The American Stroke Association has released the 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, marking a significant update that expands treatment eligibility for adults and provides 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 new evidence that has transformed acute stroke care over the past decade.
According to the American Heart Association's 2026 Heart Disease and Stroke Statistics, stroke remains the fourth leading cause of death in the U.S., with nearly 800,000 Americans experiencing a stroke annually. Ischemic stroke, caused by blood clots blocking brain vessels, represents the most common type and is a leading cause of serious, long-term disability. The updated 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. The guideline expands access to cutting-edge treatments like clot-removal procedures and medications, simplifies imaging requirements so more hospitals can act quickly, and introduces guidance for pediatric stroke for the first time. Since the 2019 update, landmark trials have transformed interventions for large vessel occlusion, clot-busting therapies, and hospital workflows.
The guideline reinforces that outcomes depend on what treatments are provided and how quickly they are delivered. Coordinated systems of care linking 9-1-1 call centers, emergency medical services, hospitals, and telemedicine networks can be key factors in preventing lifelong disability. Mobile stroke units—ambulances equipped with CT scanners and stroke-trained teams—demonstrate how faster response times can accelerate recognition and treatment delivery. In regions with access to thrombectomy-capable stroke centers, EMS should transport patients with suspected large vessel occlusion directly to these facilities to reduce delays.
For the first time, the guideline addresses 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 including sudden severe headache with vomiting, new onset seizures, sudden confusion, vision problems, or difficulty walking. Since available stroke screening tools were developed for adults and don't accurately distinguish strokes from mimics like migraine or seizure in children, the guideline advises rapid magnetic resonance imaging and angiography to identify blockages. For treatment, intravenous clot-busting agent alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits, while mechanical clot-removal may be effective for large-vessel blockages in children six years and older within six hours.
The guideline endorses using 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 administration period. For some patients who wake with symptoms or arrive after the standard window, clot-busting treatment may still be effective up to 24 hours if advanced imaging shows salvageable brain tissue. Endovascular thrombectomy (EVT), the mechanical removal of blood clots, remains powerful for major strokes caused by large-vessel blockages, with eligibility now expanded to include selected patients up to 24 hours after symptom onset and some patients with blockages in the posterior circulation.
Hospitals are encouraged 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 emphasized, noting the guideline shows how systems can work together to cut 30 to 60 minutes off treatment time to improve outcomes and reduce disability likelihood. The new guideline will be featured at the American Heart Association's 2026 International Stroke Conference in New Orleans.
