What Really Changed?
Based on Prabhakaran et al. (2026)
sICH after IVT
2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association
IVT
Thrombolytic Agent
2018: Alteplase only (standard 0.9 mg/kg)
2026: Tenecteplase (0.25 mg/kg) or alteplase — both Class I recommended
*Tenecteplase 1st-line, if LVO bridging therapy, patients requiring rapid workflow, difficult IV access or prehospital administration
NIHSS and Disability
2018: NIHSS severity emphasized
2026: Any disabling deficit should receive IVT — NIHSS alone should not delay therapy
Ex: aphasia, hemianopia, dominant-hand weakness
Non-disabling stroke
2026: IVT not recommended; DAPT preferred
Extended Window
2018: Mainly MRI DWI–FLAIR mismatch (“wake‑up stroke”)
2026: Perfusion-based IVT up to 9 hours, including wake-up/unknown onset strokes
-CTP
-bMRI D/H: DWI lesion involving <1/3 of MCA territory with no FLAIR signal changes
Contraindication
-prior ICH, DOAC exposure, and stroke within the past 3-months are now relative contraindications
EVT
Time Window
2018: 0–6 hrs standard; 6–24 hrs selective (DAWN/DEFUSE‑3)
2026: 0–24 hrs broadly accepted with imaging selection
Large Core Infarcts
2018: Mostly excluded
2026: ASPECTS 3–5 recommended; even 0–2 reasonable in select cases (Class IIb)
>Supported by RESCUE‑Japan, SELECT2, ANGEL‑ASPECT data
Posterior Circulation
2018: No strong recommendation
2026: Class I recommendation for basilar artery thrombectomy (≤24 hrs)
>Supported by ATTENTION & BAOCHE
Pre-stroke Disability
2026: mRS 2 patients now included
Pediatric EVT (NEW)
≥6 years: Class IIa
<6 years: Class IIb selected cases
First formal pediatric interventional guidance
Pediatric AIS
Imaging
-MRI/MRA preferred, but if MRI cannot be obtained within 25 minutes, use CT/CTA to evaluate for LVO
Treatment
-IV alteplase: May be safe, but efficacy remains unclear
-EVT in pediatric LVO (see above)
Early BMT
Glycoprotein IIb/IIIa inhibitors
-No established benefit for IV tirofiban
-IV abciximab is discouraged
Oral anticoagulation
-Early initiation reasonable for mild strokes with Afib
Post‑EVT BP management
-Avoid intensive SBP <140 immediately after thrombectomy
DAPT
-Now recommended for patients presenting within 72h, NIHSS ≤5, and suspected atherosclerotic disease
Remaining gaps
-EVT for NIHSS ≤6
-Optimal intra‑arterial thrombolysis dosing
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