Updated guidance from the American Heart Association (AHA)/American Stroke Association (ASA) expands eligibility for acute stroke therapies and outlines the first formal recommendations for diagnosing and treating stroke in children.

“This update brings the most important advances in stroke care from the last decade directly into practice,” Shyam Prabhakaran, MD, chair of the writing group, said in a statement.

“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,” noted Prabhakaran, chair of the Department of Neurology at the University of Chicago Medicine in Chicago.

The 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke was published online on January 26 in Stroke. It replaces the 2018 edition, and its 2019 update to reflect a surge of new evidence in acute ischemic stroke care, the AHA/ASA said.

Fourth Leading Cause of Death

Stroke is now the fourth leading cause of death in the US, with one person dying about every 3 minutes, according to the latest statistics.

Over the past decade, several landmark trials have reshaped acute stroke care, including interventions for large vessel occlusion, thrombolysis, or endovascular thrombectomy (EVT), and streamlined hospital workflows.

“The 2026 guidance 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 AHA/ASA noted. 

The latest guideline reinforces that stroke outcomes depend on both treatment selection and speed of delivery, with a strong focus on integrated stroke systems from the 9-1-1 call through hospital discharge.

It endorses rapid brain imaging, recommending completion of an initial scan within 25 minutes of hospital arrival to distinguish ischemic stroke from intracranial hemorrhage and allow for timely clot-dissolving or clot-removal therapy.

For thrombolysis, the guideline supports use of either intravenous alteplase or tenecteplase within 4.5 hours of symptom onset. While both medications are effective at dissolving clots, tenecteplase, a single-dose intravenous infusion, has the advantage of simplifying treatment compared to the 60-minute period needed for alteplase infusion, the guideline states. 

For patients who wake up with stroke symptoms or arrive at the hospital after the 4.5-hour treatment window, 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.

For clot removal, EVT is recommended for major stroke caused by large vessel occlusion. Based on new evidence, eligibility for EVT has been expanded to selected patients up to 24 hours after symptom onset, including certain core infarcts and posterior circulation stroke.

A strategy to forgo intravenous thrombolysis to facilitate EVT is not recommended, based on several recently completed randomized controlled trials. Patients who are eligible for thrombolysis and EVT should receive both, rapidly and sequentially, without delaying the EVT to determine whether symptoms improve, the guideline states. 

First-Time Guidance for Pediatric Stroke

A major addition in the update is guidance on pediatric stroke care.

Though rare, stroke can occur in infants, children, and teens, and warning signs may be similar to adults, as described by the F.A.S.T acronym (face drooping, arm weakness, speech difficulty, and time to call 9-1-1), the guideline notes.

However, stroke signs in children may also include sudden severe headache, especially with vomiting and sleepiness; new onset of seizures, typically on one side; sudden confusion, trouble speaking or understanding others; sudden trouble seeing in one or both eyes; and/or sudden difficulty walking, dizziness, and loss of balance or coordination. 

The guideline points out that currently available stroke screening tools have been developed for adults and do not accurately distinguish stroke in the pediatric population from stroke “mimics” such as migraine, seizure, traumatic brain injury, or brain tumor. 

The guideline advises rapid MRI and magnetic resonance angiography for suspected pediatric stroke to identify blockages, differentiate arterial ischemic stroke from hemorrhagic stroke, and rule out mimics. CT is considered reasonable if MRI cannot be obtained quickly.

For treatment of ischemic stroke in children, intravenous alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits; mechanical thrombectomy may be effective for large-vessel blockages in children 6 years or 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. They also highlight how much more we still need to learn about pediatric stroke,” Prabhakaran said.

The guideline also encourages hospitals to use reporting systems such as the 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 30-60 minutes off treatment time to improve patient outcomes and reduce the likelihood of disability.”

The updated acute ischemic stroke guideline will be featured at the AHA’s 2026 International Stroke Conference, to be held February 4-6, 2026, in New Orleans.

The new guideline was 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.