Key US Updates in Acute Ischemic Stroke Management

Recent US stroke guidelines incorporate significant advances across the care continuum. Mobile Stroke Units (MSUs) are now recommended for their ability to accelerate thrombolysis. For suspected large vessel occlusion, bypassing to an endovascular thrombectomy (EVT)-capable center is endorsed when efficient. Intravenous thrombolysis (IVT) guidelines now include tenecteplase as non-inferior to alteplase within 4.5 hours and support advanced imaging to extend the window for select patients, while advising against thrombolysis for non-disabling deficits where dual antiplatelet therapy is preferred. Adjuvant antithrombotics with IVT are not recommended. EVT criteria are expanded to include patients with larger ischemic cores and those with basilar artery occlusion presenting within 24 hours. For the first time, guidelines include pediatric stroke, supporting the consideration of endovascular intervention. Management updates advise against intensive glucose control (80-130 mg/dL) and intensive systolic blood pressure reduction to <140 mmHg even post-reperfusion, due to lack of benefit and potential harm. Source: https://www.ahajournals.org/