Linking To And Excerpting From “2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association” With Links To Four Video Summaries From EM Note

Posted on January 30, 2026 by Tom Wade MD

Note: This post contains the article’s Abstract, Top Ten Take-Home Messages, and The Table of Contents links. Reviewing these resources  is a good start to learning this outstanding new guideline.

Review the article’s resources in the [Full-Text HTML] rather than in this post as the [Full-Text HTML] link has a much better and faster flow for review then using the links in this post.

In addition to today’s resource, please review EM Note‘s excellent summaries of the 2026 Guideline.

Today, I review, link to, and excerpt from “2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association“. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Stroke. 2026 Jan 26. doi: 10.1161/STR.0000000000000513. Online ahead of print.

All that follows is from the above resource.

Abstract

Aim: The “2026 Guideline for the Early Management of Patients With AIS” replaces the “2018 Guidelines for the Early Management of Patients With AIS” and the 2019 update to reflect recent advances in evidence. This updated guideline is intended to provide a comprehensive, up-to-date, evidence-based set of recommendations, advising management from prehospital evaluation through acute treatment and early in-hospital management of complications and initiation of early secondary prevention measures. The intended audience includes prehospital care professionals, physicians, allied health professionals, and hospital administrators.

Methods: A search for literature derived from research principally involving human subjects, published in English since the last AIS guideline in 2018 and the 2019 update, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between September and December 2024. Additional high impact studies and articles published through March 2025 were added later, where appropriate.

Structure: This guideline represents the most current and comprehensive evidence available in AIS care. Key updates include the incorporation of new evidence related to thrombolytic choice and eligibility, determination of eligibility for endovascular thrombectomy, and management of hyperglycemia and dysphagia; a focused consideration of the pediatric population; and modification of the approach to thrombolysis contraindications. Although this guideline reflects significant advances, it also highlights gaps in knowledge and underscores the urgent need for continued research to further refine and improve treatment strategies.

Keywords: AHA Scientific Statements; endovascular procedures; guideline; ischemic stroke; stroke; thrombolytic therapy.

TOP TAKE-HOME MESSAGES

1.
Mobile stroke units (MSU) enable rapid identification and treatment of thrombolytic-eligible patients with acute ischemic stroke (AIS). Recent studies have highlighted the benefit of MSUs over conventional emergency medical services and, when available, the guideline now includes recommendations related to the implementation of MSUs, based on their safety and benefit.
2.
Identification of appropriate transport destination for patients with suspected stroke in the prehospital setting remains challenging. Previous guidelines recommended transport to the nearest thrombolytic-capable facility. Given recent evidence, this guideline endorses consideration of the characteristics of the local system of care and direct transport to the closest endovascular thrombectomy (EVT)-capable hospital in the absence of well-functioning systems with rapid interhospital transfer processes.
3.
Intravenous thrombolysis (IVT) is a mainstay of medical management for patients with AIS. Given numerous international trials showing noninferiority and the potential advantages of intravenous tenecteplase compared with alteplase, the new guidelines endorse the use of either alteplase or tenecteplase in the 4.5-hour thrombolytic treatment window. Furthermore, we emphasize rapid thrombolytic treatment in eligible patients with disabling deficits, regardless of National Institutes of Health Stroke Scale (NIHSS) score, within the 4.5-hour window without advanced imaging selection. In addition, the guidelines provide support for extended window thrombolysis for select patients with stroke of unknown onset or 4.5–9 hours from onset using advanced imaging criteria (eg, diffusion weighted imaging-fluid attenuated recovery or perfusion-based mismatch).
4.
For patients with non-disabling (eg, isolated sensory syndrome) deficits in the 4.5-hour window, trials have failed to demonstrate benefit of thrombolysis. Dual antiplatelet therapy is preferred and recommended in this population.
5.
New studies have examined the role of adjuvant antithrombotic therapy, such as argatroban and eptifibatide, concurrently with IVT. These studies have shown no benefit and, therefore, adjuvant antithrombotic drugs are not recommended to enhance the outcomes from thrombolytic therapy.
6.
EVT has been established as a standard treatment for patients with AIS with large vessel occlusion (LVO) based on numerous randomized controlled trials. Recent evidence supports expanding EVT to populations previously considered ineligible. Specifically, several studies indicate that EVT benefits some patients with larger ischemic core strokes as determined by diagnostic imaging.
7.
Based on several trials showing improvement in functional outcomes compared with medical management alone, the guidelines also provide a strong recommendation for EVT in patients with basilar artery occlusion presenting within 24 hours of symptom onset and NIHSS score ≥10.
8.
For the first time, the guidelines include recommendations for interventional treatment in pediatric patients with AIS. Although much work remains to adapt prehospital and hospital stroke protocols for pediatric patients, expert consensus and recent studies highlight the importance of early stroke recognition in children and support the safety and potential benefit of endovascular interventions in select pediatric patients with AIS. These recommendations serve as a foundation for future recommendations and address the phases of pediatric acute stroke care.
9.
Glycemic management in patients with AIS has been updated since the prior guidelines such that intensive glucose control to the range of 80 to 130 mg/dL is not recommended to improve clinical outcome and increases the risk of severe hypoglycemia.
10.
Several new trials have assessed the efficacy and safety of blood pressure (BP) lowering after IVT and EVT in adult patients, providing new evidence that more intensive BP reduction does not improve functional outcome after IVT and may result in harm after EVT. Therefore, intensive systolic BP lowering to <140 mm Hg is not recommended even in the setting of complete reperfusion (eg, Thrombolysis In Cerebral Infarction grade 3 flow).

Table of Contents

Disclosures  eXXX
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