Acute ischemic stroke therapy reference (2026)

Acute ischemic stroke therapy in 2026 organises around two main interventions plus secondary prevention.

Intravenous thrombolysis: tenecteplase has displaced alteplase as standard thrombolytic in many centres based on non-inferiority and superior workflow data, with a window typically up to 4.5 hours from onset (extended in selected imaging-defined cases).

Mechanical thrombectomy: standard within 6 hours of onset for large vessel occlusion, extended to 24 hours in selected patients with imaging-confirmed salvageable tissue (DAWN, DEFUSE-3, and follow-on trials). The procedural network (comprehensive stroke centres, telemedicine-supported transfers from primary stroke centres, mobile stroke units) defines geographic access.

Secondary prevention: antiplatelet therapy (aspirin, clopidogrel, dual antiplatelet in selected populations and time windows), statin therapy, blood-pressure management, anticoagulation for atrial fibrillation. Factor XIa inhibitor programs are in late-stage trials with the proposition of stroke-prevention efficacy without the bleeding penalty of current anticoagulants.

The geographic access question matters. Mechanical thrombectomy availability and door-to-needle time are major determinants of outcome and define the addressable population for advanced stroke care.