Recent Stroke Guidelines (2024-2026)

1. AHA/ASA 2026 Guideline for Early Management of Acute Ischemic Stroke

IV Thrombolysis

• Tenecteplase is now co-endorsed alongside alteplase as first-line treatment for IVT within 4.5 hours of onset. Previously, tenecteplase was only suggested as an "alternative." The 2026 guideline grants both equal standing.
  • Tenecteplase: 0.25 mg/kg IV push (max 25 mg) - single bolus, fewer dosing complexities
  • Alteplase: 0.9 mg/kg (max 90 mg), 10% bolus + remainder over 60 minutes
• Extended time window for IVT: In select patients with salvageable brain tissue on advanced imaging (CT perfusion/MRI), IVT can now be given beyond 4.5 hours. This is supported by the EXTEND and TRACE-3 trials.
• Contraindications to thrombolysis have been modified and relaxed in several areas compared to the 2018 guideline.

Endovascular Thrombectomy (EVT)

• Expanded eligibility - broader criteria for large vessel occlusion (LVO) stroke
• Evidence from multiple landmark trials since 2019 has reinforced EVT as standard of care for LVO; the 2026 guideline standardizes its use across hospitals of all sizes
• Emphasis on LVO bypass protocols: EMS should consider bypassing to thrombectomy-capable centers when LVO is suspected

Blood Pressure Management

• Preferred IV agents: nicardipine or clevidipine infusions

Glycemic Management

• Less aggressive glycemic targets endorsed compared to prior guidelines - treatment of persistent hyperglycemia remains recommended but intensive control is not supported

Anticoagulation in AF-related Stroke

• Oral anticoagulation should generally be started 2-14 days after stroke onset
• Early anticoagulation (<48 hours) is not recommended - does not reduce early neurological worsening (Class III)
• Bridging heparin is generally not beneficial

Dysphagia

• Updated management recommendations for dysphagia screening and feeding post-stroke

Mobile Stroke Units

• Endorsed as a system-level intervention to accelerate prehospital diagnosis and treatment

Pediatric Stroke - NEW

• First detailed recommendations for diagnosing and treating AIS in children in any AHA/ASA guideline
• Alteplase appears safe in children, but efficacy of thrombolysis in pediatric stroke remains uncertain

2. AHA/ASA 2024 Guideline for Primary Prevention of Stroke

Key Updates

• Aligned with AHA's Life's Essential 8 (diet, physical activity, nicotine, sleep, BMI, blood lipids, blood glucose, blood pressure)
• New sex-specific recommendations for stroke screening and prevention (not in the 2014 guideline)
• Updated risk factor management: hypertension, diabetes, hyperlipidemia, obesity, AF, sleep apnea, migraine with aura
• Lifestyle interventions (diet, exercise, smoking cessation) strongly emphasized for stroke prevention across the lifespan
• Screening strategies for at-risk populations broadened

3. ESO 2024 Guidelines on Patent Foramen Ovale (PFO)

4. ACC/AHA 2023 AF Guidelines (Stroke Prevention)

• DOAC preference over warfarin for non-valvular AF
• Updated stroke risk scoring (CHA2DS2-VASc)
• Integrated AF management pathways

5. ESO 2023 Motor Rehabilitation Consensus

Summary of the Biggest 2026 Changes at a Glance