What changed recently

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.

The 6th edition refreshes the evidence-based chapter with a new set of clinical questions and GRADE-style answers, and substantially rewrites the 'what matters to patients' material using direct input from patient advisors in the EGS Patient Involvement Project, including eight practical communication tips for clinicians.

This GRADE-based joint ESO/EANS document replaces the 2014 ESO ICH guideline, answering 37 PICO questions with evidence accumulated from a decade of randomised trials. It supports early intensive blood-pressure lowering mainly for reducing haematoma expansion rather than for proven functional benefit, weighs anticoagulation reversal explicitly against thromboembolic harm, treats minimally invasive evacuation alongside open craniotomy as options for supratentorial haemorrhage, and advises against anti-inflammatory drugs outside trials.

The 2025 ILAE position paper revises the 2017 operational seizure classification, keeping the four main classes but separating diagnostic classifiers from descriptors, expanding the scheme to 21 seizure types, classifying focal and unknown-onset seizures by whether consciousness is impaired or preserved, and adding negative myoclonus as a recognised generalised seizure type.

The 2025 POAG PPP strengthens the endorsement of selective laser trabeculoplasty as an initial rather than merely adjunctive therapy, drawing on the LiGHT trial's six-year extension data, and newly incorporates evidence on sustained-release drug delivery and minimally invasive glaucoma surgery, macular and ganglion-cell-layer imaging, corneal hysteresis as a risk metric, and more intensive monitoring for rapid progressors.

The updated position statement drops the requirement that patients first fail conventional preventives before receiving CGRP-targeting drugs, placing the anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and the gepants rimegepant and atogepant alongside older agents as first-line migraine prevention.

The 2024 revision of the 2019 Diabetic Retinopathy PPP folds in the evidence accumulated since 2019 on intravitreal anti-VEGF therapy for centre-involving diabetic macular oedema and for reducing retinopathy severity in proliferative disease, adds a caution that rapid tightening of glycaemic control with newer agents such as semaglutide can precipitate early worsening of retinopathy, and reinforces topical povidone-iodine antisepsis before every intravitreal injection.

Replacing the 2013 EFNS/MDS-ES recommendations, this first GRADE-based European guideline covers invasive therapy specifically: subthalamic deep brain stimulation is the best-supported option for advanced disease with fluctuations inadequately controlled on oral drugs and may also be offered when fluctuations appear early, but should not be used in early disease without fluctuations, while levodopa-carbidopa intestinal gel and apomorphine infusion are alternatives and MRI-guided focused ultrasound is restricted to registry use.

The 2022 EHF update promotes anti-CGRP monoclonal antibodies from the third-line position they held in 2019 (after failure of two other preventive classes) to a first-line option, and newly advises pausing treatment after 12-18 continuous months with restart as needed, citing head-to-head data favouring erenumab over topiramate.

The 2022 revision of the 2015 ICH guideline downgraded several long-standing practices, stating that graduated compression stockings, prophylactic antiseizure drugs and steroids are of uncertain or no benefit, while adding new recommendations on regional systems of care with rapid transfer to neurocritical/neurosurgical centres, on anticoagulation reversal, on minimally invasive haematoma evacuation, and on using imaging and clinical markers to anticipate haematoma expansion.

The 2022 update reassesses the 2013 guideline against 18 new systematic reviews and 27 randomised trials, keeps the bar against tube insertion for a single effusion episode lasting under three months, requires a hearing evaluation once effusion persists three months or before surgery, and adds a new strong recommendation that the surgeon or a designee re-examine the child's ears within three months of insertion and set expectations for periodic follow-up.

This update of the AAN's 2002 practice parameter on initiating Parkinson treatment re-evaluates levodopa, dopamine agonists and MAO-B inhibitors as initial therapy, concluding that levodopa gives greater motor benefit than dopamine agonists and that although it carries a higher dyskinesia risk, severe or disabling dyskinesia is uncommon in the first five years of treatment.

The 2021 secondary-prevention guideline reorganised recommendations around the specific cause of the index stroke or TIA, added a new requirement to complete the diagnostic work-up within 48 hours of symptom onset, endorsed percutaneous PFO closure in selected younger patients with non-lacunar stroke, and advised against angioplasty/stenting as first-line therapy for severe intracranial stenosis in favour of aggressive medical management plus short-term dual antiplatelet therapy.

This update of the 2004 AAN guideline on new-onset epilepsy re-graded the second- and third-generation antiseizure drugs, concluding that lamotrigine should be considered for reducing seizure frequency in adults with new-onset focal epilepsy, that levetiracetam and zonisamide may be considered, and that in patients aged 60 and over lamotrigine should and gabapentin may be considered.

The AAN retired its 2002 disease-modifying therapy guideline in April 2018 and replaced it with this document, which covers the far larger modern DMT armamentarium and, unlike its predecessor, gives explicit recommendations on starting therapy after a first demyelinating event with MRI lesions, on monitoring adherence and tolerability, on switching agents when breakthrough disease activity occurs, and on when discontinuation may be discussed.

A new ICO task force reworked the 2014 diabetic eye care guidelines around resource setting, tiering screening, referral and follow-up schedules separately for high-resource versus low- and intermediate-resource countries, and adding guidance on optical coherence tomography for diabetic macular oedema plus intravitreal anti-VEGF therapy plus corticosteroids in selected cases alongside laser photocoagulation.