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

Authors, Journal, Affiliations, Type, DOI

• Authors: Shyam Prabhakaran et al. (AHA/ASA Guideline Writing Group)
• Journal: Stroke, 2026;57
• Type: Full clinical practice guideline (replaces 2018 AIS guideline)
• Endorsements: AAN, ACEP, AANN, AANS, ACR, ASNR, CNS, DASI, NASCI, SNIS, SNO, SIR
• DOI: https://doi.org/10.1161/STR.0000000000000513

Overview

This 2026 AHA/ASA guideline is the full replacement of the 2018 AIS guideline and covers the complete spectrum of acute ischemic stroke management from prehospital triage through in-hospital acute care and early rehabilitation. The most practice-defining changes are: (1) tenecteplase 0.25 mg/kg is now COR 1A equivalent to alteplase, marking the end of the alteplase era in acute stroke thrombolysis; (2) EVT indications are substantially broadened — ASPECTS 3–5 is now COR 1A, basilar artery occlusion within 24 hours is COR 1A, and pediatric EVT has been added; (3) two important harmful recommendations are established — lowering SBP <140 mmHg within 72 hours post-successful EVT is COR 3:Harm, and elastic compression stockings are COR 3:Harm for DVT prevention in AIS. Mobile Stroke Units receive COR 1A for thrombolytic-eligible patients, and pharyngeal electrical stimulation is newly added as COR 2a for post-stroke dysphagia.

Keywords

Acute ischemic stroke, thrombolysis, tenecteplase, alteplase, endovascular thrombectomy, mechanical thrombectomy, ASPECTS, NIHSS, blood pressure management, antiplatelet therapy, DAPT, dysphagia, decompressive craniectomy, basilar artery occlusion, mobile stroke unit, rehabilitation

Key Takeaways

Prehospital and EMS

• Mobile Stroke Units (MSU): COR 1 A — recommended over conventional EMS for thrombolytic-eligible patients in areas with MSU programs; MSU reduces door-to-needle and onset-to-treatment times
• EMS destination: Direct transport to closest EVT-capable hospital preferred; in well-coordinated systems, bypass to distant TSC may be acceptable for selected patients, but direct to closest EVT-capable facility is the default
• Field triage tools: Standardized pre-hospital stroke severity scales (LAMS, CPSS, sNIHSS) should guide destination selection

Intravenous Thrombolysis (IVT)

• Tenecteplase 0.25 mg/kg (max 25 mg) — COR 1 A: Non-inferior to alteplase 0.9 mg/kg; single IV bolus administration (vs 1-hour alteplase infusion) — preferred agent for IVT in AIS in most patients; multiple RCTs (EXTEND-IA TNK, ATTEST-2, NOR-TEST 2A, TASTE, AcT)
• Tenecteplase 0.4 mg/kg — COR 3: No Benefit: Higher dose (0.4 mg/kg) does not improve outcomes and is not recommended
• Alteplase 0.9 mg/kg (max 90 mg) remains COR 1 A when tenecteplase is not available
• IVT for large vessel occlusion (LVO) before EVT: Do not skip IVT to facilitate faster EVT — bridging thrombolysis is the standard approach (COR 1)
• Extended window 4.5–9h (or wake-up stroke) with perfusion imaging mismatch — COR 2a: EXTEND, ECASS-4, WAKE-UP trials; applies to patients with DWI-FLAIR mismatch (wake-up stroke)
• Non-disabling minor deficits — COR 3: No Benefit: IVT not recommended for minor non-disabling stroke (NIHSS 0–5 without disabling symptoms); DAPT preferred in this population
• IVT contraindications: SBP ≥185 mmHg or DBP ≥110 mmHg must be treated before administration; prior intracranial hemorrhage; platelets <100,000; anticoagulation with elevated INR or direct Xa/thrombin inhibitor use
• Pre-IVT BP target: SBP <185 mmHg / DBP <110 mmHg (use labetalol, nicardipine, or clevidipine)

Endovascular Thrombectomy (EVT) — Adults

• Device selection: Stent retrievers and aspiration devices have similar efficacy; choice by operator experience
• Anesthesia: General anesthesia vs. conscious sedation — no definitive superiority; procedural considerations guide choice

Basilar Artery Occlusion (BAO)

• EVT within 24h, NIHSS ≥10, PC-ASPECTS ≥6 — COR 1 A: ATTENTION (HR 2.06 for functional independence) and BAOCHE trials established EVT benefit; represents major upgrade from 2018 guideline
• IVT should not be withheld if eligible while EVT is being prepared (bridging approach)

Pediatric Stroke and EVT

• Age ≥6y, within 6h — COR 2a: Reasonable by extrapolation from adult data
• Age ≥6y, 6–24h — COR 2a: Extended window reasonable in selected children
• Age 28 days–6y, within 24h — COR 2b: May be considered; limited evidence base

Blood Pressure Management

• Pre-IVT: Lower SBP to <185 mmHg / DBP to <110 mmHg before thrombolysis
• Post-IVT (24h): Maintain BP <180/105 mmHg; targeting SBP <140 mmHg post-IVT — COR 3: No Benefit (ENCHANTED trial — no improvement in outcomes with intensive lowering)
• Post-EVT with successful reperfusion (mTICI 2b/2c/3) — SBP <140 mmHg within 72h — COR 3: HARM: ENCHANTED2/MT trial: intensive BP lowering to <140 mmHg within 72h of successful EVT increased death and disability vs. <180 mmHg target; optimal target is 140–180 mmHg
• No reperfusion after EVT: BP management individualized; avoid SBP >180 mmHg
• Permissive hypertension: SBP up to 220 mmHg acceptable in first 24h in patients not receiving reperfusion therapy (no evidence to lower unless organ damage)

Blood Glucose Management

• Hyperglycemia: Treat blood glucose >180 mg/dL with insulin infusion (target 140–180 mg/dL); COR 1
• Intensive glucose control (80–130 mg/dL) — COR 3: No Benefit: SHINE trial (n=1,151): intensive IV insulin targeting 80–130 mg/dL showed no difference in functional outcome vs. standard care and increased hypoglycemia; moderate control preferred
• Hypoglycemia: Treat immediately; glucose <60 mg/dL is a stroke mimic and absolute contraindication to IVT

Antiplatelet Therapy

• DAPT for minor AIS or high-risk TIA within 24h — COR 1 A:
  • Aspirin 325 mg loading + clopidogrel 300–600 mg loading, then aspirin 75–100 mg + clopidogrel 75 mg × 21 days → aspirin or clopidogrel monotherapy
  • CHANCE (n=5,170, Asian) and POINT (n=4,881, Western) trials; CHANCE-2 (ticlopidine-guided genotyping)
• Ticagrelor + aspirin × 30 days for high-risk minor AIS/TIA with LAA etiology — COR 2a: THALES trial (HR 0.83 for stroke/death); higher bleeding vs. aspirin alone; consider in LAA (large artery atherosclerosis) mechanism
• Aspirin within 24–48h of AIS (if IVT not given) — COR 1 A: IST, CAST trials — modest but consistent benefit
• Aspirin NOT within 24h of IVT: Risk of hemorrhagic transformation

Early Anticoagulation After AF-Related Stroke

• Early OAC initiation (within 4–14 days) vs. delayed (≥14 days) — COR 2a: ELAN trial (N=2,013): early OAC (within 48h for minor, 3–7d for moderate, 6–7d for severe strokes) — non-inferior to late OAC for recurrent stroke, with no increase in symptomatic ICH; early initiation reasonable for milder strokes
• Timing still individualized based on infarct size, hemorrhagic transformation risk, and clinical severity; severe strokes (NIHSS >15) with large infarcts: delay ≥14 days
• Heparin bridging — COR 3: Harm: Not recommended while awaiting OAC initiation — no benefit, increased hemorrhage

DVT Prevention

• Intermittent pneumatic compression (IPC) — COR 1 A: CLOTS 3 trial — reduces proximal DVT (4.6% vs. 7.7%); recommended in all immobilized AIS patients
• Elastic compression stockings — COR 3: HARM: CLOTS 1 trial — elastic stockings showed no benefit and increased skin breakdown; contraindicated in AIS DVT prevention
• Subcutaneous anticoagulants (heparin/LMWH): Not recommended within first 24h; may be used for DVT prevention in stable patients after 24h if reperfusion not given and no hemorrhagic transformation

Dysphagia and Nutritional Support

• Swallowing screening before oral feeding — COR 1: All patients; bedside water swallow screen or formal speech pathology evaluation
• Pharyngeal electrical stimulation (PES) for dysphagia — COR 2a: NEW recommendation; PHAST trial showed modest improvement in dysphagia; can be delivered via nasogastric tube electrode
• Early enteral nutrition if unable to swallow: Nasogastric tube preferred over PEG in first 2–3 weeks (no survival difference: FOOD trial)

Rehabilitation and Recovery

• Early mobilization within 24–72h (low-to-moderate intensity) — COR 1: Short, gentle sitting/standing to prevent complications
• High-dose, very early mobilization <24h after AIS — COR 3: HARM: AVERT trial — early high-intensity mobilization within first 24h associated with worse 3-month outcomes (OR 0.59 for favorable outcome); contraindicates very early aggressive physiotherapy
• SSRIs for motor recovery — COR 3: No Benefit: FOCUS, AFFINITY, EFFECTS trials (n=>3,000 combined): fluoxetine 20 mg daily for 6 months does not improve functional outcome and increases fracture risk
• tPA or EVT for improved functional recovery: Evidence reviewed; functional outcomes improve in parallel with successful reperfusion

Brain Swelling and Herniation

• Decompressive hemicraniectomy ≤60 years with malignant MCA infarction — COR 1 A: DESTINY, DECIMAL, HAMLET, HAMLET-D trials — NNT 2 for survival; significant reduction in mortality (78% → 29%); 43% achieve mRS ≤3 (acceptable disability)
• Decompressive hemicraniectomy >60 years — COR 2b: DESTINY II: reduces mortality (33% → 70% at 6 months) but majority survive with severe disability (mRS 4–5); decision requires individualized goals-of-care discussion
• IV glibenclamide (3 mg/day) for cerebral edema in large MCA infarct — COR 3: No Benefit: CHARM trial (n=94, phase 2b): failed to meet primary outcome of reduced brain swelling on MRI; not recommended
• Osmotic therapy (mannitol/hypertonic saline): Reasonable for acute herniation as bridge to surgery; no RCT data on outcomes

Limitations of the Document

• Guideline scope: Covers early management (prehospital through first days of hospitalization); secondary prevention and long-term rehabilitation are addressed in separate AHA guidelines
• Pediatric evidence base: EVT and IVT recommendations for children are largely extrapolated from adult RCTs; dedicated pediatric stroke trials are limited
• ASPECTS inter-observer variability: ASPECTS scoring is subject to significant inter-reader variability (kappa 0.3–0.7); AI-assisted ASPECTS may improve consistency but is not yet standard of care
• Non-LVO IVT: Expanded EVT eligibility means fewer patients with LVO may receive IVT; optimal strategy in LVO with rapid door-to-groin time remains debated
• Extended window imaging selection: Not all centres have 24/7 perfusion imaging; selection criteria for extended EVT window require MRI/CT perfusion — limits applicability in resource-limited settings
• Basilar artery occlusion: ATTENTION enrolled predominantly Asian patients; PC-ASPECTS ≥6 threshold requires validation in diverse populations

Key Concepts Mentioned

• concepts/DAPT-Strategies — minor AIS/TIA antiplatelet management (COR 1A; 21-day regimen)
• concepts/ASCVD-Risk-Assessment — secondary stroke prevention risk framework

Key Entities Mentioned

• entities/Ischemic-Stroke — primary entity created from this source
• entities/Hypertension — BP management post-IVT and post-EVT; post-EVT COR 3:Harm for SBP <140
• entities/Atrial-Fibrillation — early OAC after AF-related AIS (ELAN trial, COR 2a)

Wiki Pages Updated

• Created: wiki/entities/Ischemic-Stroke.md
• Updated: wiki/entities/Hypertension.md — post-EVT BP harm data
• Updated: wiki/entities/Atrial-Fibrillation.md — early anticoagulation after AIS section
• Updated: wiki/concepts/DAPT-Strategies.md — AIS/TIA DAPT regimens
• Updated: wiki/sourceindex.md
• Updated: wiki/wikiindex.md