New Resident Guide to Stroke Alerts - Part 2

In part two of this series, Dr. Andy Southerland and Dr. Dan Ackerman discuss a few rapid‑fire concepts from the 2026 guidelines, focusing on what is new and how emerging data may shape patient care. 

Show transcript: 

Dr. Andy Southerland:

Hello, everyone. This is Andy Southerland from the University of Virginia. And for today's Neurology Minute, I'm speaking with my friend and colleague, Dan Ackerman, Chief of Neurology and Director of Stroke at St. Luke's University Health System. We've been speaking in the main neurology podcast on tips for updated clinical practice related to the 2026 American Heart Association guidelines for the early management of patients with acute ischemic stroke. I'm going to hit Dan with a few rapid fire concepts that were touched on the guidelines that I think are new or provide some new insights, new based on the data and to how we treat patients.

So Dan, you ready for it? Rapid fire, acute stroke treatment decision making?

Dr. Dan Ackerman:

Absolutely. Hit me.

Dr. Andy Southerland:

All right, Dan. I'm a resident going to my first stroke alert on July one this year and I've got a patient coming in, they're having disabling stroke symptoms and they're, in every other way, eligible to receive thrombolysis, but they have a history of paroxysmal atrial fibrillation. They are on apixaban and they took a dose of that apixaban. They forgot to take one yesterday, but they took one the day before, had the evening before. And so 36 hours ago, they took a dose of their apixaban. So based on previous dogma, I think prior guidelines might've said if it's within that 48 hour window, that's a relative contraindication of thrombolysis. What, say, you based on the new guidelines and then how do they inform us about making that decision?

Dr. Dan Ackerman:

I would actually say the new guidelines are a little bit more aligned with what you just said. You mentioned it as a relative contraindication to thrombolysis. I think before these guidelines came out, a lot of people would've said, "No, that is a strict contraindication to thrombolysis." And a lot of folks would run a stroke code or a stroke lid a little slower knowing that, hey, this person is on, whether it's apixaban, rivaroxaban, edoxaban, dabigatran, et cetera, any of these direct oral anticoagulants and say, "Well, no, we know that person's not a candidate for thrombolytics." Well, no, the newer guidelines would suggest that that is a relative contraindication, not a strict contraindication. And when we look back at studies on this, it has not been suggested that there is a big contribution in terms of exactly how long ago that last dose was. Was it two hours ago, 12 hours ago, 20 hours ago? And there has not been shown to be a clear benefit of testing for factor Xa activity levels, bleeding time and the like.

So the guidelines do suggest that, hey, we need more data on this. It's not to, say, that this is 100% perfectly fine. Remember, that's a relative contraindication, so it's still a risk benefit discussion, but studies have not shown an increased risk for hemorrhagic complications in patients who have had recent DOAC exposure who receive IV thrombolysis otherwise according to the guidelines. So I would tend to offer it in that situation and make sure that we document what drugs someone's on, how long ago was their last dose, all of this kind of information in addition to what we might normally otherwise get down.

Dr. Andy Southerland:

Does that change, Dan, if they took the DOAC in the last 24 hours or even 12 hours? They took it last night, and they're presenting in the morning with their stroke-like symptoms?

Dr. Dan Ackerman:

The guideline just suggests less than 48 hours, and the data, to my knowledge, doesn't really delineate, at this point, any particular timeframe where we would say, no, there's a cutoff there at two hours or eight hours or 12 hours. So at this point, I would not use that as a way to decide not to offer thrombolysis based on that timeframe.

Dr. Andy Southerland:

Fair enough. I think that's very reasonable. And I think, again, it's always a good conversation to have either with your attending, if you're that resident on July 1, but particularly with the patient and their family on the risk-benefit of what we know based on the data.

Well, that's all the time we have for this Neurology Minute. We hope this discussion will continue to help everyone out there in the hyperacute management of patients with acute ischemic stroke, making those difficult treatment decisions. Good luck.