AHA Key Updates – from the 2026 ASA Ischemic Stroke Guideline
AHA Key Updates – from the 2026 ASA Ischemic Stroke Guideline
“American Stroke Association (ASA), a division of the AHA
Published in: Stroke (AHA Journal)”
🔹 Early Recognition clinical tool in EMS or ER – FAST & BE-FAST
• FAST: Face droop, Arm weakness, Speech difficulty, Time
• BE-FAST adds:
• Balance disturbance
• Eye/visual symptoms
• Used by community and EMS for early detection
• BE-FAST improves detection of posterior circulation strokes
• Early recognition triggers rapid stroke alert activation
🔹 Coordinated Systems of Care
• Integration between EMS, stroke centers, telemedicine networks, and emergency departments
• “Time is brain” remains the central principle
• Suspected large vessel occlusion (LVO) → direct transport to a thrombectomy-capable center when feasible
• Pre-notification reduces door-to-CT and door-to-treatment time
🔹 Immediate Imaging
• Non-contrast CT is mandatory for all suspected stroke patients to R/O Hemorrhage
• Imaging target: within 25 minutes of hospital arrival
• CT angiography performed when thrombectomy is being considered in large vessel occlusions LVO
• Purpose:
• Exclude hemorrhage
• Confirm ischemic stroke
• Identify LVO
🔹 Reperfusion Therapy
IV Thrombolysis
• Tenecteplase or alteplase within 4.5 hours of symptom onset
• Selected patients may be treated up to 24 hours based on imaging in LVO
Endovascular Thrombectomy (EVT)
• Recommended up to 24 hours in selected LVO patients
• Increasing evidence supports use in posterior circulation stroke
• May be combined with IV thrombolysis
🔹 Posterior vs Anterior Circulation Considerations
• Anterior strokes: typically motor and speech deficits
• Posterior strokes: dizziness, ataxia, visual symptoms, brainstem signs
• Posterior strokes may appear subtle but can deteriorate rapidly
• Basilar artery occlusion carries high mortality without reperfusion
🔹 Pediatric Stroke – First Detailed Recommendations
• First dedicated ASA guidance for children
• MRI and angiography preferred for rapid diagnosis
• Alteplase may be administered within 4.5 hours (age 28 days–18 years)
Clinical Message
Modern stroke care depends on:
• Early recognition (FAST / BE-FAST)
• Organized regional stroke systems
• Immediate mandatory CT imaging
• Rapid reperfusion strategies