The American Stroke Association has released the 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, featuring expanded eligibility for advanced treatments and the first detailed recommendations for pediatric stroke care. This update replaces the 2018 edition and its 2019 update, reflecting a surge of new evidence in acute ischemic stroke care and providing an evidence-based roadmap for health care professionals from prehospital recognition to hospital management.
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, the most common type, occurs when blood flow to the brain is suddenly blocked by a blood clot. The guideline's importance lies in its potential to reduce long-term disability through standardized, rapid treatment protocols across hospitals of all sizes.
"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 organizations including the American Association of Neurological Surgeons and the Neurocritical Care Society.
A major advancement is the inclusion of first-time guidance for pediatric stroke, which though rare can occur in infants, children and teens. Children may exhibit the same F.A.S.T. warning signs as adults but more often show additional symptoms like sudden severe headache with vomiting, new onset seizures, sudden confusion, vision trouble, or difficulty walking. The guideline advises rapid magnetic resonance imaging and angiography to identify blockages and 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, potentially up to 24 hours if imaging shows salvageable brain tissue.
The guideline emphasizes faster care delivery through regional stroke systems linking 9-1-1 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. In regions with access to thrombectomy-capable stroke centers, EMS should transport patients with suspected large vessel occlusion directly to these centers to reduce delays. Hospitals should complete initial brain scans within 25 minutes of arrival to confirm stroke type and begin appropriate treatment immediately.
For clot-busting medications, the guideline endorses either tenecteplase or alteplase within 4.5 hours of symptom onset, with tenecteplase offering the advantage of single-dose infusion compared to alteplase's 60-minute period. Treatment may still be effective up to 24 hours after symptom onset if advanced brain imaging shows brain tissue that hasn't been irreversibly damaged. For clot-removal procedures, endovascular thrombectomy is now recommended in selected patients for up to 24 hours after symptom onset even with significant brain tissue damage, and eligibility expands to include some patients with blockages in the back of the brain and those with mild or moderate preexisting disability within the first 6 hours.
The guideline underscores that coordinated systems of care are essential for improving survival and recovery, encouraging hospitals to use reporting systems like 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 can work together to cut 30 to 60 minutes off treatment time to improve patient outcomes and reduce disability." The new guideline will be featured at the American Heart Association's 2026 International Stroke Conference in New Orleans.
