Summarize the 2026 American Heart Association/American Stroke Association guideline for early management of acute ischemic stroke.

2026 AHA/ASA Acute Ischemic Stroke Guidelines Summary

Note: The evidence provided contains 2013 AHA/ASA guidelines, not 2026 guidelines. The most recent comprehensive guideline update available in the evidence is from 2013, with subsequent updates through 2019. 1, 2 The following summary reflects the current state of evidence-based acute ischemic stroke management based on these AHA/ASA recommendations.

Core Principle: Time-Critical Reperfusion

Intravenous alteplase 0.9 mg/kg (maximum 90 mg) administered within 3-4.5 hours of symptom onset is the single most critical intervention for acute ischemic stroke, with every 30-minute delay reducing favorable outcomes by 10.6%. 3, 4, 5

Prehospital and Emergency Response

EMS Activation and Transport

• Activate 911/EMS immediately when stroke symptoms are recognized—EMS use is strongly associated with faster hospital arrival and treatment within the critical therapeutic window. 4
• EMS should bypass hospitals without stroke treatment resources and transport directly to the closest facility capable of acute stroke care (Class I, Level B). 1
• Triage stroke patients with the same priority as acute myocardial infarction or serious trauma, regardless of neurological deficit severity. 1

Stroke Systems of Care

• Creation of Primary Stroke Centers (PSCs) is recommended (Class I, Level B), with certification by independent external bodies such as The Joint Commission or state health departments. 1
• Teleradiology systems approved by the FDA are recommended for sites without in-house imaging interpretation expertise to enable timely review of brain CT and MRI scans (Class I, Level B). 1

Emergency Department Evaluation

Critical Time Targets

• Obtain non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes. 3
• Complete CT interpretation within 45 minutes for thrombolytic candidates (door-to-interpretation time). 3
• Determine the exact time of last known well—this is the zero-hour for all treatment decisions. 3

Immediate Diagnostic Workup

• Obtain fingerstick glucose immediately to rule out hypoglycemia as a stroke mimic. 3
• Calculate NIHSS score to quantify stroke severity and guide treatment intensity. 3
• Perform complete blood count, electrolytes, renal function, glucose, coagulation studies, and ECG concurrently with imaging. 4, 5
• Add CT angiography if considering endovascular thrombectomy to identify large vessel occlusion. 3

Stroke Mimics to Exclude

• Hypoglycemia: History of diabetes, low serum glucose, decreased level of consciousness. 1
• Seizures with Todd's paralysis: History of seizures, witnessed seizure activity, postictal period. 1, 3
• Complicated migraine: History of similar events, preceding aura, headache. 1
• Hypertensive encephalopathy: Headache, delirium, significant hypertension, cortical blindness, cerebral edema. 1

Intravenous Thrombolysis Protocol

Eligibility and Administration

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if symptom onset is within 3 hours (Class I, Level A), with extended window to 4.5 hours in selected patients. 3, 4, 5
• Dosing: 10% as bolus over 1 minute, remaining 90% infused over 60 minutes. 3
• Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%. 3

Blood Pressure Requirements for Thrombolysis

• Reduce systolic/diastolic pressure to <185/110 mmHg BEFORE initiating alteplase (Class I, Level B). 3, 4, 5
• Maintain blood pressure ≤180/105 mmHg throughout the alteplase infusion and for the subsequent 24 hours (Class I, Level B). 3, 4, 5

Critical Contraindications

• Do NOT give aspirin or other antiplatelet agents within 24 hours of IV thrombolysis—this increases hemorrhage risk. 3, 4, 5
• Do NOT postpone intravenous thrombolysis to obtain advanced multimodal imaging (e.g., perfusion CT or MRI)—rapid treatment is critical (Class III, Level B). 3

Blood Pressure Management (Non-Thrombolysis Patients)

Permissive Hypertension Strategy

• Permissive hypertension is recommended in acute ischemic stroke unless thrombolysis is planned or systolic/diastolic pressure exceeds 220/120 mmHg—aggressive lowering may jeopardize penumbral perfusion (Class III, Level A). 3
• If systolic/diastolic pressure is <220/120 mmHg, antihypertensive therapy initiated within the first 48-72 hours does not reduce death or dependency (Class III, Level A). 3
• When pressure is ≥220/120 mmHg, a modest reduction of approximately 15% during the first 24 hours may be considered, but the benefit is uncertain (Class IIb, Level C). 3

Mechanical Thrombectomy

Eligibility Criteria (ALL Must Be Met)

• Prestroke modified Rankin Scale (mRS) score 0-1 3, 4
• Causative large vessel occlusion confirmed on CT angiography 3, 4
• Age ≥18 years 3
• NIHSS score ≥6 3, 4
• ASPECTS score ≥6 3, 4
• Groin puncture can be initiated within 6 hours of symptom onset 3, 4

Technical Requirements

• Use stent retriever devices (Solitaire, Trevo)—these are superior to older coil retrievers based on multiple randomized trials (MR CLEAN, ESCAPE, SWIFT PRIME). 3
• Delivery mandates qualified interventionalists and comprehensive stroke-center resources (Class I, Level C). 3

Intra-Arterial Thrombolysis

• Intra-arterial thrombolysis may be considered for patients with major middle-cerebral-artery occlusion presenting <6 hours after symptom onset who are ineligible for IV alteplase (Class I, Level C). 3
• This approach requires an experienced stroke center with immediate angiography capability and qualified interventionalists. 3
• Availability of intra-arterial therapy should not preclude the use of IV alteplase in eligible patients (Class III, Level C). 3

Antiplatelet Therapy

Aspirin Administration

• Start aspirin 325 mg within 24-48 hours after stroke onset (or after repeat CT if thrombolysis was given)—this timing is Class I, Level A. 3, 4, 5
• Aspirin's primary benefit is reduction of early recurrent stroke rather than mitigation of the initial neurological injury. 3
• Aspirin is not a substitute for intravenous alteplase in patients who meet thrombolysis criteria. 3

Agents NOT Recommended

• Clopidogrel alone or in combination with aspirin is not recommended for acute ischemic stroke (Class III, Level C). 3
• Intravenous glycoprotein IIb/IIIa inhibitors are not recommended outside clinical trials (Class III, Level B). 3

Anticoagulation in the Acute Phase

Full-dose unfractionated heparin or low-molecular-weight heparin should NOT be used for acute ischemic stroke—they do not improve outcomes and increase hemorrhage risk (Class III, Level A). 3

Evidence Against Acute Anticoagulation

• Emergency anticoagulation does not lower the risk of early recurrent stroke, even in cardioembolic sources (Class III, Level B). 3
• Anticoagulation does not prevent early neurological worsening (Class III, Level B). 3
• Most randomized trials have failed to demonstrate a benefit of acute-phase anticoagulation on functional outcomes (Class III, Level B). 3

Hospital Admission and Stroke Unit Care

Stroke Unit Requirements

• Admit ALL stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff (Class I, Level B). 3, 4, 5
• Stroke unit care reduces mortality and morbidity comparably to the effects of alteplase itself. 3
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists. 5

Quality Improvement

• Healthcare institutions should organize a multidisciplinary quality improvement committee to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes (Class I, Level B). 1

Monitoring and Supportive Care

Respiratory Management

• Maintain peripheral oxygen saturation ≥92% using pulse-oximetry; provide supplemental oxygen only when saturation falls below 94% (Class I, Level B). 3
• Immediately intubate patients who develop neurological deterioration with respiratory insufficiency to protect the airway and maintain adequate oxygenation. 5

Temperature Management

• Check core temperature every 4 hours for the first 48 hours and treat fever promptly (target ≤37.5°C) (Class I, Level A)—fever reduction in the acute phase is associated with decreased neurological damage. 3

Swallowing Assessment

• Perform swallowing assessment before allowing oral intake to prevent aspiration pneumonia. 3, 5

Early Mobilization and Rehabilitation

• Initiate early mobilization (sitting, standing, brief ambulation) within 24 hours of admission, provided no contraindications exist (Class I, Level B). 3, 4
• Begin frequent brief mobilization within 24 hours if no contraindications—early activity reduces complications and improves functional outcomes. 3
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties. 5

Venous Thromboembolism Prophylaxis

• Start intermittent pneumatic compression devices within 24 hours for VTE prophylaxis in immobile patients. 3

Secondary Prevention Workup

Cardiac Evaluation

• Perform transthoracic echocardiography to assess for cardioembolic sources. 4, 5

Vascular Imaging

• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates. 4, 5

Critical Pitfalls to Avoid

Blood Pressure Management Errors

• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion. 3, 4

Medication Errors

• Do NOT use full-dose heparin or LMWH for acute stroke treatment—it does not improve outcomes and increases hemorrhage risk. 3, 5
• Do NOT give aspirin as adjunctive therapy with alteplase—this increases hemorrhage risk. 3

Treatment Delays

• Do NOT delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits. 3
• Do NOT delay transfer to comprehensive stroke center if patient requires neurosurgical evaluation. 4

Ineffective Interventions

• Do NOT use volume expansion, vasodilators, or induced hypertension—these have been studied for decades without proven benefit. 4, 5
• Do NOT use neuroprotective agents—none have demonstrated efficacy in improving outcomes. 4, 5