Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Hasnain Ali Moryani, MBBS[2]
For detailed guidelines please refer here, AHA/ASA complete guidelines for management of Acute Ischemic Stroke.
Summary Evolution of AHA/ASA Stroke Guidelines: 2018[1], 2019[2], 2021[3], and 2026[4]
Scope of Each Guideline:
2018:Comprehensive guideline for early/acute management of AIS in adults. Replaced 2013 guideline.
2019: Focused update to 2018, incorporating new evidence on wake-up stroke thrombolysis, DAPT for minor stroke, and EVT extended windows.
2021: Comprehensive guideline for secondary stroke prevention. Replaced 2014 guideline. Covers risk factor management, antithrombotics, etiology-specific treatment.
2026: New comprehensive guideline for early/acute management of AIS. Replaces 2018/2019. Includes pediatric stroke for the first time.
PART 1: ACUTE MANAGEMENT — EVOLUTION FROM 2018 → 2019 → 2026
IV Thrombolysis
| Topic |
2018 |
2019 Update |
2026
|
| Thrombolytic agent |
Alteplase 0.9 mg/kg (max 90 mg) was the only recommended agent (Class I). Tenecteplase 0.4 mg/kg was Class IIb, investigational only. |
No change from 2018. |
Tenecteplase 0.25 mg/kg (max 25 mg) OR alteplase 0.9 mg/kg — both Class I. Tenecteplase 0.4 mg/kg is now Class III (Harm).
|
| Standard time window (0–3 h) |
Alteplase within 3 h of onset (Class I, LOE A). |
No change. |
Alteplase or tenecteplase within 4.5 h (Class I). Single unified window.
|
| Extended window (3–4.5 h) |
Alteplase within 3–4.5 h (Class I, LOE B-R) with additional exclusion criteria (age >80, OAC use, NIHSS >25, prior stroke + DM). |
No change. |
Merged into single 0–4.5 h window. Exclusion criteria updated in full guideline text.
|
| Wake-up stroke / unknown onset |
Not specifically addressed in 2018 original. |
NEW: Alteplase within 4.5 h of recognition if DWI-positive/FLAIR-negative on MRI (Class IIa, LOE B-R). |
Extended to 4.5–9 h from last known well or midpoint of sleep with perfusion imaging showing salvageable penumbra (Class IIa).
|
| CMBs and IVT |
1–10 CMBs: Class IIa to proceed. >10 CMBs: Class IIb, uncertain benefit. |
No change. |
Carried forward (consult full guideline).
|
| Pediatric IVT |
Not addressed. |
Not addressed. |
NEW: Alteplase within 4.5 h in patients aged 28 days–18 years (Class IIb).
|
| Door-to-needle time |
Goal <60 min from ED arrival (Class I). |
No change. |
Reaffirmed: initiate as quickly as possible, avoid delays for multimodal imaging (Class I).
|
Endovascular Thrombectomy
| Topic |
2018 |
2019 Update |
2026
|
| Standard window (0–6 h) — ASPECTS threshold |
ICA/M1 occlusion, NIHSS ≥6, prestroke mRS 0–1, ASPECTS ≥6 (Class I, LOE A). |
No change. |
ASPECTS 3–10 (Class I). Major expansion to include large-core infarcts.
|
| Extended window (6–24 h) — standard core |
DAWN or DEFUSE 3 criteria: small core, large mismatch (Class I within 6–16 h; Class IIa within 16–24 h). |
No change. |
ASPECTS 3–5 within 6–24 h, age <80, NIHSS ≥6, no mass effect (Class I). Broader eligibility.
|
| Large core (ASPECTS 0–2) |
Not addressed. |
Not addressed. |
NEW: ASPECTS 0–2 within 6 h, age <80, no mass effect (Class IIa).
|
| Prestroke mRS 2 |
Not addressed (only mRS 0–1 studied). |
Not addressed. |
NEW: mRS 2 with ASPECTS ≥6 within 6 h (Class IIa).
|
| Posterior circulation (basilar) |
Class IIb, limited evidence, uncertain benefit. |
No change. |
NEW: Basilar occlusion, mRS 0–1, NIHSS ≥10, PC-ASPECTS ≥6, within 24 h (Class I). Major upgrade.
|
| M2/M3 occlusions |
Class IIb, uncertain benefit. |
No change. |
Carried forward (consult full guideline).
|
| Pediatric EVT (≥6 years) |
Not addressed. |
Not addressed. |
NEW: Within 6 h (Class IIa); 6–24 h with salvageable tissue (Class IIa).
|
| Pediatric EVT (28 days–6 years) |
Not addressed. |
Not addressed. |
NEW: Within 24 h with salvageable tissue (Class IIb).
|
| Stent retrievers |
Preferred over coil retrievers (Class I). |
No change. |
Stent retriever or direct aspiration (Class I).
|
| Tirofiban before EVT |
Not addressed. |
Not addressed. |
NEW: Not useful (Class III, No Benefit).
|
| Reperfusion goal |
mTICI 2b/3 (Class I). |
No change. |
Reaffirmed (mTICI 2b, 2c, or 3).
|
Blood Pressure Management
| Topic |
2018 |
2019 Update |
2026
|
| Pre-IVT |
Lower to <185/110 mm Hg before IVT (Class I). |
No change. |
Carried forward.
|
| Post-IVT |
Maintain <180/105 mm Hg for 24 h (Class I). |
No change. |
Intensive target <140 mm Hg is Class III (No Benefit). Standard <180/105 remains.
|
| Post-EVT (successful recanalization) |
Maintain ≤180/105 mm Hg (Class IIa). |
No change. |
Intensive target <140 mm Hg for 72 h is Class III (Harm).
|
| No reperfusion therapy |
Treat only if SBP >220 or DBP >120 (Class I). Lower by 15% in first 24 h (Class I). |
No change. |
Carried forward.
|
| Prehospital BP reduction |
Not addressed. |
Not addressed. |
NEW: Early reduction to 130–140 mm Hg is Class III (No Benefit / Harm).
|
Blood Glucose Management
| Topic |
2018 |
2019 Update |
2026
|
| Hyperglycemia target |
Target 140–180 mg/dL reasonable (Class IIa). Treat hypoglycemia <60 mg/dL (Class I). |
No change. |
IV insulin targeting 80–130 mg/dL is Class III (No Benefit). Prior 140–180 range remains reasonable.
|
Antiplatelet Treatment (Acute Phase)
| Topic |
2018 |
2019 Update |
2026
|
| Aspirin |
Aspirin within 24–48 h (Class I, LOE A). Delay 24 h after IVT. |
No change. |
Carried forward.
|
| DAPT for minor stroke |
Not in original 2018. |
NEW: DAPT (ASA + clopidogrel) within 24 h for minor stroke (NIHSS ≤3) or high-risk TIA, for 21 days (Class I, LOE A). |
DAPT threshold expanded to NIHSS ≤5 (Class IIa). Duration 21–90 days.
|
Anticoagulants (Acute Phase)
| Topic |
2018 |
2019 Update |
2026
|
| Urgent anticoagulation |
Not recommended for preventing early recurrence (Class III, Harm). |
No change. |
Carried forward.
|
| Early OAC in AF |
Not specifically addressed. |
Not specifically addressed. |
NEW: Early OAC in milder AIS with AF is reasonable (Class IIa). Efficacy for early recurrence prevention not established.
|
Stroke Systems of Care / Prehospital
| Topic |
2018 |
2019 Update |
2026
|
| Mobile stroke units |
Not specifically recommended. |
Not addressed. |
NEW: MSUs recommended where available (Class I).
|
| EMS destination — bypass to distant TSC |
Transport to closest capable center (Class I). |
No change. |
NEW: Bypass to distant TSC (45–60 min) does not improve outcomes when local center available (Class III, No Benefit).
|
| DIDO protocols |
Not specifically addressed. |
Not addressed. |
NEW: Hospitals and EMS should establish transfer protocols to reduce DIDO times (Class I).
|
| Neurointerventionalist credentialing |
Not addressed. |
Not addressed. |
NEW: TSC/CSC hospitals should credential operators using established standards (Class I).
|
| EVT quality tracking |
Not addressed. |
Not addressed. |
NEW: Comprehensive tracking of time metrics and outcomes (Class I).
|
| Prehospital RIC |
Not addressed. |
Not addressed. |
NEW: Class III (No Benefit).
|
| Prehospital GTN |
Not addressed. |
Not addressed. |
NEW: Class III (No Benefit / Harm).
|
| Pediatric prehospital stroke tools |
Not addressed. |
Not addressed. |
NEW: Adult tools perform poorly; pediatric tools uncertain (Class IIb).
|
| Pediatric imaging |
Not addressed. |
Not addressed. |
NEW: MRI/MRA preferred (Class IIa); CT/CTA if MRI unavailable within 25 min (Class IIa).
|
In-Hospital Management & Complications
| Topic |
2018 |
2019 Update |
2026
|
| Dysphagia — PES |
Not addressed. |
Not addressed. |
NEW: Pharyngeal electrical stimulation can be beneficial (Class IIa).
|
| Glibenclamide for brain swelling |
Not addressed. |
Not addressed. |
NEW: Not effective (Class III, No Benefit).
|
| Decompressive craniectomy |
Effective for malignant MCA edema (Class I). Effective for cerebellar infarction (Class I). |
No change. |
Carried forward.
|
| DVT prophylaxis |
Subcutaneous anticoagulants (Class I). IPCs if anticoagulants contraindicated (Class IIa). |
No change. |
Carried forward.
|
| Swallowing assessment |
Before oral intake (Class I). |
No change. |
Carried forward.
|
PART 2: SECONDARY PREVENTION — 2021 GUIDELINE (NEW STANDALONE)
The 2021 guideline (Kleindorfer et al.) was the first comprehensive secondary prevention guideline since 2014. It introduced etiology-based organization and numerous new recommendations. Key highlights are summarized below.
Risk Factor Management
| Topic |
2014 (Prior Guideline) |
2021 Update
|
| Blood pressure target |
<140/90 mm Hg (Class I). |
<130/80 mm Hg for most patients (Class I, LOE B-R). More aggressive target.
|
| Lipid therapy — atherosclerotic stroke |
High-intensity statin (Class I). |
High-intensity statin + ezetimibe if needed to LDL-C <70 mg/dL (Class I, LOE A). Added ezetimibe target.
|
| Lipid therapy — no known CHD |
Statin recommended. |
Atorvastatin 80 mg if LDL-C >100 mg/dL (Class I, LOE A). Specific agent/dose.
|
| Hypertriglyceridemia |
Not specifically addressed for stroke. |
NEW: Icosapent ethyl 2 g BID if TG 135–499, LDL 41–100, on statin (Class IIa).
|
| Diabetes — glucose-lowering agents |
General glycemic control recommended. |
NEW: Use agents with proven CV benefit (Class I, LOE B-R). HbA1c ≤7% for most (Class I).
|
| Pioglitazone |
Not specifically addressed. |
NEW: May be considered ≤6 months post-stroke with insulin resistance, HbA1c <7%, no HF/bladder cancer (Class IIb).
|
| Diet |
General healthy diet. |
NEW: Mediterranean-type diet recommended (Class IIa). Sodium reduction by ≥1 g/d (Class IIa).
|
| Physical activity |
General recommendation. |
NEW: Specific targets — moderate 10 min × 4/wk or vigorous 20 min × 2/wk (Class I). Break sedentary time every 30 min (Class IIb).
|
| Obesity |
Weight loss recommended. |
Referral to intensive multicomponent behavioral program (Class I). Annual BMI calculation (Class I).
|
| OSA |
Not specifically addressed. |
NEW: CPAP can be beneficial (Class IIa). Evaluation for OSA may be considered (Class IIb).
|
Antithrombotic Therapy (Secondary Prevention)
| Topic |
2014 |
2021 Update
|
| Noncardioembolic stroke — SAPT |
Aspirin, clopidogrel, or ASA/dipyridamole (Class I). |
No change (Class I, LOE A).
|
| Minor stroke / high-risk TIA — DAPT |
Limited recommendation. |
NEW: DAPT (ASA + clopidogrel) within 12–24 h, for 21–90 days, then SAPT (Class I, LOE A). NIHSS ≤3, ABCD2 ≥4.
|
| Ticagrelor + ASA |
Not addressed. |
NEW: For NIHSS ≤5, ABCD2 ≥6, or ≥30% stenosis, for 30 days (Class IIb). Increased bleeding risk noted.
|
| DAPT >90 days |
Not recommended. |
Class III (Harm) — excess hemorrhage risk (LOE A).
|
| AF — anticoagulation |
Warfarin or DOACs (Class I). |
DOACs preferred over warfarin in nonvalvular AF (Class I, LOE B-R). Paroxysmal = persistent = permanent (Class I).
|
| AF — timing of OAC after stroke |
Not well defined. |
High hemorrhagic risk: delay >14 days (Class IIa). Low risk: 2–14 days (Class IIb). TIA: immediate (Class IIa).
|
| AF — LAA closure |
Not addressed for secondary prevention. |
NEW: Watchman device if contraindication to lifelong OAC but can tolerate ≥45 days (Class IIb).
|
| ESUS |
Not defined as category. |
NEW: DOACs not recommended (Class III). Ticagrelor not recommended (Class III).
|
Etiology-Specific Management (New in 2021)
| Etiology |
Key 2021 Recommendations
|
| Intracranial atherosclerosis (50–99%) |
ASA 325 mg/d preferred over warfarin (Class I). DAPT (ASA + clopidogrel) for 90 days if 70–99% stenosis within 30 days (Class IIa). Angioplasty/stenting NOT as initial treatment (Class III, Harm). EC-IC bypass not recommended (Class III).
|
| Extracranial carotid stenosis |
CEA for 70–99% stenosis if periop risk <6% (Class I). CEA for 50–69% based on patient factors (Class I). CEA preferred over CAS in age ≥70 or within 1 week (Class IIa). Revascularize within 2 weeks (Class IIa). No revascularization if <50% (Class III).
|
| PFO |
NEW: Closure reasonable in ages 18–60 with nonlacunar stroke, undetermined cause, high-risk PFO features (Class IIa). Shared decision-making required (Class I).
|
| Dissection |
Antithrombotic therapy ≥3 months (Class I). ASA or warfarin both reasonable <3 months (Class IIa).
|
| Antiphospholipid syndrome |
Warfarin with INR 2–3 (Class IIa). Rivaroxaban NOT recommended in triple-positive APS (Class III, Harm).
|
| Sickle cell disease |
Chronic transfusion to HbS <30% (Class I). Hydroxyurea if transfusion unavailable (Class IIa).
|
| Valvular disease |
Mechanical valve: warfarin (Class I). Dabigatran with mechanical valve: Class III (Harm).
|
| LV thrombus |
Warfarin ≥3 months (Class I). DOAC safety uncertain (Class IIb).
|
| Cardiomyopathy (sinus rhythm, reduced EF) |
Anticoagulation vs antiplatelet uncertain; individualize (Class IIb). Dabigatran with LVAD: Class III (Harm).
|
| Moyamoya |
Surgical revascularization (Class IIa). ASA monotherapy (Class IIb).
|
| Carotid web |
Antiplatelet therapy (Class I). Stenting/CEA if refractory (Class IIb).
|
| FMD |
Antiplatelet + BP control + lifestyle (Class I).
|
Diagnostic Workup (New Section in 2021)
| Topic |
2021 Recommendation
|
| Brain imaging |
CT or MRI to confirm diagnosis (Class I).
|
| ECG |
Screen for AF/flutter (Class I).
|
| Timing |
Diagnostic evaluation completed or underway within 48 h (Class I).
|
| Carotid imaging |
Noninvasive imaging for anterior circulation stroke candidates for revascularization (Class I).
|
| Blood tests |
CBC, PT, PTT, glucose, HbA1c, creatinine, lipid profile (Class I).
|
| Cryptogenic stroke — echo |
TTE with or without contrast (Class IIa).
|
| Cryptogenic stroke — rhythm monitoring |
Long-term monitoring with ILR or MCOT (Class IIa).
|
| Hypercoagulable workup |
As clinically indicated in cryptogenic stroke (Class IIa).
|
Health Systems & Behavior Change (New in 2021)
| Topic |
2021 Recommendation
|
| Quality programs |
Hospital-based or outpatient quality monitoring recommended (Class I).
|
| Multidisciplinary teams |
Team-based approach for BP, lipids, risk factors (Class IIa).
|
| Behavior change |
Interventions targeting stroke literacy, lifestyle, medication adherence (Class I). Information alone is insufficient (Class III, No Benefit).
|
| Health equity |
Address social determinants of health (Class I). Monitor performance measures for disparities (Class I). Adopt health literacy toolkit (Class I).
|
PART 3: CROSS-GUIDELINE SUMMARY — SCOPE AND RELATIONSHIP
|
2018 |
2019 |
2021 |
2026
|
| Full Citation |
Powers et al., Stroke 2018 |
Powers et al., Stroke 2019 |
Kleindorfer et al., Stroke 2021 |
Prabhakaran et al., Stroke 2026
|
| PMID |
29367334 |
31662037 |
34024117 |
41582814
|
| Scope |
Acute AIS management (adults) |
Focused update to 2018 |
Secondary stroke prevention |
Acute AIS management (adults + pediatric)
|
| Replaces |
2013 AIS guideline |
Sections of 2018 |
2014 secondary prevention guideline |
2018 and 2019 AIS guidelines
|
| Current Status (2026) |
Superseded by 2026 |
Superseded by 2026 |
Still active — no replacement published |
Current active guideline
|
| Key Innovations |
EVT with stent retrievers (Class I); EVT 6–16 h DAWN/DEFUSE 3; comprehensive acute management |
Wake-up stroke IVT (DWI-FLAIR mismatch); DAPT for minor stroke (NIHSS ≤3); tenecteplase 0.4 mg/kg (Class IIb) |
Etiology-based organization; PFO closure; BP <130/80; LDL <70 with ezetimibe; ESUS recommendations; health equity section |
Tenecteplase 0.25 mg/kg (Class I); EVT for large core (ASPECTS 0–5); basilar EVT (Class I); pediatric stroke; MSUs (Class I); multiple Class III (Harm/No Benefit) for intensive BP, glucose, prehospital interventions
|
References
- ↑ Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K; et al. (2018). “2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”. Stroke. 49 (3): e46–e110. doi:10.1161/STR.0000000000000158. PMID 29367334.
- ↑ Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K; et al. (2019). “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association”. Stroke. 50 (12): e344–e418. doi:10.1161/STR.0000000000000211. PMID 31662037.
- ↑ Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D; et al. (2021). “2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association”. Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 .
- ↑ Prabhakaran S, Gonzalez NR, Zachrison KS, Adeoye O, Alexandrov AW, Ansari SA; et al. (2026). “2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association”. Stroke. 57. doi:10.1161/STR.0000000000000513. PMID 41582814 .
