The American Stroke Association (ASA), a division of the American Heart Association (AHA), has released its 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, introducing major updates that broaden eligibility for advanced reperfusion therapies and reinforce coordinated systems of care for both adults and children. The guideline, published in the Association’s flagship peer-reviewed journal Stroke, replaces the 2018 guideline and its 2019 focused update.
The update comes amid the continuing public health burden of stroke in the United States. According to the AHA’s 2026 Heart Disease and Stroke Statistics, stroke is now the nation’s fourth leading cause of death, with nearly 800,000 events annually and stroke remaining a leading cause of long term disability. Ischemic stroke, due to acute cerebral arterial occlusion, accounts for the vast majority of cases.
The 2026 guideline synthesizes a surge of evidence from recent landmark trials that have reshaped acute stroke care. Advances in thrombolytic therapy, endovascular thrombectomy, and hospital workflow optimization have significantly improved outcomes. The recommendations provide an evidence-based roadmap across the entire continuum of care from the initial 9-1-1 call and EMS response through in hospital management and early recovery, with an emphasis on standardizing high quality care across diverse healthcare settings.
A central theme of the update is that speed and coordination are critical determinants of outcome. The guideline emphasizes strengthening regional stroke systems that integrate emergency call centers, EMS, hospitals, and telemedicine networks. Mobile stroke units, equipped with CT scanners and specialized stroke teams, are highlighted as an effective strategy to enable earlier diagnosis and treatment. For adults with suspected large vessel occlusion, the guideline recommends direct EMS transport to the nearest thrombectomy capable stroke center when feasible. In regions without immediate access, referring hospitals should minimize door in door out times during interfacility transfer. The guideline also reiterates that brain imaging should be completed within 25 minutes of hospital arrival to rapidly distinguish ischemic from hemorrhagic stroke and initiate appropriate therapy.
The guideline endorses the use of either alteplase or tenecteplase for intravenous thrombolysis within 4.5 hours of symptom onset. Tenecteplase, administered as a single IV bolus, offers logistical advantages over alteplase’s 60 minute infusion. For selected patients with wake up stroke or late presentation, thrombolysis may still be considered up to 24 hours after onset when advanced imaging demonstrates salvageable brain tissue.
Mechanical clot removal via endovascular thrombectomy remains a cornerstone of therapy for major ischemic strokes. The 2026 update expands eligibility, recommending endovascular thrombectomy in carefully selected patients up to 24 hours after symptom onset, including some with larger established infarcts than previously considered. New evidence also supports thrombectomy for certain posterior circulation strokes and for some patients with mild or moderate pre-existing disability. For patients eligible for both intravenous thrombolysis and thrombectomy, the guideline stresses that both therapies should be delivered rapidly, without delaying the procedure to assess early clinical response.
A notable update addresses pediatric stroke, a rare but often underrecognized condition. While children may present with classic adult warning signs summarized by the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services), they may also have severe headache, seizures, confusion, visual disturbance, or gait imbalance. Because most screening tools were developed for adults, the guideline recommends rapid use of MRI and MR angiography to confirm diagnosis and exclude stroke mimics in children. For treatment, intravenous alteplase may be considered within 4.5 hours in children aged 28 days to 18 years with disabling ischemic stroke. Endovascular thrombectomy may also be effective for large vessel occlusion in children aged six years and older, with treatment windows extending up to 24 hours in selected cases.
The guideline also underscores the importance of continuous quality improvement through participation in registries such as the ASA’s Get With The Guidelines Stroke program, which enables hospitals to track treatment times, adherence to evidence based practices, and patient outcomes. As the writing committee notes, time is brain, and coordinated systems of care from EMS to in hospital teams can reduce treatment delays by 30 to 60 minutes, improving survival and functional outcomes.
The new guideline will be featured at the American Heart Association’s 2026 International Stroke Conference, scheduled for February 4 to 6 in New Orleans.
Reference
- Prabhakaran S, Gonzalez NR, Zachrison KS, Adeoye O, Alexandrov AW, Ansari SA, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke [Internet]. [cited 2026 Jan 27];0(0). Available from: https://www.ahajournals.org/doi/10.1161/STR.0000000000000513