The American Stroke Association has released the 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, featuring expanded treatment eligibility and the first detailed recommendations for pediatric stroke care. Published in the journal Stroke, the guideline aims to standardize and accelerate care across hospitals to improve patient outcomes. According to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, stroke is the fourth leading cause of death in the U.S., with nearly 800,000 people affected annually. Ischemic stroke, caused by a blocked blood vessel in the brain, is the most common type.
Dr. Shyam Prabhakaran, chair of the writing group, stated that this update brings the most important advances in stroke care from the last decade directly into practice. The guideline expands access to clot-removal procedures and medications, simplifies imaging requirements, and introduces pediatric guidance for the first time. For pediatric stroke, which is rare but critical to recognize promptly, the guideline advises rapid magnetic resonance imaging (MRI) and angiography (MRA) to differentiate arterial ischemic stroke from hemorrhagic stroke and rule out mimics like migraine or seizure. The intravenous clot-busting agent alteplase may be considered for children within 4.5 hours, and mechanical clot-removal may be effective for those six years and older within 6 hours, potentially up to 24 hours if imaging shows salvageable brain tissue. More information on stroke warning signs in children is available at https://www.stroke.org/en/about-stroke/stroke-symptoms.
The guideline emphasizes coordinated systems of care linking 9-1-1 call centers, emergency medical services, hospitals, and telemedicine networks. Mobile stroke units, ambulances equipped with CT scanners, can accelerate treatment. In regions with access to thrombectomy-capable stroke centers (TSCs), patients with suspected large vessel occlusion should be transported directly to the nearest TSC to reduce delays. Hospitals should complete an initial brain scan within 25 minutes of arrival to confirm stroke type. The guideline endorses using either tenecteplase or alteplase within 4.5 hours of symptom onset, with tenecteplase offering a simpler single-dose infusion. For some patients, clot-busting treatment may be effective up to 24 hours if advanced imaging shows viable brain tissue.
Clot-removal procedures (endovascular thrombectomy or EVT) are recommended for eligible patients with large-vessel blockages, now including some with blockages in the posterior circulation and those with mild to moderate preexisting disability within 6 hours. EVT is not routinely recommended for smaller blockages but may be considered in clinical trials. The guideline underscores that coordinated care systems are essential for improving survival and recovery. Hospitals are encouraged to use reporting systems like the American Stroke Association’s Get With The Guidelines® - Stroke Registry to track outcomes. The new recommendations will be featured at the American Heart Association’s 2026 International Stroke Conference in New Orleans. Additional resources on stroke management are available at https://www.heart.org/en/professional/guidelines-and-statements.
