The American Stroke Association has released its 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, featuring expanded eligibility for clot-removal procedures, new evidence supporting clot-busting medications, and the first detailed recommendations for diagnosing and treating stroke in children. Published in the Association's flagship journal Stroke, the guideline replaces the 2018 edition and its 2019 update to incorporate a decade of advances in stroke care.
Stroke remains the fourth leading cause of death in the United States, with nearly 800,000 people experiencing a stroke annually, according to the American Heart Association's 2026 Heart Disease and Stroke Statistics. Ischemic stroke, caused by blocked blood flow to the brain, is the most common type and a leading cause of serious long-term disability. The new guideline provides an evidence-based roadmap for healthcare professionals from prehospital recognition through hospital management and early recovery.
"This update brings the most important advances in stroke care from the last decade directly into practice," said Shyam Prabhakaran, M.D., M.S., FAHA, chair of the writing group. "New recommendations expand access to cutting-edge treatments, simplify imaging requirements so more hospitals can act quickly, and introduce guidance for pediatric stroke for the first time." The guideline is endorsed by multiple professional societies including the American Association of Neurological Surgeons and the Neurocritical Care Society.
For pediatric stroke, which though rare can occur in infants, children and teens, the guideline provides first-time detailed recommendations. Children may exhibit the same F.A.S.T. warning signs as adults but more often show additional symptoms including sudden severe headache with vomiting, new onset seizures, sudden confusion, vision problems, or difficulty walking. The guideline advises rapid magnetic resonance imaging to differentiate arterial ischemic stroke from hemorrhagic stroke and rule out mimics like migraine or brain tumor. For treatment, intravenous alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits, and mechanical clot-removal may be effective for large-vessel blockages in children 6 years and older within 6 hours.
The guideline emphasizes faster care delivery through enhanced regional stroke systems linking 9-1-1 call centers, emergency medical services, hospitals and telemedicine networks. Mobile stroke units equipped with CT scanners demonstrate how faster response times can accelerate recognition and treatment. Hospitals should complete initial brain scans within 25 minutes of arrival to confirm stroke type and begin appropriate treatment immediately.
For medication treatment, the guideline endorses either tenecteplase or alteplase within 4.5 hours of symptom onset, with tenecteplase offering the advantage of a single-dose infusion compared to alteplase's 60-minute infusion period. Clot-busting treatment may still be effective up to 24 hours after symptom onset for some patients if advanced brain imaging shows salvageable brain tissue.
For clot-removal procedures (endovascular thrombectomy or EVT), eligibility has expanded to include selected patients up to 24 hours after symptom onset, even with certain large core infarcts, and now includes some patients with blockages in the posterior circulation. Patients eligible for both clot-busting medications and thrombectomy should receive both rapidly and sequentially without delay. The guideline recommends that in regions with reasonable access to thrombectomy-capable stroke centers, EMS should transport patients with suspected large vessel occlusion directly to the nearest center to reduce treatment delays.
The guideline underscores that coordinated systems of care are essential for improving survival and recovery, with hospitals encouraged to use reporting systems such as the American Stroke Association's Get With The Guidelines® - Stroke Registry to track treatment times and outcomes. "Time is brain," Prabhakaran said. "This new guideline makes that concept real, showing how systems, from EMS to hospitals, can work together to cut 30 to 60 minutes off treatment time to improve patient outcomes and reduce the likelihood of disability." The new guideline will be featured at the American Heart Association's 2026 International Stroke Conference in New Orleans.
