Ischemic stroke
Also known as: CVA · stroke · thrombectomy · thrombolysis
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2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke
American Heart Association / American Stroke Association (AHA/ASA) · 2026
The AHA/ASA's comprehensive guideline covering the acute phase of ischemic stroke care in adults, from prehospital recognition and EMS routing through emergency evaluation, reperfusion decisions, and the first days of in-hospital management, including early complication prevention and starting secondary prevention. Published in the journal Stroke in January 2026, it replaces the 2018 guideline and its 2019 update, and adds pediatric acute ischemic stroke content for the first time.
- Covers the full acute care pathway: prehospital triage and transport, emergency assessment, reperfusion therapy, and early in-hospital management. source
- Supersedes both the 2018 acute ischemic stroke guideline and its 2019 update. source
- Indexed in PubMed as a 2026 guideline from the American Heart Association/American Stroke Association published in Stroke. source
European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke
European Stroke Organisation (ESO) · 2021
ESO's GRADE-based guideline on the use of intravenous thrombolytic drugs in acute ischaemic stroke. It addresses treatment time windows, stroke of unknown onset including wake-up stroke, imaging-based patient selection, specific patient subgroups, contraindications, and thrombolytic agent choice. Published in the European Stroke Journal in 2021.
- Developed with GRADE methodology under the ESO standard operating procedure for guidelines. source
- Covers time windows, imaging selection strategies, contraindications, patient subgroups, and thrombolytic agent choice. source
- Published in the European Stroke Journal and listed in ESO's official guideline directory. source
US vs EU key differences
- Thrombolytic choice differs: the ESO 2021 guideline suggests alteplase over tenecteplase for patients treated within 4.5 hours who are not going for thrombectomy (weak recommendation, low-quality evidence), reserving tenecteplase 0.25 mg/kg for large-vessel-occlusion patients heading to thrombectomy, whereas the 2026 AHA/ASA guideline treats tenecteplase 0.25 mg/kg (max 25 mg) and alteplase 0.9 mg/kg as equally preferred within 4.5 hours. source
- The two documents converge on imaging-selected late thrombolysis: ESO 2021 makes a strong recommendation for alteplase in stroke of known onset 4.5-9 hours with CT or MRI core/perfusion mismatch and in wake-up stroke with MRI DWI-FLAIR mismatch, and the 2026 AHA/ASA guideline likewise extends thrombolysis out to about 9 hours in perfusion-selected patients. source
- Scope and currency differ sharply: the European document is a 2021 guideline restricted to intravenous thrombolysis (about forty recommendations), while the US guideline is a 2026 comprehensive early-management document that also covers EMS triage, mobile stroke units, endovascular thrombectomy including basilar occlusion and large-core patients, and the first AHA/ASA recommendations for paediatric acute ischaemic stroke. source
What changed recently
- US2019 Update → 20262026-01-26
The 2026 guideline supersedes the 2018 guideline and its 2019 focused update, placing tenecteplase 0.25 mg/kg on equal footing with alteplase inside the 4.5-hour window, allowing imaging-selected thrombolysis out to roughly 9 hours, widening thrombectomy eligibility to include basilar occlusions and large ischaemic cores, endorsing mobile stroke units and refined EMS triage, and adding the first AHA/ASA recommendations for paediatric acute ischaemic stroke.
See the full update feed for changes across every system.