Stroke New Guidelines 2026

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

1. Thrombolysis - Expanded & Updated

• Both alteplase and tenecteplase are now endorsed as effective thrombolytics. Tenecteplase is specifically noted as a single-bolus alternative that simplifies time-sensitive administration.
• IV thrombolysis is affirmed within 4.5 hours of symptom onset for eligible patients.
• Contraindications have been modified - several formerly absolute contraindications are now reconsidered with a more nuanced approach, allowing more patients to receive tPA.
• Advanced imaging can identify candidates for thrombolysis beyond the traditional time window when salvageable tissue is demonstrated.

2. Endovascular Thrombectomy (EVT) - Expanded Criteria

• EVT eligibility now extends to selected patients up to 24 hours from symptom onset when advanced imaging (perfusion CT/MRI) confirms salvageable brain tissue.
• New evidence supports EVT for posterior circulation strokes (basilar artery occlusion) in selected patients.
• Patients with larger infarct cores may now be considered for EVT based on imaging criteria - a significant departure from prior strict core volume cutoffs.
• When a patient qualifies for both IV thrombolysis and EVT, both therapies should be given rapidly and sequentially without delaying clot removal.

3. Blood Pressure Management

• Pre-thrombectomy: Maintain BP < 185/110 mmHg before IV thrombolysis bolus.
• Post-thrombolysis/thrombectomy: Target BP < 180/105 mmHg for 24 hours.
• Intensive SBP lowering below 140 mmHg in the first 24 hours after successful thrombectomy is now explicitly discouraged - the ENCHANTED2/MT trial showed worse outcomes with aggressive BP reduction post-procedure.
• Pre-hospital BP lowering in suspected stroke is advised against (ESO 2025/2026 update, PMID 42095756).

4. Pediatric Stroke - First-Ever Formal Guidance

• Imaging protocols to differentiate stroke from mimics in children
• Evidence-informed guidance on thrombolytic therapy in children
• Selected use of mechanical clot removal in pediatric patients

5. Hyperglycemia and Dysphagia Management

• Updated evidence on hyperglycemia management post-stroke is incorporated with specific targets.
• Dysphagia screening recommendations are updated, emphasizing early assessment to reduce aspiration pneumonia risk.

6. Prehospital & Systems of Care

• EMS should use validated stroke recognition tools (e.g., FAST, BEFAST) to expedite triage.
• Streamlined direct transport to thrombectomy-capable centers is emphasized.
• Integrated stroke care pathways connecting EMS, neurology, and rehabilitation are a stated priority.

European Stroke Organisation (ESO) Updates 2025-2026

CHOICE-2 Trial - Practice-Changing Evidence Post-Thrombectomy

Other Relevant 2025-2026 Guideline Updates

• 2025 ESO - Blood Pressure in AIS/ICH (PMID 42095756): Refined BP targets for each stroke subgroup.
• 2024 ACC Expert Consensus - Arrhythmia Monitoring After Stroke (PMID 39692645): Guidance on cardiac monitoring duration to detect paroxysmal AF post-stroke.
• ILEP Lipid Consensus (PMID 41249078): Updated LDL targets for primary and secondary stroke prevention (aligned with the 2026 ACC/AHA dyslipidemia guidelines recommending more aggressive LDL lowering).
• Cerebral Amyloid Angiopathy (PMID 40721902): Joint WSO/ICAA scientific statement on diagnosis and management, including guidance on anticoagulation decisions.

Summary of the Biggest Practice Changes