Intravenous Thrombolysis in Acute Ischaemic Stroke: Practice Points from Current Guidelines

Abstract

The 2026 American Heart Association/American Stroke Association guideline on the early management of acute ischaemic stroke replaces the 2018 guideline and its 2019 update and revises several decisions taken at the CT console. Tenecteplase 0.25 mg/kg as a single bolus now carries the same standing as alteplase within 4.5 hours; thrombolysis is recommended for a disabling deficit irrespective of the NIHSS score; imaging-selected treatment is endorsed in extended and unknown-onset windows, including up to 24 hours in large-vessel occlusion where thrombectomy is unavailable; and the approach to contraindications has been restructured. This article distils these changes into six practice points for general physicians, emergency physicians and postgraduate residents, with tables of eligibility windows, weight-band dosing and contraindications.