New Stroke Guidelines for Early Management of Acute Ischemic Stroke from the American Heart Association – What Do I Need to Know?

The American Heart Association published the updated 2026 Guidelines for Acute Ischemic Stroke.   So, “What Do I Need to Know?”

1. Tenecteplase (TNK) is in!

• It is equally preferred to alteplase in the 4.5-hour treatment window for thrombolysis. There are benefits for giving TNK. A major benefit is the ease of administration. The TNK dose is 0.25 mg/kg given as a 5-second IVP, with a max 25 mg. The risk of a medication error is lower compared to alteplase.

2. IV thrombolysis can be given to a selected group of patients for up to 9 hours, since onset (instead of the traditional 4.5 hours).

• Patients with salvageable brain penumbra on imaging
• The last known well is now the midpoint of sleep instead of the right before going to bed within 4.5 hours of symptom recognition.  This allows for inclusion of more patients for therapy.

3. IV thrombolysis should NOT be given for mild, non-disabling stroke.

4. Criteria for dual antiplatelet therapy (DAPT) has changed.

• Can be given for NIHHS of 4 or 5 (was 3 or less)
• Can be started up to 72 hours after stroke onset (not just within 24 hours)

5. Endovascular thrombectomy (EVT) was used for patients with large vessel occlusion (LVO). Now data suggests expanding to other diagnoses such as basilar artery occlusion presenting within 24 hours of symptom onset and NIHSS score ≥ 10.

6. Don’t do intensive blood pressure reduction. Intensive blood pressure lowering does not always improve outcomes!  Can do more harm especially in endovascular thrombectomy therapy.

• Blood pressure goals are the same: 220/100 mm Hg after an acute ischemic stroke not a candidate for IV thrombolysis or endovascular treatment.  This is permissive HTN to perfuse the penumbra of the damaged area.
• Before thrombolytics or EVT, goals are the same: 185/110 mm Hg once you start the medication or therapy and 180/105 for 24 hours after therapy.

7. Don’t aim for a stricter blood glucose goal of 80 – 130 mg/dL.  It’s better to avoid hypoglycemia.  Hypoglycemia is defined as < 60 mg/dL

8. Mobile stroke units are endorsed for rapid thrombolysis delivery and triage.

9. The AHA made their first pediatric stroke recommendations including imaging, registries and treatment considerations.

10. Pharyngeal electrical stimulation is now recommended for post stroke dysphagia.  Post acute stroke care needs to expand to innovative rehabilitation.

Stay tuned for our next blog on Understanding Intracranial Pressure (ICP).  We are doing a few blog posts the month of May.  Be sure to follow along!

May is National Stroke Awareness Month!  If you want more information on recognizing strokes, treating them and preventing them, check out Michelle’s on-demand online Stroke Review Bootcamp course or if you want to increase your neuro knowledge, consider taking Nicole’s on-demand CCRN Review Course, PCCN Review Course or grabbing her Critical Care Survival Guide!

References:

Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., et al. (2026). Guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication, https://doi.org/10.1161/STR.000000000000051

2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association | Stroke