Expanded eligibility for advanced stroke therapies and new recommendations for diagnosing and treating stroke in children and adults are among the major updates in the new 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke from the American Stroke Association, a division of the American Heart Association.
According to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, stroke is the #4 leading cause of death in the U.S. Every year, nearly 800,000 people in the U.S. have a stroke, and it is also a leading cause of serious, long-term disability. Ischemic stroke is the most common type of stroke and occurs when blood flow to the brain is suddenly blocked in a vessel, usually by a blood clot.
The updated guideline reflects new evidence in acute ischemic stroke care. It provides an evidence-based roadmap for health care professionals to recognize, diagnose and treat ischemic stroke, from prehospital recognition to 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 for the guideline and the James Nelson and Anna Louise Raymond Professor of Neurology and chair of the department of neurology at the University of Chicago Medicine. “New recommendations in the guideline expand access to cutting-edge treatments, such as clot-removal procedures and medications, simplify imaging requirements so more hospitals can act quickly, and introduce guidance for pediatric stroke for the first time.”
First-time guidance for pediatric stroke
Though rare, stroke can occur in infants, children, and teens, and prompt recognition is critical. Children can exhibit the same warning signs as adults described by the acronym F.A.S.T.: Face Drooping; Arm Weakness; Speech Difficulty; Time to Call 911. However, stroke warning signs in children more often may also include:
- Sudden severe headache, especially with vomiting and sleepiness
- New onset of seizures, usually on one side of the body
- Sudden confusion, difficulty speaking or understanding others
- Sudden trouble seeing in one or both eyes, and/or
- Sudden difficulty walking, dizziness, loss of balance or coordination
Currently available stroke screening tools were developed for adults, so they do not accurately distinguish strokes in children from mimics (conditions with similar symptoms) like migraine, seizure, traumatic brain injury, or brain tumor. The guideline advises rapidly performing magnetic resonance imaging (MRI) and angiography (MRA) to identify blockages to differentiate arterial ischemic stroke from hemorrhagic stroke and rule out mimics in pediatric stroke.
For treating ischemic stroke in children, the clot-busting agent alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits. Also, mechanical clot-removal may be effective for large-vessel blockages in children 6 years and older within 6 hours and may be reasonable up to 24 hours after symptoms begin if imaging shows salvageable brain tissue.
“These recommendations represent a major step toward standardized, evidence-based care for children,” Prabhakaran said. “They also highlight how much more we still need to learn about pediatric stroke.”
Faster care from the field to the hospital
The guideline emphasizes the need for regional stroke systems of care that link 9-1-1 call centers, emergency medical services (EMS) agencies, hospitals, and telemedicine networks. Mobile stroke units (ambulances equipped with CT scanners and stroke-trained care teams) demonstrate how faster response times can accelerate recognition and treatment delivery.
In regions with access to thrombectomy-capable stroke centers (TSCs), EMS should transport patients with suspected large vessel occlusion to the nearest TSC for immediate evaluation. In regions without geographic access to TSCs, the guideline focuses on reducing door-in-door-out times at hospitals transferring patients to TSCs.
Rapid diagnosis and imaging
Speed and accuracy are critical for diagnosing and treating stroke. Hospitals should complete an initial brain scan within 25 minutes of arrival to confirm that symptoms are caused by an ischemic stroke and not a brain bleed, so that the right treatment can begin immediately. Confirming the stroke type ensures that clot-dissolving or clot-removal treatments can begin safely and without delay.
Clot-busting medications
The guideline endorses using either tenecteplase or alteplase within 4.5 hours of symptom onset. Both medications are effective at dissolving blood clots. For people who wake up with stroke symptoms or arrive at the hospital after the standard 4.5-hour window for treatment, clot-busting treatment may still be effective up to 24 hours after the onset of stroke symptoms.
Clot-removal procedures (endovascular thrombectomy or EVT)
Removing clots directly from blocked brain arteries, a procedure called thrombectomy, remains a powerful treatment for major strokes caused by large-vessel blockages in eligible patients. Patients eligible for both clot-busting medications and thrombectomy should receive both, rapidly and sequentially.
Improving survival and recovery
The guideline underscores that coordinated systems of care are essential for improving survival and recovery.
“Time is brain,” Prabhakaran said. “This new guideline makes that concept real, showing how systems, from EMS to hospitals, can work together to cut 30 to 60 minutes off treatment time to improve patient outcomes and reduce the likelihood of disability.”
2026 International Stroke Conference
The new guideline will be featured at the American Heart Association’s 2026 International Stroke Conference, to be held February 4-6 in New Orleans.
- What’s New in the 2026 Acute Ischemic Stroke Guideline: Process Overview and Key Updates from the Chairs; Thursday, February 5, 2:30-3:30 p.m. CT
- Acute Ischemic Stroke Guidelines: Q&A Part I (Fireside Chat); Thursday, February 5, 3:45-4:45 p.m. CT
- Acute Ischemic Stroke Guidelines: Q&A Part II (Fireside Chat); Thursday, February 5, 5:00-6:00 p.m. CT
This guideline was prepared by the volunteer writing group on behalf of the American Heart Association’s Stroke Council and the American Stroke Association.