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AHA/ASA 2026 Stroke

2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke

Published on 26 January 2026, this guideline replaces the 2018 AHA/ASA acute ischaemic stroke guideline and its 2019 update, covering the whole early pathway — prehospital triage and mobile stroke units, imaging, thrombolysis, endovascular thrombectomy, early complication management and the start of secondary prevention. The main shifts are a broader role for tenecteplase within 4.5 hours, wider eligibility for thrombectomy (including basilar occlusion and large ischaemic cores), a rewritten list of thrombolysis contraindications, and the first dedicated recommendations for paediatric stroke. This page groups the register's reperfusion trials by the theme they inform.

This guideline cites 9 of the 61 landmark trials in our Emergency medicine register.

Source
Prabhakaran S, Gonzalez NR, Zachrison KS, et al. Stroke. 2026; online ahead of print, 26 January 2026.
Read the full guideline ↗

Intravenous thrombolysis2

  • 2008ECASS IIIEmergency · Stroke · IV thrombolysisThrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke
  • 1995NINDS rt-PAEmergency · Stroke · IV thrombolysisTissue Plasminogen Activator for Acute Ischemic Stroke

Imaging-guided selection & unknown-onset stroke1

  • 2018WAKE-UPEmergency · Stroke · MRI-guided lysisMRI-Guided Thrombolysis for Stroke with Unknown Time of Onset

Tenecteplase & choice of thrombolytic1

  • 2018EXTEND-IA TNKEmergency · Stroke · TenecteplaseTenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke

Endovascular thrombectomy — early window1

  • 2015MR CLEANEmergency · Stroke · ThrombectomyEndovascular Treatment for Acute Ischemic Stroke

Late-window, perfusion-selected thrombectomy2

  • 2018DAWNEmergency · Stroke · Late-window thrombectomyThrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
  • 2018DEFUSE 3Emergency · Stroke · Late-window thrombectomyThrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Large-core thrombectomy2

  • 2023SELECT2Emergency · Stroke · Large-core thrombectomyTrial of Endovascular Thrombectomy for Large Ischemic Strokes
  • 2023ANGEL-ASPECTEmergency · Stroke · Large-core thrombectomyTrial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct