AHA and ASA launch 2026 guideline for Acute Ischemic Stroke management

Headline change

Tenecteplase (0.25 mg/kg) is now recommended as an alternative to alteplase for IV thrombolysis in adult patients within 4.5 hours of symptom onset.

Bedside action

Evaluate your current thrombolytic protocols to incorporate tenecteplase as a primary option for eligible adult AIS patients, and review new pediatric imaging and treatment pathways.

The American Heart Association and American Stroke Association have released their 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke. This comprehensive update integrates significant new evidence, particularly regarding thrombolytic choice, expanded endovascular thrombectomy criteria, and, for the first time, dedicated recommendations for pediatric patients. Clinicians should review these changes to optimize acute stroke care and improve patient outcomes.

Versus the Previous Version

This 2026 guideline significantly updates the 2019 version, incorporating new evidence that refines prehospital management, expands treatment options, and introduces specific guidance for pediatric populations.

Thrombolytic Choice

Previous version

The 2019 guideline recommended IV alteplase (0.9 mg/kg) for selected patients within 4.5 hours of symptom onset.

This version

The 2026 guideline recommends tenecteplase (0.25 mg/kg, max 25 mg) or alteplase (0.9 mg/kg) for adult patients with AIS presenting within 4.5 hours of symptom onset or last known well and eligible for IVT.

Clinical impact Clinicians now have an alternative thrombolytic agent, tenecteplase, which may offer practical advantages due to its single bolus administration.

Pediatric Stroke Care

Previous version

The 2019 guideline did not include specific recommendations for pediatric patients with AIS.

This version

The 2026 guideline includes several new recommendations for pediatric patients, covering prehospital assessment, emergent imaging (MRI/MRA or CT/CTA), and consideration of IVT with alteplase and EVT.

Clinical impact Pediatric patients with suspected stroke now have dedicated, evidence-based pathways for early management, improving recognition and treatment.

Prehospital LVO Transport

Previous version

The 2019 guideline stated that the benefit of bypassing the closest IV alteplase-capable hospital for a higher level of stroke care (including mechanical thrombectomy) was uncertain (IIb B-NR).

This version

The 2026 guideline states that in areas with well-coordinated SSOC and proficient local hospitals, direct transport of suspected LVO patients to a distant TSC does not improve 3-month clinical outcomes (COR 3: No Benefit, B-R).

Clinical impact In well-coordinated systems, direct transport to a distant thrombectomy center for suspected LVO is not beneficial, reinforcing the importance of local thrombolysis and efficient transfer.

Mobile Stroke Units (MSUs)

Previous version

The 2019 guideline did not contain specific recommendations for the use of Mobile Stroke Units.

This version

The 2026 guideline strongly recommends the use of MSUs over conventional EMS for thrombolytic-eligible patients to ensure faster onset-to-treatment times and improve functional outcomes (COR 1, A).

Clinical impact MSUs are now a strongly recommended component of prehospital stroke care, emphasizing their role in rapid diagnosis and treatment for eligible patients.

Intensive SBP Reduction Post-IVT

Previous version

The 2019 guideline did not specifically address intensive SBP reduction post-IVT for mild to moderate AIS.

This version

The 2026 guideline states that intensive SBP reduction to <140 mm Hg is not recommended for mild to moderate AIS patients treated with IVT, as it does not improve functional outcomes (COR 3: No Benefit, B-R).

Clinical impact Avoid intensive SBP reduction to <140 mm Hg in mild to moderate AIS patients post-IVT, as it offers no benefit and may increase risk.

Intensive SBP Reduction Post-EVT

Previous version

The 2019 guideline did not specifically address intensive SBP reduction post-EVT for successfully recanalized LVO.

This version

The 2026 guideline states that intensive SBP reduction to <140 mm Hg for the first 72 hours is harmful and not recommended for AIS patients with anterior circulation LVO successfully recanalized by EVT, without other BP management indications (COR 3: Harm, A).

Clinical impact Intensive SBP reduction to <140 mm Hg post-EVT for successfully recanalized LVO is harmful and should be avoided.

Intensive Glucose Control

Previous version

The 2019 guideline suggested it was reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL (IIa C-LD).

This version

The 2026 guideline states that treatment with IV insulin to achieve blood glucose levels of 80 to 130 mg/dL is not recommended for hospitalized AIS patients with hyperglycemia, as it does not improve 3-month functional outcomes (COR 3: No Benefit, A).

Clinical impact Avoid intensive IV insulin to achieve blood glucose 80-130 mg/dL in hospitalized AIS patients with hyperglycemia, as it offers no benefit and increases hypoglycemia risk.

Practice Notes

Consider these critical practice points for immediate implementation and patient safety.

Caution

Do not delay IV thrombolysis for additional multimodal neuroimaging if the diagnosis of ischemic stroke is highly likely.

The benefit of IVT is highly time-dependent. NCCT is sufficient to rule out hemorrhage, and advanced imaging should not impede rapid treatment initiation.

Red flag

Avoid intensive SBP reduction to <140 mm Hg in patients with AIS post-IVT or successfully recanalized EVT.

This practice has been shown to offer no benefit after IVT and may be harmful after successful EVT, potentially worsening functional outcomes.

Stop doing this

Discontinue routine intensive IV insulin for blood glucose targets of 80-130 mg/dL in hospitalized AIS patients with hyperglycemia.

This intensive approach does not improve functional outcomes and increases the risk of severe hypoglycemia, which can be detrimental.

Do not miss

Prioritize rapid evaluation and treatment for pediatric patients with suspected AIS.

New recommendations highlight the importance of emergent brain and vascular imaging (MRI/MRA or CT/CTA) and considering IVT/EVT in select pediatric cases, which were previously less defined.

Implementation

Integrate tenecteplase (0.25 mg/kg) into your thrombolysis protocols as an alternative to alteplase.

Tenecteplase offers comparable efficacy and safety with the practical advantage of single-bolus administration, potentially streamlining workflow and reducing treatment delays.

Shared decision point

Engage in shared decision-making with patients or representatives regarding IVT risks and benefits.

While treatment is time-sensitive, discussion of potential emergent adverse effects like bleeding and angioedema is crucial when feasible, especially for new thrombolytic options.

Key Recommendations

These key recommendations highlight critical updates and reinforce established best practices in the early management of acute ischemic stroke. They cover prehospital care, diagnostic imaging, thrombolytic and endovascular therapies, and supportive care, guiding clinicians toward optimal patient outcomes.

Key recommendations15 highlighted

In adult patients with AIS presenting within 4.5 hours of symptom onset or last known well and eligible for IVT, administer tenecteplase at a dose of 0.25 mg/kg body weight (max 25 mg) or alteplase at a dose of 0.9 mg/kg body weight.

Recommendation ClassCOR 1

Level of EvidenceA

EvidenceMultiple large phase 3 RCTs (e.g., ACT, NOR-TEST) involving over 6000 patients have shown noninferiority of tenecteplase (0.25 mg/kg) to alteplase (0.9 mg/kg) for functional outcomes at 90 days, with similar safety profiles. Tenecteplase offers ease of administration as a single bolus.

For practiceTenecteplase is now a primary, equally recommended option for IVT, simplifying administration.

p. 5 · Choice of Thrombolytic Agent

In pediatric patients aged 28 days to 18 years with confirmed AIS presenting within 4.5 hours of symptom onset and disabling deficits, consider IVT with alteplase.

Recommendation ClassCOR 2b

Level of EvidenceC-LD

EvidenceThe randomized pediatric TIPS trial was stopped due to lack of recruitment, but retrospective analysis of 26 included patients confirmed safety of IV alteplase (0.9 mL/kg) within 0-4.5 hours for PedNIHSS ≥4. Efficacy remains uncertain.

For practiceIV alteplase can be considered for pediatric AIS, but with careful patient selection and awareness of limited efficacy data.

CaveatEfficacy is uncertain, and this is based on limited data.

p. 4 · Thrombolysis Decision-Making

In pediatric patients ≥6 years with acute neurological symptoms and ischemic stroke due to LVO and within 6 hours from symptom onset, perform EVT if performed by experienced neurointerventionalists to improve functional outcomes.

Recommendation ClassCOR 2a

Level of EvidenceB-NR

EvidenceExpert consensus and recent studies highlight the safety and potential benefit of endovascular interventions in select pediatric patients with AIS, forming a foundation for future recommendations.

For practiceEVT is a reasonable option for older pediatric patients with LVO, provided specialized expertise is available.

CaveatRequires experienced neurointerventionalists.

p. 4 · Endovascular Thrombectomy in Pediatric Patients

In patients with suspected AIS eligible for thrombolysis, use Mobile Stroke Units (MSUs) over conventional EMS where available for transport and management.

Recommendation ClassCOR 1

Level of EvidenceA

EvidenceMultiple randomized studies and meta-analyses (e.g., B_PROUD, BEST-MSU trials) have shown that MSU management improves functional outcomes at 90 days, reduces onset-to-treatment times, and increases the proportion of patients receiving IVT within 60 minutes.

For practicePrioritize MSU utilization for eligible patients to achieve faster treatment times and better outcomes.

CaveatApplicable where MSUs are available.

p. 4 · Role of Mobile Stroke Units

In patients with mild to moderate severity AIS who have been treated with IVT, do not intensively reduce SBP to <140 mm Hg (compared with <180 mm Hg).

Recommendation ClassCOR 3: No Benefit

Level of EvidenceB-R

EvidenceA post-hoc analysis of a high-quality RCT demonstrated that intensive SBP reduction to <140 mm Hg resulted in a lower risk of ICH but no benefit in functional outcome compared with a target of <180 mm Hg.

For practiceAvoid aggressive SBP lowering below 140 mmHg in this population, as it offers no functional benefit.

p. 5 · Blood Pressure Management

In patients with AIS with anterior circulation LVO successfully recanalized by EVT (mTICI 2b, 2c, or 3) and without other BP management indications, do not target intensive SBP reduction to <140 mm Hg for the first 72 hours.

Recommendation ClassCOR 3: Harm

Level of EvidenceA

EvidenceTwo high-quality RCTs and meta-analyses demonstrated that intensive SBP reduction to <140 mm Hg after EVT leads to lower functional independence and higher mortality, and a target of <120 mm Hg leads to more early neurological deterioration and major disability.

For practiceIntensive SBP reduction to <140 mmHg post-EVT is harmful and should be avoided.

CaveatApplies only if no other indication for BP management target exists.

p. 5 · Blood Pressure Management

In hospitalized patients with AIS with hyperglycemia, do not treat with IV insulin to achieve blood glucose levels in the range of 80 to 130 mg/dL.

Recommendation ClassCOR 3: No Benefit

Level of EvidenceA

EvidenceThe SHINE randomized trial ended early for futility, showing no benefit of intensive blood glucose control (80-130 mg/dL) on functional outcome at 3 months, and increased the risk of severe hypoglycemia.

For practiceAvoid intensive glucose control (80-130 mg/dL) with IV insulin in AIS patients, as it is not beneficial and increases hypoglycemia risk.

p. 5 · Blood Glucose Management

In patients with suspected AIS in areas with well-coordinated SSOC and local hospitals proficient in thrombolysis and interhospital transfer, do not directly transport patients with suspected LVO to a distant (e.g., 45–60 min) TSC compared with transport to a local stroke center.

Recommendation ClassCOR 3: No Benefit

Level of EvidenceB-R

EvidenceThe RACECAT trial in nonurban Catalonia, Spain, found no difference in 90-day mRS scores between direct transport to a distant TSC and transport to a local non-TSC, highlighting the efficiency of local systems.

For practiceIn efficient local systems, prioritize the closest appropriate stroke center for initial care rather than bypassing for a distant TSC.

CaveatApplies to well-coordinated systems with efficient local thrombolysis and transfer capabilities.

p. 4 · EMS Destination Management

In hospitals providing EVT for acute stroke (TSC, CSC hospitals), develop a system to comprehensively track key time metrics and other care processes relevant to thrombectomy (e.g., door-to-puncture time, successful reperfusion), as well as long-term patient outcomes.

Recommendation ClassCOR 1

Level of EvidenceB-R

EvidencePerformance metrics and QI activities are crucial for EVT, which has an NNT as low as 3. Case examples of successful QI programs exist, serving as templates for improving thrombectomy care.

For practiceImplement robust tracking and QI systems for EVT metrics to ensure optimal and timely care.

p. 5 · Organization and Integration of Components

In adult patients with AIS eligible for IVT within 4.5 hours of symptom onset, initiate treatment as quickly as possible, avoiding potential delays associated with additional multimodal neuroimaging (e.g., CTA/MRA, CT/MR perfusion imaging).

Recommendation ClassCOR 1

Level of EvidenceB-NR

EvidenceNCCT was the only neuroimaging modality used in the NINDS rt-PA trial and ECASS III, demonstrating its sufficiency for IVT decisions. Multimodal imaging is not necessary if the diagnosis is highly likely and can delay time-sensitive IVT.

For practicePrioritize rapid IVT administration; do not delay for advanced imaging if basic imaging is sufficient to rule out hemorrhage.

CaveatUnless there is substantial diagnostic uncertainty or concern for increased hemorrhagic risk.

p. 5 · Thrombolysis Decision-Making

In patients with minor (NIHSS score ≤5) noncardioembolic AIS or high-risk TIA (ABCD2 score ≥4) within 24-72 hours from onset, or NIHSS 4-5 within 24 hours, who did not receive IVT, with presumed atherosclerotic cause, administer DAPT (clopidogrel and aspirin) for 21 days followed by SAPT.

Recommendation ClassCOR 2a

Level of EvidenceB-R

EvidenceEarlier studies confirmed the efficacy and safety of DAPT in patients with minor stroke or high-risk TIA. A multicenter randomized trial showed DAPT was noninferior to IV alteplase in 90-day functional outcomes for minor, nondisabling strokes, with fewer bleeding events.

For practiceDAPT is a reasonable strategy for specific minor AIS/TIA patients who did not receive IVT, to reduce recurrent stroke risk.

p. 5 · Antiplatelet Treatment

In carefully selected (e.g., milder severity) patients with AIS with atrial fibrillation, implement a strategy of early oral anticoagulation poststroke.

Recommendation ClassCOR 2a

Level of EvidenceB-NR

EvidenceA strategy of early oral anticoagulation poststroke is low risk and reasonable compared with delayed anticoagulation, though its efficacy for preventing early recurrent stroke is not established.

For practiceConsider early oral anticoagulation in selected AIS patients with AF, recognizing it is low risk but with unproven efficacy for early recurrent stroke prevention.

CaveatEfficacy for preventing early recurrent stroke is not established.

p. 5 · Anticoagulants

In patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting within 6 hours from onset of symptoms, with NIHSS score ≥6, prestroke mRS score of 0 to 1, and ASPECTS 3 to 10, perform EVT to improve functional clinical outcomes and reduce mortality.

Recommendation ClassCOR 1

Level of EvidenceA

EvidenceNumerous randomized controlled trials have established EVT as a standard treatment for AIS with LVO, demonstrating significant improvement in functional outcomes and reduced mortality.

For practiceEVT is strongly indicated for eligible patients with proximal anterior circulation LVO within 6 hours.

p. 5 · Endovascular Thrombectomy for Adults

In selected patients* with AIS from anterior circulation proximal LVO of the ICA or M1, presenting between 6 and 24 hours from onset of symptoms, with age <80 years, NIHSS score ≥6, prestroke mRS score 0 to 1, ASPECTS 3 to 5, and without significant mass effect on imaging, perform EVT to improve functional clinical outcomes and reduce mortality.

Recommendation ClassCOR 1

Level of EvidenceA

EvidenceTrials like DAWN and DEFUSE 3 demonstrated significant benefits of EVT in extended time windows (6-24 hours) for carefully selected patients based on imaging and clinical criteria.

For practiceEVT is strongly recommended for selected patients with anterior circulation LVO up to 24 hours post-onset, guided by advanced imaging.

CaveatRequires specific patient selection criteria based on advanced imaging and clinical profile.

p. 5 · Endovascular Thrombectomy for Adults

In patients with AIS, with basilar artery occlusion, a baseline mRS score of 0 to 1, NIHSS score ≥10 at presentation, and PC-ASPECTS ≥6, perform EVT within 24 hours from onset of symptoms to achieve better functional outcome and reduce mortality.

Recommendation ClassCOR 1

Level of EvidenceA

EvidenceSeveral trials have shown improvement in functional outcomes compared with medical management alone, leading to a strong recommendation for EVT in patients with basilar artery occlusion.

For practiceEVT is strongly recommended for eligible patients with basilar artery occlusion within 24 hours.

p. 5 · Posterior Circulation Stroke

SOURCE GUIDELINE

2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke

AHA/ASA

Year2026

TypeFull Guideline

JournalStroke

DOI10.1161/STR.0000000000000513