Ischemic Stroke — Thrombolysis and Thrombectomy

Key Points

• Treat glucose abnormalities and obtain noncontrast head CT immediately in suspected acute stroke.
• Establish last-known-well time and whether the current deficit is disabling, not just the NIHSS number.
• The 2026 guideline permits either tenecteplase or alteplase for eligible patients in the 4.5-hour IV thrombolysis window.
• CTA should be obtained early when large-vessel occlusion is possible.
• Do not delay IV thrombolysis while arranging thrombectomy when the patient is eligible for both.
• Thrombectomy eligibility now extends to broader imaging-selected anterior-circulation and basilar-artery occlusion populations.
• Blood-pressure management differs before thrombolysis, after reperfusion, and in patients not receiving reperfusion.
• Stroke-unit care, dysphagia screening, secondary prevention, and etiologic evaluation begin during the same hospitalization.

Algorithm

1. Activate the stroke team and document last-known-well, baseline function, current disability, anticoagulants, surgery, bleeding history, and glucose.
2. Obtain urgent noncontrast CT and CTA when large-vessel occlusion is possible.
3. Determine IV thrombolysis eligibility and lower blood pressure to the required treatment threshold when necessary.
4. Give protocol-based tenecteplase or alteplase without avoidable delay when eligible.
5. Determine thrombectomy eligibility from vessel imaging, clinical severity, time window, and advanced imaging when needed.
6. Transfer rapidly to a thrombectomy-capable center when indicated while continuing stroke care.
7. After reperfusion, perform frequent neurologic and blood-pressure checks and obtain follow-up brain imaging before antithrombotic initiation per protocol.
8. Complete swallowing evaluation, rehabilitation assessment, vascular and cardiac workup, and secondary prevention planning.

Clinical Synopsis & Reasoning

Activate a stroke pathway for sudden focal neurologic deficits such as unilateral weakness or numbness, aphasia, dysarthria, neglect, visual loss, gaze deviation, ataxia, or other abrupt deficits. Establish the exact last-known-well time, medication use, baseline functional status, recent surgery or bleeding, and anticoagulant exposure. Check glucose immediately because severe hypo- or hyperglycemia can mimic or worsen stroke.

Noncontrast head CT is obtained urgently to exclude intracranial hemorrhage and identify major established infarction. CT angiography should be performed early when large-vessel occlusion is possible and should not be postponed for unnecessary laboratory delays. Advanced perfusion or MRI selection can identify patients who may benefit from reperfusion beyond conventional time windows, including selected wake-up strokes, according to institutional stroke capability and the 2026 guideline.

The NIH Stroke Scale standardizes deficit severity but should not be used to dismiss a disabling deficit with a low score. A small language, visual, or hand-function deficit may be disabling for the individual patient. Conversely, the 2026 guideline includes specific antiplatelet approaches for some non-disabling presentations in whom thrombolysis is not favored. Reperfusion decisions should be made rapidly with a stroke specialist and based on disability, imaging, time, bleeding risk, and vessel status.

Treatment Strategy & Disposition

For eligible adults within 4.5 hours, the 2026 AHA/ASA guideline endorses either alteplase or tenecteplase for IV thrombolysis. Tenecteplase is given as a single weight-based bolus under stroke protocol, while alteplase is infused after the initial bolus. Blood pressure must be below the thrombolysis threshold before treatment and monitored closely afterward. Do not delay IV thrombolysis for endovascular transfer when the patient is eligible for both and treatment can be started promptly.

Endovascular thrombectomy is standard for selected anterior-circulation large-vessel occlusion and is now supported in broader imaging-defined populations, including some patients with larger established cores and selected basilar artery occlusion. Eligibility depends on vessel, time, imaging, neurologic severity, premorbid function, and local neurointerventional expertise. CTA or MRA should be obtained quickly and transfer to a thrombectomy-capable center should begin while the rest of the evaluation proceeds.

After reperfusion therapy, admit to a stroke-capable monitored unit for neurologic and blood-pressure surveillance, hemorrhage monitoring, swallowing evaluation, and etiologic workup. Avoid antiplatelet or anticoagulant therapy during the immediate post-thrombolysis period until follow-up imaging confirms no hemorrhage according to protocol. For patients not receiving thrombolysis, antiplatelet timing and dual antiplatelet use depend on stroke subtype and disability.

Epidemiology / Risk Factors

• Ischemic stroke is a leading cause of long-term disability and mortality.
• Atrial fibrillation, hypertension, diabetes, dyslipidemia, smoking, carotid disease, and prior TIA or stroke are major risk factors.
• Large-vessel occlusion accounts for a minority of ischemic strokes but a disproportionate share of severe disability.
• Mobile stroke units and optimized EMS triage can shorten time to reperfusion in equipped systems.
• Disparities in stroke recognition, transport, and access to thrombectomy influence outcomes.

Investigations

Reperfusion Pathways

Pharmacology

Prognosis / Complications

• Earlier reperfusion is associated with better functional outcome, making treatment time clinically important even within accepted windows.
• Large infarct burden, severe baseline deficits, advanced age, hemorrhagic transformation, and delayed recanalization are associated with worse prognosis.
• Successful thrombectomy can produce substantial recovery even in severe large-vessel stroke when appropriate tissue remains salvageable.
• Post-stroke pneumonia, cerebral edema, recurrent stroke, venous thromboembolism, and cardiac complications affect hospital outcome.
• Long-term recovery depends on infarct location, rehabilitation intensity, cognition, mood, social support, and secondary prevention.

Patient Education / Counseling

• Teach patients and families to call emergency services immediately for recurrent face weakness, arm weakness, speech disturbance, sudden vision loss, severe imbalance, or other abrupt focal deficits.
• Explain the final suspected stroke mechanism and the reason for antiplatelet, anticoagulant, statin, blood-pressure, or other preventive therapy.
• Patients with atrial fibrillation need a clear anticoagulation-start plan that balances recurrent embolic risk against hemorrhagic transformation.
• Driving, work, swallowing, fall risk, and medication adherence should be addressed before discharge.
• Rehabilitation should begin early and may include physical, occupational, speech, and cognitive therapy.
• Depression, fatigue, sleep disorders, and caregiver burden are common and should be actively screened during follow-up.

Notes

The 2026 AHA/ASA guideline materially changes older library language by placing tenecteplase alongside alteplase in the standard treatment window and by expanding evidence-supported thrombectomy populations.

Reperfusion is only one part of acute stroke care. Airway protection, oxygenation when hypoxemic, glucose correction, blood-pressure strategy, fever treatment, dysphagia precautions, and stroke-unit monitoring prevent secondary injury.

References

1. AHA/ASA 2026 Guideline for Early Management of Acute Ischemic Stroke — Link
2. AHA 2026 Acute Ischemic Stroke Guideline Hub — Link