Summary

The 2026 AHA/ASA guideline replaces the 2018 guideline and 2019 update for early management of acute ischemic stroke, spanning prehospital care through early in-hospital management. Major updates include endorsement of tenecteplase as equivalent to alteplase within 4.5 hours, expanded EVT eligibility (large cores, basilar occlusion to 24 h, selected pediatric patients), extended-window IVT (4.5–9 h with perfusion mismatch), abandonment of intensive glucose (80–130 mg/dL) and intensive post-EVT BP (<140 mm Hg) targets, mobile stroke unit endorsement, and first-time pediatric EVT/IVT recommendations.

Key Recommendations

Use either tenecteplase 0.25 mg/kg (max 25 mg) IV bolus or alteplase 0.9 mg/kg (max 90 mg, 10% bolus then infusion) for eligible AIS within 4.5 hours of symptom onset.
Initiate IVT as quickly as possible without delay for advanced multimodal imaging (CTA/MRA, CTP) when patient is otherwise eligible within 4.5 hours.
Do not give IVT for mild, non-disabling deficits within 4.5 hours; use DAPT (clopidogrel + aspirin) instead in this population.
Offer EVT for anterior-circulation ICA/M1 LVO with NIHSS ≥6, prestroke mRS 0–1, ASPECTS 3–10 within 6 hours, and for selected patients up to 24 hours including those with large cores (ASPECTS 3–5).
Perform EVT within 24 hours for basilar artery occlusion with NIHSS ≥10, mRS 0–1, and PC-ASPECTS ≥6.
Do not target SBP <140 mm Hg after IVT (no benefit) or after successful EVT recanalization (harm); maintain SBP 140–180 mm Hg post-IVT.
Do not use intensive insulin to target glucose 80–130 mg/dL; treat hyperglycemia >180 mg/dL while avoiding hypoglycemia, and correct glucose <60 mg/dL.
Use mobile stroke units over conventional EMS where available to accelerate thrombolytic treatment and improve functional outcomes.
Give DAPT (clopidogrel + aspirin) for 21 days followed by SAPT in minor noncardioembolic AIS (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), starting within 24 hours.
In AIS with atrial fibrillation, early initiation of oral anticoagulation (within 4 days for minor/moderate stroke) is reasonable and safe.
Use intermittent pneumatic compression (not graded compression stockings) for DVT prophylaxis in immobile stroke patients; avoid elastic stockings due to skin injury.
Do not give adjunctive argatroban, eptifibatide, or pre-EVT tirofiban with thrombolysis — no benefit and possible harm; do not skip IVT before EVT in eligible patients within 4.5 hours.
Maintain SpO2 >94% with supplemental oxygen only if hypoxic; treat fever >37.5°C to maintain normothermia (do not induce hypothermia).

Thresholds & Doses

IVT window: within 4.5 hours of symptom onset or last known well for standard treatment.
Tenecteplase dose: 0.25 mg/kg IV bolus, maximum 25 mg.
Alteplase dose: 0.9 mg/kg IV (max 90 mg), 10% as bolus over 1 min, remainder infused over 60 min.
Pre-thrombolysis BP target: <185/110 mm Hg; post-IVT BP: <180/105 mm Hg for 24 hours.
Post-EVT BP: avoid SBP <140 mm Hg in first 72 hours after successful recanalization (mTICI 2b/2c/3).
Glucose target: 140–180 mg/dL; treat hypoglycemia <60 mg/dL; avoid intensive control to 80–130 mg/dL.
Temperature: treat >37.5°C to maintain normothermia.
Oxygen: supplement to maintain SpO2 >94%; not routinely for nonhypoxic patients.
EVT eligibility 0–6 h: NIHSS ≥6, prestroke mRS 0–1, ASPECTS 3–10, anterior LVO (ICA/M1).
EVT eligibility 6–24 h: age <80, NIHSS ≥6, prestroke mRS 0–1, ASPECTS 3–5 with salvageable tissue.
Basilar EVT: within 24 hours, NIHSS ≥10, PC-ASPECTS ≥6, baseline mRS 0–1.
Extended-window IVT: 4.5–9 hours from onset or wake-up <9 h from sleep midpoint with perfusion mismatch (ratio >1.2, mismatch >10 mL, core <70 mL).
DAPT eligibility: NIHSS ≤3 (CHANCE/POINT) or ≤5 (THALES/INSPIRES), ABCD2 ≥4; clopidogrel 300–600 mg load then 75 mg/d + aspirin for 21–90 days.
Door-to-needle target: ≤25 minutes door-to-imaging; door-in-door-out target ≤120 minutes for transfers.
Pediatric EVT: age ≥6 years with LVO within 6 hours (or 6–24 h with salvageable tissue); age 28 days–6 years may be reasonable with experienced operators.
Pediatric IVT: alteplase 0.9 mg/kg in patients 28 days–18 years with disabling AIS within 4.5 hours (efficacy uncertain).
Decompressive hemicraniectomy: within 48 hours for malignant MCA infarction (strongest benefit ≤60 years).
Tenecteplase 0.4 mg/kg dose is not recommended (no added benefit, possible harm).
EMS scene time target: ≤15 minutes; dispatch within 90 seconds of 9-1-1 call.

Citations

Section 4.6.2 (Choice of Thrombolytic Agent), COR 1 — tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg within 4.5 hours.
Section 4.7.2 (EVT for Adults) and Figure 3 — anterior circulation LVO EVT eligibility criteria and time windows including large-core trials.
Section 4.7.3 (Posterior Circulation Stroke), COR 1 — basilar artery occlusion EVT within 24 hours with PC-ASPECTS ≥6.
Section 4.3 (Blood Pressure Management), COR 3 No Benefit/Harm — intensive SBP <140 mm Hg post-IVT/post-EVT.
Section 4.5 (Blood Glucose Management), COR 3 No Benefit — SHINE trial; intensive glucose 80–130 mg/dL not recommended.
Section 4.8 and Table 9 (DAPT trials: CHANCE, POINT, THALES, INSPIRES, CHANCE-2) — DAPT regimens for minor stroke/high-risk TIA.
Section 2.5 (Role of Mobile Stroke Units), COR 1 — MSU over conventional EMS based on B_PROUD and BEST-MSU trials.
Section 4.6.3 and Table 3 — extended-window IVT imaging criteria (WAKE-UP, EXTEND, TRACE-III, TIMELESS).
Section 5.4 (DVT Prophylaxis) — CLOTS 1/2/3 trials supporting IPC and against graded compression stockings.
Top Take-home Messages 1–10 and ‘What Is New and of High Impact’ table — summary of practice-changing recommendations.