Acute ischemic stroke (AIS) remains a leading cause of disability and death worldwide. The 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, from the American Heart Association/American Stroke Association (AHA/ASA), replaces the 2018 guideline and 2019 focused update. It incorporates evidence from randomized controlled trials, meta-analyses, and observational studies published through early 2025, addressing prehospital systems, emergency evaluation, reperfusion therapies, supportive care, in-hospital complications, and early secondary prevention for adults, with new guidance extending to select pediatric cases.
A multidisciplinary writing group reviewed high-quality evidence from MEDLINE, PubMed, and Cochrane databases (searched September–December 2024, with updates through March 2025). Recommendations use Class of Recommendation (COR) and Level of Evidence (LOE) grading, emphasizing time-sensitive interventions to improve functional outcomes, reduce symptomatic intracranial hemorrhage, and minimize long-term disability.
Prehospital: Endorse mobile stroke units and refined EMS triage for direct transport to comprehensive centers. Emergency: Prioritize NIHSS assessment, non-contrast CT/MRI to rule out hemorrhage, and rapid vascular imaging for large vessel occlusion (LVO). Reperfusion: Tenecteplase (0.25 mg/kg bolus) is preferred over alteplase for IV thrombolysis within 4.5 hours for disabling deficits; extended windows (up to 9–24 hours) use imaging mismatch. Endovascular thrombectomy (EVT) is strongly recommended for anterior LVO (within 6–24 hours) and basilar occlusion (up to 24 hours), with expanded criteria for larger infarct cores. Antiplatelet therapy includes short-term dual therapy for minor non-cardioembolic strokes; early direct oral anticoagulants are safe in atrial fibrillation-related AIS. Supportive care: Maintain normothermia, avoid intensive BP lowering post-reperfusion, screen for dysphagia, use intermittent pneumatic compression for DVT prophylaxis, and admit to stroke units. Pediatric: Select cases ≥6 years with LVO may benefit from EVT.
This guideline promotes equitable, rapid, evidence-based AIS care through coordinated systems, advanced therapies, and multidisciplinary management. It identifies gaps (e.g., >24-hour windows, rural access, neuroprotection) for future research, aiming to further reduce stroke burden globally.
