Stroke

Acute ischemic stroke guideline: treatment options expand, pediatric guidance added

February 3, 2026

The 2026 AHA/ASA acute ischemic stroke guideline update reflects new trial data and system‑level learnings to accelerate drug delivery and expand access to advanced therapies without delaying thrombectomy. Guidance now spans adults and children, emphasizes direct transport to thrombectomy‑capable centers where feasible, and standardizes rapid imaging—even when advanced perfusion is unavailable. The new guidance will be presented at the annual International Stroke Conference (February 4-6, 2026).

Key drug-related updates

IV thrombolysis

• Tenecteplase or alteplase recommended within 4.5 hours for eligible patients, elevating tenecteplase to a first‑line alternative with simpler bolus dosing
• Treat disabling deficits regardless of National Institutes of Health Stroke Scale (NIHSS) score when patients present within the standard 4.5‑hour window.
• Extended IV thrombolysis (4.5–9 hours) may be used in select patients with favorable advanced imaging.

Antiplatelet therapy

• Dual antiplatelet therapy preferred over thrombolysis in patients with non‑disabling deficits presenting within 4.5 hours.

Combination therapy

• Don’t delay thrombectomy to assess response to IV thrombolysis; eligible patients should receive both therapies rapidly and sequentially.

BP management

• Avoid intensive systolic BP lowering (<140 mm Hg) in patients with mild–moderate acute ischemic stroke treated with IV thrombolytics (no benefit compared with <180 mm Hg).
• Don’t use intensive BP lowering after successful endovascular therapy (EVT) in patients without another indication for BP control, due to potential harm.

Pediatric stroke

• IV alteplase may be considered within 4.5 hours in children (28 days–18 years) with disabling ischemic stroke. EVT reasonable in children age ≥6 years within 6 hours or 6 to 24 hours if imaging shows salvageable brain tissue.

Sources:

Prabhakaran S, et al; Peer Review Committee. (2026, January 26). Stroke. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. https://pubmed.ncbi.nlm.nih.gov/41582814/

(2026, January 26). American Heart Association. New guideline expands stroke treatment for adults, offers first pediatric stroke guidance. https://newsroom.heart.org/news/new-guideline-expands-stroke-treatment-for-adults-offers-first-pediatric-stroke-guidance