New Stroke Guideline Expands Treatment Access and Adds First Pediatric Recommendations

The American Stroke Association has released the 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke, featuring significant updates that expand treatment eligibility and introduce the first detailed recommendations for pediatric stroke care. This guideline replaces the 2018 edition and its 2019 update, reflecting substantial new evidence in acute stroke management. According to the American Heart Association’s 2026 Heart Disease and Stroke Statistics, stroke remains a critical health concern as the fourth leading cause of death in the United States, affecting nearly 800,000 people annually and causing serious long-term disability.

The guideline emphasizes that outcomes depend on both the treatments provided and the speed of delivery, reinforcing that coordinated systems of care from the initial 9-1-1 call through hospital discharge can prevent lifelong disability. Key advances include expanded eligibility for clot-removal procedures, new evidence supporting the use of the clot-busting medication tenecteplase, and implementation of mobile stroke units to accelerate care delivery. The guideline also simplifies imaging requirements, enabling more hospitals to act quickly without advanced perfusion imaging by using standard CT scoring systems like ASPECTS to identify candidates for clot-removal procedures.

For the first time, the guideline provides comprehensive recommendations for diagnosing and treating stroke in children, addressing a significant gap in pediatric care. While stroke is rare in children, prompt recognition is critical, and the guideline advises that children may exhibit the same stroke warning signs in children as adults described by the F.A.S.T. acronym, along with additional symptoms like sudden severe headache, new onset seizures, or sudden confusion. Since available stroke screening tools were developed for adults and may not accurately distinguish strokes from mimics in children, the guideline recommends rapid magnetic resonance imaging and angiography to identify blockages and differentiate arterial ischemic stroke from hemorrhagic stroke.

Regarding treatment, the guideline states that the intravenous clot-busting agent alteplase may be considered within 4.5 hours for children ages 28 days to 18 years with disabling deficits. Mechanical clot-removal performed by experienced neurointerventionalists 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 pediatric recommendations represent a major step toward standardized, evidence-based care for children with stroke.

The guideline also focuses on enhancing regional stroke systems of care that link emergency medical services, hospitals, and telemedicine networks. Mobile stroke units, which are ambulances equipped with CT scanners and stroke-trained care teams, demonstrate how faster response times can accelerate recognition and treatment delivery. In regions with reasonable access to thrombectomy-capable stroke centers, emergency medical services should transport patients with suspected large vessel occlusion directly to these centers to reduce delays in diagnosis and treatment.

For clot-busting medications, the guideline endorses the use of either tenecteplase or alteplase within 4.5 hours of symptom onset, noting that tenecteplase has the advantage of simplifying treatment as a single-dose infusion compared to the 60-minute period needed for alteplase. For some patients who wake up with stroke symptoms or arrive after the standard window, clot-busting treatment may still be effective up to 24 hours after symptom onset if advanced brain imaging shows brain tissue that has not been irreversibly damaged.

Clot-removal procedures, known as endovascular thrombectomy, remain a powerful treatment for major strokes caused by large-vessel blockages. The guideline now recommends this procedure in selected patients for up to 24 hours after symptom onset even if imaging shows certain large core infarcts, and expands eligibility to include some patients with blockages in the posterior circulation and those with mild or moderate preexisting disability within the first 6 hours. Hospitals are encouraged to use reporting systems such as the American Stroke Association’s Get With The Guidelines® - Stroke Registry to track treatment times and outcomes.

The new guideline will be featured at the American Heart Association’s 2026 International Stroke Conference in New Orleans. This update brings the most important advances in stroke care from the last decade directly into practice, expanding access to cutting-edge treatments and standardizing care across hospitals of all sizes to ensure rapid, evidence-based treatment for every patient regardless of location.