2026 AHA/ASA Guidelines Expand Stroke Treatment Options

The American Heart Association/American Stroke Association (AHA/ASA) has released its most comprehensive update to acute ischemic stroke management guidelines since 2018 — and the changes are significant. From expanded eligibility for thrombolysis and mechanical thrombectomy to the first-ever guidance on pediatric stroke, this overhaul reflects years of accumulated clinical trial data and is already reshaping how stroke care is delivered.

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Why These Guidelines Matter

Seven years have passed since the last full guideline. In that time, a wave of landmark stroke trials produced results that "changed practice and should change practice more," according to Dr. Shyam Prabhakaran of the University of Chicago Medicine and chair of the writing group. The new guideline, published in Stroke and presented at the International Stroke Conference in New Orleans, aims to close that gap — and the AHA has committed to more frequent, real-time updates going forward.

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Mobile Stroke Units: A New Class 1 Recommendation

One of the most headline-worthy additions is a Class 1 recommendation in support of mobile stroke units (MSUs) — specialized ambulances equipped with CT scanners and trained teams capable of administering IV thrombolysis in the field. Supported by trials including B_PROUD and BEST-MSU, MSUs have demonstrated measurable improvements in functional outcomes for patients with suspected acute ischemic stroke.

The challenge? Adoption in the United States remains limited due to staffing constraints and a lack of reimbursement pathways. The hope is that this guideline nudges policymakers toward broader financial support.

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Thrombolysis: Expanded Windows and a New First-Line Option

Tenecteplase Reaches Class 1 Status

Perhaps the most practice-changing update in thrombolysis is the elevation of tenecteplase (0.25 mg/kg) to a Class 1 recommendation alongside alteplase (0.9 mg/kg) for patients presenting within 4.5 hours of stroke onset. Multiple trials established tenecteplase's non-inferiority, and its practical advantages are compelling: it's administered as a single injection rather than a one-hour infusion, simplifying workflows and facilitating rapid interhospital transfer.

Extended Treatment Windows

The guidelines also push the boundaries of when thrombolysis can be considered:

• 4.5 to 9 hours after onset (or wake-up stroke): Class 2a recommendation when advanced imaging confirms salvageable brain tissue (supported by the EXTEND trial).
• 4.5 to 24 hours in select patients with large-vessel occlusions (LVOs) who cannot undergo thrombectomy: Class 2b recommendation, supported by the HOPE and TRACE-III trials (despite the TIMELESS trial's neutral findings for tenecteplase in this window).

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Mechanical Thrombectomy: More Patients, More Conditions

Large-Core Strokes and Extended Windows

Thrombectomy eligibility has expanded substantially. A new Class 1 recommendation supports thrombectomy for patients with anterior circulation LVOs presenting 6 to 24 hours after onset who are under 80, have an NIHSS score ≥ 6, and show an ASPECTS score of 3 to 5 without significant mass effect — based on the SELECT2 and ANGEL-ASPECT trials.

Posterior Circulation

Evidence from the ATTENTION and BAOCHE trials now supports thrombectomy for basilar artery occlusion (Class 1): patients with an NIHSS ≥ 10 and mild ischemic damage presenting within 24 hours should be considered for the procedure to improve outcomes and reduce mortality.

Where Evidence Is Still Limited

The guidelines are more cautious about medium- and small-vessel occlusions (distal vessels), where current device technology has not yet demonstrated consistent efficacy. More trials are anticipated as technologies improve.

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Medical Management Updates

Blood Glucose Control

A Class III recommendation advises against using IV insulin to target blood glucose of 80–130 mg/dL in hospitalized stroke patients with hyperglycemia. The approach hasn't shown functional benefit and raises the risk of severe hypoglycemia.

Blood Pressure Targets After Reperfusion

Two important Class III recommendations address blood pressure management:

1. After IV thrombolysis for mild-to-moderate stroke, do not lower systolic BP below 140 mmHg (vs. the previous 180 mmHg target) — intensive reduction showed no functional benefit.
2. After successful endovascular thrombectomy for anterior circulation LVO, avoid BP goals below 140 mmHg for the first 72 hours post-recanalization, as supported by ENCHANTED2/MT and OPTIMAL-BP — this approach may cause harm.

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Pediatric Stroke: A First Step

For the first time, the guidelines include dedicated guidance on pediatric stroke — addressing diagnosis, and considering thrombolysis and endovascular thrombectomy in younger patients. The evidence base here is still developing, but clinicians now have a starting framework. Further trials in this underserved population are a clear priority.

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What's on the Horizon?

Several knowledge gaps remain ripe for future research:

• Distal vessel thrombectomy as device technology matures
• Advanced imaging to safely guide thrombolysis in extended windows, particularly in low-resource settings
• Neuroprotective agents as adjunctive therapy in the modern reperfusion era — a category that may warrant revisiting given improved patient selection

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The Bottom Line

The 2026 AHA/ASA guidelines represent a meaningful leap forward in stroke care, driven by a decade of robust clinical trial data. The expansion of treatment eligibility — in terms of both time windows and patient profiles — offers clinicians more tools and more opportunities to improve outcomes. As the AHA transitions to real-time guideline updates, clinicians can expect the evidence to keep moving. The key question now is whether health systems, payers, and policymakers will keep pace.

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Source: AHA/ASA Early Management of Acute Ischemic Stroke Guideline, published in Stroke (January 2026). Presented at the International Stroke Conference, New Orleans, LA.