Updated AHA/ASA guidelines for Acute Ischemic Stroke

What clinicians need to know 

The American Heart Association/American Stroke Association has released the first updates to the Guidelines for the Early Management of Acute Ischemic Stroke in seven years—representing some of the most significant changes to acute stroke care in over a decade. We want to ensure all providers across the region are aware of these important updates, which will directly impact clinical decision-making for our stroke patients. Please note that while the treatment guidelines have changed, our internal Code Stroke process has not changed—an activation should continue to occur for all patients demonstrating stroke symptoms with a last known well (LKW) within a 24-hour window. 

Key changes to thrombolytic therapy 

One of the most notable updates is the extension of the treatment window for thrombolytics from 4.5 hours to up to 24 hours for select patients. This expanded window allows us to consider treating individuals who would previously have been excluded. Patient eligibility will be determined on a case-by-case basis and requires CT Perfusion imaging along with additional clinical criteria. Treatment decisions will be made in collaboration with the covering Neurologist or Tele-neurologist. 

Additionally, DOAC use is no longer considered an absolute contraindication for thrombolytic therapy. Neurology consultation will remain essential in evaluating these patients and guiding appropriate care. 

Updates to endovascular therapy 

On the interventional side, criteria for pursuing thrombectomy have broadened. Eligibility will incorporate a combination of baseline functional status, NIHSS score, and neuroanatomy based on CTA/CTP, increasing the pool of candidates who may benefit. We anticipate this may lead to a modest increase in thrombectomy volumes. 

Guidance on antiplatelet therapy 

The AHA/ASA has also issued clearer recommendations regarding dual antiplatelet therapy (DAPT) for non-cardioembolic ischemic stroke and high-risk TIA. This guidance will be shared in more detail with our Hospitalist and Family Medicine teams. 

What this means for our workflows 

While these guideline updates may appear to greatly expand the number of patients eligible for advanced therapies, the reality is that careful, individualized assessment remains central. We do not expect a dramatic increase in thrombolytic administration, but we are optimistic about improved access to thrombectomy for appropriate patients. 

Above all, these changes reinforce the importance of early Neurology involvement to ensure patients receive the most effective and timely care. 

If you have questions or would like further discussion or would like to review the associated guidelines or studies, please reach out to: