TdC 329: Manejo de AVC isquêmico - Guideline AHA/ASA 2026

·38 min·2 clips

Basilar artery occlusion carries over 50% mortality in some series — and now thrombectomy is indicated up to 24 hours after symptom onset with PC-ASPECTS above 6.

1. Ta de Clinicagem hosts Lucas Cirilo and João Urbano review the 2026 AHA/ASA ischemic stroke guideline, describing it as the most significant update since the prior version and covering four major topic areas. 2. Both hosts are identified as neurologists; the episode is structured as a high-level synthesis of guideline changes rather than a comprehensive stroke management primer. 3. The episode's core thesis is identifying what has changed in the 2026 guideline and whether the changes are clinically meaningful, framed as updates to prior knowledge rather than starting from scratch. 4. Tenecteplase is now incorporated as the recommended thrombolytic for ischemic stroke, shown non-inferior to alteplase in multiple trials, with the key practical advantage of a single 5–10 second IV bolus at 0.25 mg/kg (max 25 mg) versus alteplase's 10% bolus plus 1-hour infusion protocol. 5. The 0.4 mg/kg tenecteplase dose was evaluated and rejected — higher symptomatic hemorrhage rate with no added efficacy — confirming 0.25 mg/kg as the approved dose. 6. ANVISA has not yet approved tenecteplase for stroke in Brazil; alteplase at 0.9 mg/kg remains the only locally approved option, but the hosts anticipate regulatory approval later in the year given a favorable prior assessment. 7. The extended thrombolysis window (4.5–9 hours) is now formally incorporated based on the XTEND trial, requiring CT perfusion with automated software to distinguish ischemic core from penumbra; wake-up stroke management (diffusion-FLAIR mismatch on MRI) was already in the prior guideline. 8. A new thrombolysis contraindication was added for patients using anti-amyloid monoclonal antibodies (lecanemab, donanemab) for Alzheimer's disease due to the risk of ARIA (amyloid-related imaging abnormalities) — both ARIA-E (edema) and ARIA-H (hemorrhage) — making prior anti-amyloid therapy a red flag to check in any patient presenting with stroke symptoms. 9. Thrombolysis in pediatric patients (28 days to 18 years) is now formally supported by the TIPS trial, which documented safety with alteplase for this age group, though efficacy evidence remains limited. 10. Mechanical thrombectomy for basilar artery occlusion is now a class 1 recommendation based on the BAOC and ATTENTION trials, with a 24-hour treatment window — longer than anterior circulation because brainstem and cerebellar structures are more ischemia-tolerant (predominantly axonal tissue rather than neuronal nuclei). 11. The PC-ASPECTS score mirrors the anterior ASPECTS system (10-point scale for posterior circulation): 2 points each for medulla, pons; 1 point each for cerebellum, occipital lobes, and thalami. 12. Large-core infarcts with ASPECTS 3–10 now have class 1/level A evidence for thrombectomy within 6 hours (SELECT-2 and ANGEL-ASPECTS trials); ASPECTS 0–2 receives a class 2A/level B recommendation with additional restrictions: age under 80 and modified Rankin Scale 0–1 at baseline. 13. Patients with ASPECTS 3–5 presenting between 6 and 24 hours can still be considered for thrombectomy if under age 80 and without cerebral edema with mass effect. 14. M2 segment (dominant branch of MCA) thrombectomy is now included under the classical criteria (onset <6 hours, ASPECTS ≥6) — a decision made by the neurointerventionalist at the time of the procedure based on branch dominance and anatomical factors. 15. For minor stroke (NIHSS ≤5) and high-risk TIA (ABCD2 ≥4) without a cardioembolic cause, dual antiplatelet therapy with aspirin 100 mg and clopidogrel 300 mg loading dose (then 75 mg daily) for 21 days remains the recommendation; a late-window study showed benefit even when initiated between 24–72 hours, earning a 2A/level B recommendation. 16. The ELAN 2023 trial introduced image-based (not NIHSS-based) stroke-size stratification for anticoagulation restart decisions — minor (<1.5 cm lesion), moderate (single superficial branch territory), major (large territory, cerebellar >1.5 cm, or brainstem) — with restart at 48 hours for minor and moderate, and 6–7 days for major strokes. 17. Prior clinical practice was to wait 14–28 days before restarting anticoagulation in major cardioembolic strokes; the guideline now endorses 6–7 days for major strokes with a 2A/level A recommendation, substantially shortening the prior delay. 18. The episode maintains a brisk, efficient pace with both hosts clearly familiar with the underlying trials, giving it the character of a peer-to-peer guideline summary rather than didactic teaching. 19. Emergency physicians, neurologists, and internal medicine residents who manage acute stroke will find the most direct clinical value in this episode. 20. Listeners seeking basic stroke anatomy or first-principles clinical management will find this episode too advanced, as it assumes prior knowledge of thrombolysis indications, NIHSS, ASPECTS, and anticoagulation principles.

Listen to the show on

Apple Podcasts Spotify

Play clips from this episode More from Ta de Clinicagem