Fawaz AlOtaibi: Why Experts Are Challenging the New Stroke Guideline
Fawaz AlOtaibi, Neurocardiology and Cerebrovascular Fellow at Western University, shared a post on LinkedIn about a recent article by Gregory W. Albers et al., published in Stroke, adding:
“Important pushback on the 2026 AHA/ASA Acute Ischemic Stroke Guideline
By Albers, Saver and other leading stroke neurologists just published a Special Report in Stroke challenging the new Class 1, Level A recommendation for thrombectomy in the 6–24h window based on ASPECTS 6–10 alone (NCCT-only selection, no perfusion imaging required).
Their argument:
- Neither DEFUSE 3 nor DAWN (the cited RCTs) used ASPECTS-only selection
- AURORA subgroup data showed no benefit in ASPECTS-only (‘undetermined mismatch’) patients, with a significant treatment-by-subgroup interaction (OR 2.28, P equals 0.03)
- RESILIENT-EXTEND, the only RCT testing this exact population out to 24h, showed no net benefit – gains offset by increased severe disability/death
- MR CLEAN-LATE showed a harm signal in small-penumbra patients selected by NCCT alone.
Their proposed fix:
- Downgrade ASPECTS-alone 6–24h EVT from Class 1A – Class IIb, Level C-LD
- Reinstate Class 1A specifically for clinical/perfusion mismatch-selected patients (where the evidence is strong and consistent)
- Restrict large-core NCCT-only selection to within 12h (per TENSION)
- Add guidance: penumbral imaging preferred for late-window selection; NCCT and CTA only when perfusion unavailable.”
Title: Proposed Corrections to the 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke
Authors: Gregory W. Albers, Steven J. Warach, Jeffrey L. Saver, Marc Fisher, Jeremy J. Heit, Colin P. Derdeyn, Maarten G. Lansberg, Lee Schwamm, Arindam R. Chatterjee, Vivek S. Yedavalli, Kevin N. Sheth, J.M. Olivot, Margy McCullough-Hicks, Carlo W. Cereda, Pierre Seners, Xiaochuan Huo, Jonathan D. Clemente, Andrew Asimos, Jenny P. Tsai, Manabu Inoue, Keith W. Muir, Jean-Claude Baron
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