Recent stroke guidelines
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AHA ASA stroke guidelines 2024 2025 update ischemic stroke management
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PMID: 41582814
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PMID: 39429201
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https://newsroom.heart.org/news/new-guideline-expands-stroke…
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2026 AHA ASA acute ischemic stroke guideline tenecteplase large vessel occlusion expanded eligibility key changes
I now have comprehensive, up-to-date information. Here is a detailed summary of the most recent stroke guidelines.
Recent Stroke Guidelines (2024-2026)
1. AHA/ASA 2026 Guideline for Early Management of Acute Ischemic Stroke
Published January 26, 2026 in Stroke (PMID: 41582814), this replaces the 2018 guidelines and their 2019 update. It is the most significant overhaul of acute ischemic stroke (AIS) care in nearly a decade.
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
| Scenario | Target |
|---|---|
| Acute AIS, no reperfusion therapy | Withhold antihypertensives unless SBP ≥220 or DBP ≥120 mmHg; if lowering needed, reduce ≤15% in first 24 hours |
| Before IVT or EVT | < 185/110 mmHg |
| Post-IVT (first 24 hrs) | < 180/105 mmHg |
| Post-EVT | < 180/105 mmHg (avoid SBP <140 - ENCHANTED2/MT showed worse outcomes with intensive control) |
| Secondary prevention (history of ischemic stroke) | < 130/80 mmHg |
- 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
Published October 2024 in Stroke (PMID: 39429201), replacing the 2014 guidelines.
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)
Published December 2024 (PMID: 38752755) - covers diagnosis and management of PFO after stroke, including PFO closure indications.
4. ACC/AHA 2023 AF Guidelines (Stroke Prevention)
(PMID: 38033089) and 2024 ESC AF guidelines (PMID: 39210723) both provide updated guidance on anticoagulation for AF-related stroke prevention, including:
- DOAC preference over warfarin for non-valvular AF
- Updated stroke risk scoring (CHA2DS2-VASc)
- Integrated AF management pathways
5. ESO 2023 Motor Rehabilitation Consensus
(PMID: 37548025) provides an evidence-based framework for motor rehabilitation after stroke, including task-oriented training, intensity, and timing of rehabilitation.
Summary of the Biggest 2026 Changes at a Glance
| Topic | Prior (2018/2019) | Updated (2026) |
|---|---|---|
| Thrombolytic | Alteplase preferred; tenecteplase alternative | Tenecteplase co-equal with alteplase |
| IVT window | 4.5 hours (strict) | Extended beyond 4.5 hrs with advanced imaging |
| EVT eligibility | Established criteria | Expanded; standardized across hospital types |
| Glycemic control | Stricter targets | Less aggressive |
| BP post-EVT | Target <180/105 | <180/105; avoid intensive (<140) - worsens outcomes |
| Pediatric stroke | No dedicated guidance | First dedicated recommendations |
| Mobile stroke units | Not addressed | Endorsed |
The AHA professional guideline hub has the full 2026 document.
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