What are the 2026 American Heart Association/American Stroke Association guidelines for early management of acute ischemic stroke?

2026 Guidelines for Early Management of Acute Ischemic Stroke

The 2026 American Heart Association/American Stroke Association guideline represents the most current comprehensive evidence-based recommendations for acute ischemic stroke management, superseding the 2018 guidelines and 2019 update. 1

Prehospital and Emergency Medical Services

EMS should bypass hospitals without stroke treatment resources and transport directly to the closest facility capable of treating acute stroke (Class I, Level B). 2

• Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs) should be certified by independent external bodies such as The Joint Commission or state health departments. 2
• For sites lacking in-house imaging interpretation, FDA-approved teleradiology systems are recommended for timely brain CT and MRI review. 2

Emergency Department Triage and Initial Assessment

Patients with suspected acute stroke must be triaged with the same priority as acute myocardial infarction or serious trauma, regardless of neurological deficit severity. 2

• Immediate stabilization of airway, breathing, and circulation (ABCs) takes precedence. 2
• Obtain non-contrast CT brain immediately to exclude hemorrhage before initiating thrombolysis. 3
• Perform CT angiography without delay to detect large vessel occlusion (internal carotid, M1/M2 middle cerebral artery, or basilar artery). 3

Key Stroke Mimics to Exclude

• Hypoglycemia (check serum glucose immediately), seizures (postictal period), complicated migraine (preceding aura, headache history), psychogenic (inconsistent examination, non-vascular distribution), and drug toxicity (lithium, phenytoin, carbamazepine). 2

Intravenous Thrombolysis

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if the patient presents within 3-4.5 hours of clearly defined symptom onset, with 10% given as bolus over 1 minute and remaining 90% infused over 60 minutes (Class I, Level A). 3

• Target door-to-needle time of less than 60 minutes in 90% of treated patients—every 30-minute delay reduces probability of favorable outcome by approximately 10.6%. 4, 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. 4, 3
• The 3-4.5 hour window represents an expansion from the original 3-hour window based on ECASS-3 trial data. 3

Key Updates in 2026 Guideline

• New evidence regarding thrombolytic choice and eligibility criteria has been incorporated. 1
• Modified approach to thrombolysis contraindications allows treatment of previously excluded patients. 1

Endovascular Thrombectomy (EVT)

Proceed with mechanical thrombectomy using stent retriever devices (Solitaire FR, Trevo) if ALL criteria are met: prestroke modified Rankin Scale (mRS) 0-1, causative large vessel occlusion on CT angiography, age ≥18 years, NIHSS ≥6, ASPECTS ≥6, and groin puncture can be initiated within 6 hours of symptom onset (Class I, Level A). 5, 3

• Do not delay IV alteplase while awaiting EVT—both therapies are complementary and should be delivered promptly. 3
• Do not wait for clinical response to IV rtPA before initiating EVT; delaying EVT worsens outcomes (Class III, Level B-R). 3
• Use a proximal balloon-guide catheter or large-bore distal-access catheter together with the stent retriever to improve recanalization rates. 3
• Aim for final angiographic result of TICI 2b/3, which is associated with highest probability of good functional outcome. 3
• Stent retrievers are preferred over coil retrievers (Merci) based on MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, and REVASCAT trials. 5, 3

New 2026 EVT Eligibility Updates

• Updated evidence for determining eligibility for endovascular thrombectomy has been incorporated. 1

Post-Thrombolysis Monitoring

Monitor neurological status and vital signs every 15 minutes during and for 2 hours after alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours post-treatment. 5, 3

• Maintain BP ≤180/105 mmHg throughout the 24-hour monitoring period. 5, 3
• Monitor for symptomatic intracranial hemorrhage, which occurs in approximately 6.4% of rtPA-treated patients. 3

Antiplatelet Therapy

Delay initiation of aspirin for at least 24 hours after IV rtPA until the post-thrombolysis CT scan has excluded intracranial hemorrhage, then initiate aspirin 150-325 mg daily (Class I, Level A). 5, 3

• Do not administer antiplatelet agents or anticoagulants for 24 hours after rtPA due to increased bleeding risk. 3
• For patients not receiving thrombolysis, oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset. 4

Blood Pressure Management

For Patients Receiving Thrombolysis

• Reduce systolic/diastolic BP to <185/110 mmHg before starting alteplase and keep it ≤180/105 mmHg during infusion and for the first 24 hours (Class I, Level A). 3

For Patients NOT Receiving Thrombolysis

• For markedly elevated BP, a reasonable goal is to lower BP by 15% during the first 24 hours; withhold medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 4

Supportive Care

Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction; maintain oxygen saturation >94%. 4

• Identify and treat sources of hyperthermia (temperature >38°C); correct hypovolemia with intravenous normal saline. 4
• Treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia; treat hyperglycemia to achieve blood glucose levels in range of 140-180 mg/dL. 4
• New 2026 guideline includes updated evidence on management of hyperglycemia. 1

Stroke Unit Care

Admit to a geographically defined stroke unit with specialized nursing staff and begin frequent brief mobilization within 24 hours if no contraindications (Class I, Level B). 5, 3

• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities. 3
• New 2026 guideline includes updated evidence on dysphagia management. 1

Malignant MCA Syndrome Management

Perform decompressive hemicraniectomy within 48 hours of symptom onset for patients with malignant cerebral edema (Class I, Level A). 3

Surgical Criteria

• Infarct involving >50% of MCA territory or lesion volume >150 cm³. 3
• Radiologic evidence of significant edema/mass effect. 3
• Age 18-60 years (strongest evidence, Class I, Level A); age 60-80 years may be considered (Class I, Level B). 3
• Decompressive surgery reduces mortality by roughly 50% but most survivors have moderate-to-severe disability (mRS 3-4). 3
• In patients >60 years, surgery lowers mortality but none achieve good functional recovery (mRS 0-2). 3

Secondary Prevention Workup

• Obtain transthoracic echocardiography to assess for cardioembolic sources; consider transesophageal echocardiography if cardioembolic source is suspected but not identified (Class IIa). 5, 3
• Initiate statin therapy for lipid lowering regardless of baseline levels. 3
• Begin antihypertensive therapy for long-term BP control before discharge. 3

Pediatric Considerations

The 2026 guideline includes focused consideration of the pediatric population with acute ischemic stroke. 1

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). 2

• Establish a stroke care data bank to identify gaps or disparities in quality stroke care. 2
• Once gaps are identified, initiate specific interventions to address these gaps or disparities. 2

Critical Pitfalls to Avoid

• Do not 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—it increases hemorrhage risk without improving outcomes (Class III). 5, 3
• Do not assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis—they may reflect the stroke pathology itself. 3
• Emergency carotid endarterectomy is generally avoided in acute ischemic stroke because of high peri-procedural risk. 3