 50% achieve good outcomes (mRS 0-3) with IVT alone when pc-ASPECTS ≥8, regardless of time window up to 48 hours 7
• Endovascular thrombectomy is recommended for BAO within 6 hours 7

Critical Pitfalls to Avoid

• Never delay IV thrombolysis to obtain advanced imaging in patients within the 3-4.5 hour window 4
• Never treat blood pressure aggressively in non-reperfusion patients during first 48-72 hours—this extends infarct size and worsens outcomes 5
• Never use sublingual nifedipine for BP control 5
• Protocol violations during thrombolysis significantly increase risk of symptomatic intracranial hemorrhage and mortality 4
• Do not withhold thrombolysis based solely on severe NIHSS score 4