Written by Jason Lesnick
Spoon Feed
These guidelines for acute ischemic stroke (AIS) are a doozy, but we’ve covered the highlights.
>100 pages of stroke guidelines In <100 seconds
This guideline from the AHA and ASA was released as an update to the 2018 guidelines and 2019 update.
Key changes and updates:
- Mobile stroke units (MSU) are included in the guideline as beneficial (when available).
- Choosing the right hospital for transport is difficult. This guideline endorses transfer to the closest endovascular thrombectomy (EVT)-capable hospital in the absence of well-functioning systems for rapid interhospital transfer.
- Tenecteplase is now endorsed for intravenous thrombolysis (IVT) within the 4.5-hour treatment window. Multiple international trials have shown noninferiority and possible advantages of tenecteplase relative to alteplase. They emphasize support for thrombolytics in patients with disabling deficits regardless of NIHSS and outline the extended window (4.5–9 hours) for select patients based on advanced imaging criteria.
- Patients with non-disabling (e.g. isolated sensory syndrome) deficits within the 4.5-hour window have failed to demonstrate benefit when receiving thrombolysis. Dual antiplatelet therapy is preferred and recommended in these patients.
- There is no role for adjuvant antithrombotic therapy (e.g. argatroban and eptifibatide) concurrently with IVT.
- EVT is established as standard treatment for patients with AIS with large vessel occlusion (LVO). EVT also benefits some patients with larger ischemic core strokes based on diagnostic imaging.
- There is a strong recommendation for EVT in patients with basilar artery occlusion within 24-hours of symptom onset and NIHSS ≥10.
- Recommendations for interventional treatment in pediatric patients with AIS have been added.
- To avoid hypoglycemia, aggressive glucose control with a goal of 80–130 mg/dL is no longer recommended; rather, 140–180 mg/dL is acceptable.
- After IVT and EVT in adults, more intensive BP reduction does not improve functional outcome after IVT and may result in harm after EVT. Thus, intensive SBP lowering to <140 is not recommended when compared to an SBP goal of <180.
How will this change my practice?
We switched over to tenecteplase as a hospital system, and I am using this as my preferred thrombolytic for adults. For pediatric stroke, I learned that there is data suggesting alteplase is safe; however, efficacy is uncertain for thrombolysis in children.
Source
2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026 Jan 26. doi: 10.1161/STR.0000000000000513. Epub ahead of print. PMID: 41582814.
