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Here is a full breakdown of the 2026 AHA/ASA Stroke Protocol - the most current guidelines, published January 26, 2026 in the journal Stroke.
2026 AHA/ASA Acute Ischemic Stroke (AIS) Protocol - Complete Overview
The 2026 AHA/ASA Guideline for the Early Management of Acute Ischemic Stroke updates the prior 2018/2019 guidelines with major advances across every phase of stroke care.
1. Core Principle: "Time Is Brain"
- Brain imaging must be completed within 25 minutes of hospital arrival
- Use CT/CTA as the primary rapid imaging modality; MRI when CT is insufficient
- Regional stroke systems should be organized for direct transport to thrombectomy-capable centers
- Mobile stroke units are now endorsed to accelerate prehospital diagnosis and treatment delivery
2. Intravenous Thrombolysis (IVT) - Major Updates
Drug Choice: Tenecteplase NOW Co-Equal With Alteplase
The biggest pharmacotherapy change: tenecteplase is now fully endorsed (not just an "alternative") alongside alteplase. Key details per the UIC Drug Information Group summary:
| Drug | Dose | Route |
|---|---|---|
| Tenecteplase | 0.25 mg/kg IV (max 25 mg) | Single IV push bolus |
| Alteplase | 0.9 mg/kg IV (max 90 mg) | 10% bolus + remainder over 60 min |
Tenecteplase's advantage: single bolus dose - simpler, faster, fewer errors in time-critical settings. Supported by multiple large RCTs.
Standard Time Window: 4.5 Hours (unchanged)
IVT is indicated for eligible patients within 4.5 hours of symptom onset or last known well.
Extended Time Window: NEW - Up to 9 Hours With Advanced Imaging
Based on the EXTEND trial and TRACE-3 trial, IVT may now be reasonable in patients who:
- Awaken with stroke symptoms within 9 hours from the midpoint of sleep, OR
- Are 4.5 to 9 hours from last known well
Condition: Salvageable ischemic penumbra must be identified on advanced CT perfusion or MRI imaging.
Extended Window for Large Vessel Occlusion (LVO): Up to 24 Hours
For AIS patients with LVO and salvageable tissue on advanced imaging, tenecteplase may be considered between 4.5 and 24 hours from last known well (TRACE-3 trial evidence, NEJM 2024).
Blood Pressure After IVT - Updated
- Less intensive BP lowering is now recommended post-IVT (relaxed from prior aggressive targets)
Glycemic Management - Updated
- Less aggressive glucose control for persistent hyperglycemia post-stroke
3. Endovascular Thrombectomy (EVT) - Expanded Eligibility
- EVT is now eligible up to 24 hours after symptom onset in selected patients with:
- Large vessel occlusion (LVO)
- Salvageable brain tissue on advanced imaging (CT perfusion or MRI-DWI/PWI mismatch)
- Updated guidance for posterior circulation strokes (basilar artery occlusion)
- Larger infarct cores may now be treated in selected patients based on imaging criteria (not automatically excluded)
- Patients eligible for both IVT and EVT should receive both, sequentially and without delay
4. Combined IVT + EVT Approach
When a patient is eligible for both:
- Give IVT first
- Proceed immediately to EVT (do not wait to see if IVT works)
- Do not delay thrombectomy for any reason
Recent meta-analyses support adjunctive intra-arterial tenecteplase after recanalization as a potential benefit for microvascular reperfusion (PMID: 41793929, 41106193).
5. Pediatric Stroke - FIRST-EVER Dedicated Recommendations
This is the first time the AHA/ASA has included detailed pediatric-specific recommendations:
- Age range: 28 days to 18 years
- IVT with alteplase: May be considered within 4.5 hours if deficits are disabling
- Dose: Alteplase 0.9 mg/kg within 4.5 hours, PedNIHSS ≥ 4
- Safety confirmed (TIPS trial), but efficacy not yet proven in children
- A pediatric neurologist should be involved in treatment decisions for young children
- EVT: Also supported for pediatric LVO cases where appropriate
- Tenecteplase is not yet endorsed for pediatric patients (insufficient data)
6. Systems of Care
| Component | New Standard |
|---|---|
| Brain imaging | Within 25 min of arrival |
| Mobile stroke units | Endorsed for prehospital triage and treatment |
| Transport | Direct to thrombectomy-capable center when possible |
| Interdisciplinary team | Streamlined workflow, rapid imaging, stroke team activation |
7. Secondary Prevention & Rehabilitation
- Early rehabilitation begins in the acute phase
- Secondary prevention: risk factor optimization (hypertension, atrial fibrillation, diabetes, lipids, anticoagulation for AF)
- Antiplatelet therapy for non-cardioembolic stroke; anticoagulation for cardioembolic
Summary of What Changed From 2018/2019 Guidelines
| Topic | Old | New (2026) |
|---|---|---|
| Thrombolytic of choice | Alteplase (primary), tenecteplase (alternative) | Tenecteplase = co-equal with alteplase |
| IVT time window | 4.5 hours | 4.5 hours standard; up to 9 hours with perfusion imaging; up to 24 h (LVO + imaging) |
| EVT time window | Up to 24 hours (DAWN/DEFUSE-3 criteria) | Expanded - larger cores, posterior circulation |
| Pediatric stroke | No specific IVT/EVT guidance | First dedicated recommendations (alteplase safe, efficacy uncertain) |
| BP after IVT | Aggressive lowering | Less intensive lowering |
| Glycemic control | Aggressive | Less aggressive |
| Mobile stroke units | Optional | Endorsed |
Source: 2026 AHA/ASA Guideline for Early Management of AIS, published January 26, 2026.
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