Guideline Highlights:
- The 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke includes key advances in stroke treatment, such as expanded eligibility for clot-removal procedures, new evidence supporting the use of the clot-busting medication tenecteplase, and the implementation of mobile stroke units to deliver care faster and reduce the risk of long-term disability.
- Also included in the guideline are the first detailed recommendations for diagnosing and treating stroke in children.
- The new guideline is endorsed by the American Association of Neurological Surgeons/Congress of Neurological Surgeons, the Neurocritical Care Society, the Society for Academic Emergency Medicine, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology. The American Academy of Neurology affirmed the guideline as an educational tool for neurologists.
DALLAS, Jan. 26, 2026 — Expanded eligibility for advanced stroke therapies and new recommendations for diagnosing and treating stroke in children and adults are among the major updates in the new 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke from the American Stroke Association, a division of the American Heart Association, published today in the Association's flagship journal Stroke.
According to the American Heart Association's 2026 Heart Disease and Stroke Statistics, stroke is now the #4 leading cause of death in the U.S. Every year, nearly 800,000 people in the U.S. have a stroke, and it is also a leading cause of serious, long-term disability. There are several types of strokes. Ischemic stroke is the most common type and occurs when blood flow to the brain is suddenly blocked in a vessel, usually by a blood clot.
The new guideline replaces the 2018 edition and its 2019 update to reflect a surge of new evidence in acute ischemic stroke care. It provides an evidence-based roadmap for health care professionals to recognize, diagnose and treat ischemic stroke, from prehospital recognition to 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 for the guideline and the James Nelson and Anna Louise Raymond Professor of Neurology and chair of the department of neurology at the University of Chicago Medicine. "New recommendations in the guideline expand access to cutting-edge treatments, such as clot-removal procedures and medications, simplify imaging requirements so more hospitals can act quickly, and introduce guidance for pediatric stroke for the first time."
Since the 2019 update, several landmark trials have transformed stroke care, including interventions for large vessel occlusion in the brain, clot-busting or clot-removal therapies, and streamlined hospital workflows. The 2026 guideline brings that progress together to standardize stroke care across hospitals of all sizes and ensure rapid, evidence-based treatment for every patient, regardless of where they live.
The guideline reinforces that outcomes depend on what treatments are provided to stroke patients and how quickly and efficiently they are delivered. From the first 9-1-1 call to hospital discharge, coordinated systems of care can be a key factor in preventing lifelong disability. The updated recommendations focus on enhancing those systems, accelerating the use of imaging techniques and medication delivery, and expanding access to advanced procedures like endovascular thrombectomy (EVT, the mechanical removal of a blood clot).
First-time guidance for pediatric stroke
Though rare, stroke can occur in infants, children and teens, and prompt recognition is critical. Children can exhibit the same warning signs as adults described by the acronym F.A.S.T.: Face Drooping; Arm Weakness; Speech Difficulty; Time to Call 911. However, stroke warning signs in children more often may also include:
- Sudden severe headache, especially with vomiting and sleepiness
- New onset of seizures, usually on one side of the body
- Sudden confusion, difficulty speaking or understanding others
- Sudden trouble seeing in one or both eyes, and/or
- Sudden difficulty walking, dizziness, loss of balance or coordination
Currently available stroke screening tools have been developed for adults, so they do not accurately distinguish strokes in the pediatric population from mimics (conditions with similar symptoms). Some examples of mimics include migraine, seizure, traumatic brain injury, or brain tumor. The guideline advises rapidly performing magnetic resonance imaging (MRI) and angiography (MRA) to identify blockages to differentiate arterial ischemic stroke fromhemorrhagic stroke and rule out mimics in pediatric stroke. Computed tomography (CT) is reasonable if MRI is not available in a timely manner, according to the guideline.
For treating ischemic stroke in children, the guideline states that the intravenous (IV) clot-busting agent alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits. Also, mechanical clot-removal performed by experienced neurointerventionalists may be effective for large-vessel blockages in children 6 years and older within 6 hours and may be reasonable up to 24 hours after symptoms begin if imaging shows salvageable brain tissue.
"These recommendations represent a major step toward standardized, evidence-based care for children," Prabhakaran said. "They also highlight how much more we still need to learn about pediatric stroke."
Faster care from the field to the hospital
The guideline emphasizes the need for regional stroke systems of care that link 9-1-1 call centers, emergency medical services (EMS) agencies, hospitals and telemedicine networks. Mobile stroke units, which are ambulances equipped with CT scanners and stroke-trained care teams, demonstrate how faster response times can accelerate recognition and treatment delivery.
In regions with reasonable access to thrombectomy-capable stroke centers (TSCs), EMS should transport patients with suspected large vessel occlusion to the nearest TSC for immediate evaluation. Direct transport to a TSC can be beneficial to reduce delays in diagnosis and treatment, helping more patients receive EVT when indicated. Further, in regions without geographic access to TSCs, the guideline focuses on reducing door-in-door-out times at hospitals transferring patients to TSCs.
Rapid diagnosis and imaging
Speed and accuracy are critical for diagnosing and treating stroke. Hospitals should complete an initial brain scan within 25 minutes of arrival to confirm that symptoms are caused by an ischemic stroke and not a brain bleed, so that the right treatment can begin immediately. Confirming the stroke type ensures that clot-dissolving or clot-removal treatments can begin safely and without delay.
Advanced brain imaging techniques such as MRI or CT perfusion can sometimes show how much the stroke has damaged the brain tissue. The new guideline also advises hospitals without advanced perfusion imaging to use a standard CT scoring system called ASPECTS to identify candidates for clot-removal procedures.
Clot-busting medications
The guideline endorses the use of either tenecteplase or alteplase within 4.5 hours of symptom onset. Both medications are effective at dissolving blood clots. However, tenecteplase, a single-dose IV infusion, has the advantage of simplifying treatment compared to the 60-minute period needed for alteplase infusion.
For some people who wake up with stroke symptoms or arrive at the hospital after the standard 4.5-hour window for treatment, clot-busting treatment may still be effective up to 24 hours after the onset of stroke symptoms, if advanced brain imaging shows brain tissue that has not been irreversibly damaged.
Clot-removal procedures (endovascular thrombectomy or EVT)
Removing clots directly from blocked brain arteries, a procedure called thrombectomy, remains a powerful treatment for major strokes caused by large-vessel blockages in eligible patients. Patients eligible for both clot-busting medications and thrombectomy should receive both, rapidly and sequentially, without delaying the procedure to "see if symptoms improve."
- EVT is now recommended in selected patients for up to 24 hours after symptom onset even if imaging shows certain large core infarcts by ASPECTS, meaning a significant area of brain tissue has been severely damaged due to lack of blood flow.
- Based on new evidence, eligibility for EVT also includes some patients with blockages in the back of the brain (posterior circulation stroke).
- Some people with mild or moderate preexisting disability may also benefit in the first 6 hours after symptom onset.
- EVT is not routinely recommended for smaller blockages in medium- or small arteries in the brain but may be considered in a clinical trial.
Improving survival and recovery
The guideline underscores that coordinated systems of care are essential for improving survival and recovery. Hospitals are encouraged to use reporting systems such as the American Stroke Association's Get With The Guidelines® - Stroke Registry to track treatment times and outcomes, expand telemedicine and imaging access, and establish transfer agreements that link primary and comprehensive stroke centers.
"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."
2026 International Stroke Conference
The new guideline will be featured at the American Heart Association's 2026 International Stroke Conference, to be held February 4-6, 2026, in New Orleans.
- What's New in the 2026 Acute Ischemic Stroke Guideline: Process Overview and Key Updates from the Chairs; Thursday, February 5, 2:30-3:30 p.m. CT
- Acute Ischemic Stroke Guidelines: Q&A Part I (Fireside Chat); Thursday, February 5, 3:45-4:45 p.m. CT
- Acute Ischemic Stroke Guidelines: Q&A Part II (Fireside Chat); Thursday, February 5, 5:00-6:00 p.m. CT
This guideline was prepared by the volunteer writing group on behalf of the American Heart Association's Stroke Council and the American Stroke Association. Since 1990, the American Stroke Association has translated scientific evidence into clinical practice guidelines with recommendations to improve cerebrovascular health.
Co-Vice Chairs of the volunteer writing group are Nestor R. Gonzalez, M.D., M.S.C.R., FAHA, and Kori S. Zachrison, M.D., M.Sc., FAHA. Co-authors and members of the writing group are Opeolu Adeoye, M.D., M.S.; Anne W. Alexandrov, Ph.D., A.G.A.C.N.P.-B.C., A.N.V.P.-B.C.; Sameer A. Ansari, M.D., Ph.D., FAHA; Sherita Chapman, M.D., FAHA; Alexandra L. Czap, M.D.; Oana M. Dumitrascu, M.D., M.Sc., FAHA; Koto Ishida, M.D.; Ashutosh P. Jadhav, M.D., Ph.D., FAHA; Brenda Johnson, D.N.P., M.S.N., F.N.P.-B.C., A.N.V.P.-B.C., FAHA; Karen C. Johnston, M.D., M.Sc.; Pooja Khatri, M.D., M.Sc., FAHA; W. Taylor Kimberly, M.D., Ph.D., FAHA; Vivien H. Lee, M.D., FAHA; Thabele M. Leslie-Mazwi, M.D.; Brian Mac Grory, M.B., B.Ch., B.A.O., M.H.Sc., M.R.C.P., FAHA; Tracy E. Madsen, M.D., M.C.T.R., Ph.D., FAHA; Bijoy Menon, M.D.; Eva A. Mistry, M.B.B.S., M.S.C.I., FAHA; Soojin Park, M.D.; Natalia Perez de la Ossa, M.D., Ph.D.; Mathew Reeves, B.V.Sc., Ph.D., FAHA; Tania Saiz; Phillip A. Scott, M.D., M.B.A., FAHA; Dana Schwartzberg; Sunil A. Sheth, M.D.; Peter Sporns, M.D., M.H.B.A.; Sabrina Times, D.H.Sc., M.P.H.; Stavropoula Tjoumakaris, M.D., M.B.A., FAHA; Stacey Q. Wolfe, M.D.; and Shadi Yaghi, M.D., FAHA. Authors' disclosures are listed in the manuscript.
