Meghanath Yenni։ What’s New in Acute Ischemic Stroke in 2026
Meghanath Yenni, Consultant Physician at Medicover Hospitals, shared a post on LinkedIn:
”What’s New in Acute Ischemic Stroke – 2026:
Tenecteplase is now first-line – equal to alteplase, with simpler bolus dosing improving real-world speed and logistics.
Treat disability, not NIHSS – even low scores need thrombolysis if the deficit is functionally significant.
Do not delay IVT for extra imaging – give thrombolysis immediately if eligible within 4.5 hours.
Late-window IVT is now viable – selected patients (4.5–9h or wake-up stroke) can be treated using imaging selection.
Avoid thrombolysis in mild non-disabling stroke – prefer short-term DAPT instead.
No role for adjunct antithrombotics with IVT – adding agents like argatroban or eptifibatide offers no benefit.
EVT expands to large-core strokes (ASPECTS 3–5) – now Class 1 in selected patients.
Very large cores (ASPECTS 0–2) are not absolute exclusions – EVT may still be reasonable early.
Pre-stroke disability is no longer a strict barrier – selected mRS of 2 or higher patients can still benefit from EVT.
Basilar artery occlusion now has clear EVT indication – strong recommendation up to 24 hours.
Aggressive BP lowering post-EVT is harmful – avoid targeting SBP less than after successful recanalization.
After IVT, lower BP targets don’t help – less than 180 mmHg remains appropriate, not less than 140.
Tight glucose control is out – intensive insulin targets increase harm without improving outcomes.
Stroke routing is system-dependent – optimize workflow rather than blindly bypassing to EVT centers.
Mobile Stroke Units are endorsed – prehospital thrombolysis improves time-to-treatment and outcomes.
Short-term DAPT (21 days) is standard in minor stroke/TIA – reduces early recurrence risk.
Earlier anticoagulation in AF stroke is reasonable – prevents recurrence with careful patient selection.
Swallow therapy advances but neuroprotection fails – PES may help dysphagia; IV glibenclamide is not recommended.
Source:
2026 Guideline for the Early Management of Acute Ischemic Stroke – Stroke, American Heart Association / American Stroke Association (AHA/ASA).”
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