If your stroke triage protocol still says "transport to the nearest thrombolytic-capable hospital," it's wrong as of January 26, 2026. The new AHA/ASA acute ischemic stroke guideline flipped the destination rule, stretched the EVT window to 24 hours, and quietly told you to stop chasing a blood pressure number you've been chasing for a decade.

Most services haven't updated the cards.

Start with the destination question, because that's the one you make at the curb.

The old rule was easy: nearest tPA-capable ED, drip and ship if they need a clot pulled. The 2026 guideline now endorses, in its own language, "direct transport to the closest EVT-capable hospital in the absence of well-functioning systems with rapid interhospital transfer processes." Translation: if your "well-functioning system" is a fax to the receiving stroke coordinator and a prayer about helicopter weather, it isn't well-functioning. Drive past the primary stroke center.

The number behind the change is real. A meta-analysis of 18 studies and 7,017 patients cited in the guideline put functional independence at 53% with direct transfer to an EVT center versus 47% with drip-and-ship. Six absolute percentage points of "walking out of rehab" isn't a rounding error. It's the entire reason your LVO screen exists.

So when your RACE or LAMS or VAN lights up, the question isn't "what's closest." It's "what's closest that can actually open the artery." If that's 25 minutes farther, and your county's interfacility transfer reliably eats 90 minutes, the math isn't close.

Mobile stroke units are now standard of care

For the first time, mobile stroke units got a Class 1, Level A recommendation for thrombolytic-eligible patients where they're available, on the strength of B_PROUD and BEST-MSU. If your region has one and dispatch isn't sending it on suspected strokes, that's a system problem worth raising at the next QA meeting. If your region doesn't have one, file that under "things hospital administrators should explain."

Tenecteplase is in. Officially.

Inside the 4.5-hour window, the guideline gives a Class 1 recommendation for either tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg. For anyone running critical-care transport: TNK is a single bolus. Alteplase is a 60-minute infusion you have to babysit through a transfer. You already know which one wins at 3 a.m. with a 40-minute drive ahead of you.

The guideline also stops requiring an NIHSS threshold or advanced imaging to treat disabling deficits inside 4.5 hours. If they're disabled and eligible, the clock is the only gatekeeper.

The window keeps getting longer

EVT eligibility now stretches to 24 hours for anterior circulation LVO with the right imaging, including patients with ASPECTS 3 to 5 and NIHSS ≥6 under age 80, on the strength of SELECT2 and ANGEL-ASPECT. Basilar occlusions get a Class 1 EVT recommendation out to 24 hours with NIHSS ≥10, courtesy of ATTENTION and BAOCHE.

The "they woke up like this, nothing we can do" reflex is dead. Last known well is the question. The answer is often still in play.

Two things to stop doing

Stop chasing tight glucose. The guideline drops the 80 to 130 mg/dL target outright because it doesn't improve outcomes and causes hypoglycemia. Treat the hypoglycemic stroke mimic. Otherwise leave the insulin drip alone.

Stop hammering the systolic under 140 after thrombolysis or thrombectomy, even on a TICI 3 reperfusion. New trial data shows no benefit after IVT and possible harm after EVT. The receiving team may still want it lower on a hemorrhage-risk patient, but the reflexive "below 140 for everybody" order has lost its evidence base.

The guideline runs 200-plus pages. The version that fits on a pocket card is shorter: bypass for EVT when the system can't move fast, push for TNK over alteplase when transfer is on the table, and treat the 24-hour window as live until imaging says otherwise.