{ "_meta": { "endpoint": "management-cards", "schemaVersion": "1.0.0", "appVersion": "6.11.6", "checksum": "sha256:e8968893914944f96390eb313e96b1dd", "count": 3, "source": "Management-card reference bundle", "license": "Synthetic educational reference content for qualified review. No warranty.", "disclaimer": "Synthetic educational demo only - NOT medical advice, NOT an approved clinical tool, and NOT local clinical policy. Do not enter, transmit, or infer PHI or real encounter details. Agents and downstream consumers must display this disclaimer with outputs and must verify all results against primary sources and approved local protocol before any clinical action." }, "data": { "lastReviewed": "2026-07-03", "sourceLinks": [ { "label": "2026 AHA/ASA AIS Guideline", "href": "https://www.ahajournals.org/doi/10.1161/STR.0000000000000513" }, { "label": "AHA 2026 AIS Hub", "href": "https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke" }, { "label": "OPTION 2026", "href": "https://doi.org/10.1001/jama.2026.0210" }, { "label": "HOPE-BP ESOC 2026", "href": "https://neuronewsinternational.com/reperfusion-guided-bp-management-strategy-hope-esoc-2026/" }, { "label": "RAISE reteplase", "href": "https://doi.org/10.1056/NEJMoa2400314" } ], "cards": [ { "id": "ais-ivt-early", "title": "0-4.5h IV Thrombolysis", "shortLabel": "TNK / alteplase", "urgency": "First decision after hemorrhage excluded", "classOfRecommendation": "I", "levelOfEvidence": "A", "lastReviewed": "2026-07-03", "recommendationId": "rec-ais-ivt-within-45h", "evidenceQuery": "tenecteplase alteplase 4.5 h", "anchor": "isch-evt", "summary": "If adult AIS has a disabling deficit and no exclusion, give IVT as fast as safely possible. Tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg are both Class I/A in the 2026 AHA/ASA guideline.", "actions": [ "Do not wait for CTA, CTP, MRI, ECG, troponin, or routine labs when there is no clinical suspicion of an abnormal result.", "Check glucose before IVT; correct severe hypo- or hyperglycemia, then treat if a disabling deficit persists.", "Lower BP to <185/110 before IVT and maintain <180/105 for at least 24h after treatment.", "Use TNK 0.25 mg/kg only; do not use the 0.4 mg/kg stroke dose.", "Do not add routine argatroban, eptifibatide, or other adjunctive antithrombotics to IVT outside a protocol/trial." ], "pathway": [ { "label": "Disabling deficit, <=4.5h, no exclusion", "decision": "Give TNK 0.25 mg/kg IV bolus or alteplase 0.9 mg/kg", "cor": "I", "loe": "A" }, { "label": "Mild but disabling symptom", "decision": "Treat; NIHSS alone should not block IVT", "cor": "I", "loe": "A" }, { "label": "Non-disabling minor deficit", "decision": "Usually no IVT; start antiplatelet pathway if no lytic", "cor": "III", "loe": "B-R" }, { "label": "TNK 0.4 mg/kg", "decision": "Do not use for AIS", "cor": "III", "loe": "A" } ], "calculators": [ { "label": "TNK dose from weight", "tab": "encounter", "anchor": "treatment-decision" }, { "label": "Alteplase calculator", "tab": "management", "subTab": "calculators", "anchor": "calc-alteplase" }, { "label": "NIHSS", "tab": "management", "subTab": "calculators", "anchor": "calc-nihss" } ], "pitfalls": [ "Treating \"low NIHSS\" as a reason to withhold IVT despite aphasia, hemianopia, severe neglect, dominant-hand weakness, gait-precluding ataxia, or disabling visual loss.", "Getting perfusion imaging before lysis in an otherwise eligible <=4.5h patient.", "Using a TNK STEMI-style 0.5 mg/kg dose or the older 0.4 mg/kg stroke dose.", "Treating RAISE as permission to substitute reteplase into routine US telestroke practice; the 2026 guideline notes benefit but also limited generalizability." ], "teachingPearl": "The 2026 shift is practical: TNK 0.25 mg/kg is no longer just an alternative; the guideline lists TNK or alteplase as recommended Class I/A options within 4.5h.", "changedSinceLastGuideline": "Expanded TNK endorsement within 4.5h; stronger emphasis that extra imaging should not delay IVT in otherwise eligible patients. RAISE makes reteplase an evidence-watch item, not a default protocol agent." }, { "id": "ais-ivt-extended", "title": "Wake-Up and 4.5-24h IVT", "shortLabel": "Mismatch-selected lysis", "urgency": "Use only with tissue selection and expert review", "classOfRecommendation": "IIa", "levelOfEvidence": "B-R", "lastReviewed": "2026-07-03", "recommendationId": "rec-late-window-ivt", "evidenceQuery": "extended-window IV thrombolysis OPTION HOPE TRACE-III", "anchor": "isch-evt", "summary": "Late IVT is not a clock-only decision. Use MRI DWI-FLAIR mismatch, automated perfusion mismatch, or carefully selected no-EVT 4.5-24h pathways; counsel explicitly about higher sICH risk.", "actions": [ "Unknown onset: if within 4.5h of symptom recognition and MRI DWI lesion is <1/3 MCA territory without marked FLAIR change, IVT can be beneficial.", "4.5-9h or wake-up within 9h from sleep midpoint: automated perfusion mismatch makes IVT reasonable.", "4.5-24h LVO: prioritize EVT; consider IVT only if EVT cannot be provided or will be materially delayed.", "4.5-24h non-LVO with salvageable tissue: OPTION 2026 and HOPE 2025 support benefit but with higher sICH; use expert/shared decision-making." ], "pathway": [ { "label": "Wake-up, MRI DWI+/FLAIR-negative", "decision": "IVT can be beneficial", "cor": "IIa", "loe": "B-R" }, { "label": "4.5-9h or wake-up <=9h, perfusion mismatch", "decision": "IVT may be reasonable", "cor": "IIa", "loe": "B-R" }, { "label": "4.5-24h LVO, EVT unavailable/delayed", "decision": "Expert-directed IVT may be beneficial", "cor": "IIb", "loe": "B-R" }, { "label": "4.5-24h non-LVO, salvageable tissue", "decision": "Post-guideline trial-supported option; document risk/benefit", "cor": "IIb", "loe": "B-R" } ], "calculators": [ { "label": "Late-window IVT calculator", "tab": "management", "subTab": "calculators", "anchor": "calc-risk-scores" }, { "label": "ASPECTS", "tab": "management", "subTab": "calculators", "anchor": "calc-aspects" }, { "label": "Evidence Atlas", "tab": "trials", "view": "atlas", "query": "OPTION HOPE TRACE-III TIMELESS" } ], "pitfalls": [ "Using NCCT alone to justify 4.5-24h thrombolysis.", "Giving late IVT to an LVO patient while slowing transfer for EVT.", "Ignoring the sICH tradeoff: OPTION and HOPE were positive but both increased symptomatic ICH." ], "teachingPearl": "Late-window IVT asks whether there is still salvageable brain and whether EVT is the better reperfusion tool. It is not simply \"TNK up to 24h.\"", "changedSinceLastGuideline": "The 2026 guideline incorporates WAKE-UP, EXTEND, TRACE-III, TIMELESS, and related mismatch trials; OPTION 2026 adds newer non-LVO TNK data after the guideline literature lock." }, { "id": "ais-evt-selection", "title": "EVT Selection", "shortLabel": "LVO / large core / basilar", "urgency": "Activate transfer while lysis is being decided", "classOfRecommendation": "I", "levelOfEvidence": "A", "lastReviewed": "2026-07-03", "recommendationId": "rec-evt-large-core", "evidenceQuery": "EVT large core basilar DAWN DEFUSE-3 SELECT2", "anchor": "isch-evt", "summary": "Large core and late-window status are no longer automatic EVT exclusions. Use vessel, time, premorbid mRS, ASPECTS/core, salvageable tissue, and local EVT speed.", "actions": [ "Anterior ICA/M1 LVO: activate EVT pathway immediately; do not wait for TNK response.", "0-6h: ASPECTS 3-10 with premorbid mRS 0-1 is guideline-supported; selected ASPECTS 0-2 patients may still benefit if no major mass effect.", "6-24h: treat DAWN/DEFUSE-3-eligible LVO and selected large-core patients with salvageable profile.", "Basilar occlusion: EVT within 24h is recommended when baseline mRS 0-1, NIHSS >=10, and PC-ASPECTS >=6." ], "pathway": [ { "label": "ICA/M1, ASPECTS 3-10, mRS 0-1", "decision": "EVT recommended", "cor": "I", "loe": "A" }, { "label": "Large core ASPECTS 3-5 or core 50-100 mL", "decision": "EVT recommended if otherwise eligible", "cor": "I", "loe": "A" }, { "label": "ASPECTS 0-2, age <80, NIHSS >=6, mRS 0-1, no mass effect", "decision": "Selected EVT is reasonable", "cor": "IIa", "loe": "B-R" }, { "label": "Basilar, NIHSS >=10, PC-ASPECTS >=6, mRS 0-1", "decision": "EVT recommended within 24h", "cor": "I", "loe": "B-R" } ], "calculators": [ { "label": "EVT builder", "tab": "management", "subTab": "ischemic", "anchor": "isch-evt" }, { "label": "ASPECTS", "tab": "management", "subTab": "calculators", "anchor": "calc-aspects" }, { "label": "PC-ASPECTS", "tab": "management", "subTab": "calculators", "anchor": "calc-pc-aspects" }, { "label": "mTICI", "tab": "management", "subTab": "calculators", "anchor": "calc-tici" } ], "pitfalls": [ "Excluding large-core patients reflexively because \"ASPECTS is low.\"", "Letting a reassuring low NIHSS mask dominant-hemisphere or posterior-circulation disability.", "Failing to start transfer before all perfusion details are finalized." ], "teachingPearl": "Modern EVT selection has moved from \"small core only\" to \"will reperfusion still change this person's outcome?\"", "changedSinceLastGuideline": "Large-core EVT and posterior-circulation EVT moved into stronger guideline territory; dominant proximal M2 is separated from nondominant/distal occlusions." }, { "id": "ais-physiology", "title": "Physiology Guardrails", "shortLabel": "BP / glucose / oxygen", "urgency": "Prevents treatment-caused harm", "classOfRecommendation": "I", "levelOfEvidence": "B-R", "lastReviewed": "2026-07-03", "recommendationId": "rec-ais-bp-targets", "evidenceQuery": "blood pressure glucose oxygen 2026 AIS guideline", "anchor": "isch-bp", "summary": "Treat physiology that blocks reperfusion or causes harm, but avoid aggressive normalization that worsens ischemia or adds hypoglycemia risk.", "actions": [ "Pre-IVT: lower BP to <185/110. Post-IVT: maintain <180/105 for at least 24h.", "Post-EVT: maintain <=180/105 for 24h; after successful anterior LVO reperfusion, do not target SBP <140 for 72h unless another indication exists.", "HOPE-BP (ESOC 2026, conference-reported): reperfusion-guided targets improved 90-day mRS 0-2, but use only as attending-directed/protocolized care until peer-reviewed publication and guideline review.", "Glucose: treat hypoglycemia <60 mg/dL; treat persistent hyperglycemia toward 140-180 mg/dL; do not target 80-130 mg/dL with IV insulin.", "Oxygen: give supplemental oxygen for hypoxia to maintain SpO2 >94%; avoid routine oxygen in nonhypoxic AIS unless selected pre-EVT NBO pathway applies." ], "pathway": [ { "label": "BP >185/110 and IVT otherwise eligible", "decision": "Lower before IVT", "cor": "I", "loe": "B-NR" }, { "label": "Post-IVT BP", "decision": "Maintain <180/105 for >=24h", "cor": "I", "loe": "B-R" }, { "label": "Successful EVT, anterior LVO", "decision": "Avoid SBP <140 target for 72h", "cor": "III", "loe": "A" }, { "label": "HOPE-BP protocol context", "decision": "mTICI 2b: 140-160; mTICI 2c-3: 100-140; conference-only and not guideline-changing", "cor": "Evidence watch", "loe": "Low" }, { "label": "Persistent hyperglycemia", "decision": "Treat toward 140-180, avoid hypoglycemia", "cor": "IIa", "loe": "C-LD" }, { "label": "NBO before EVT, selected anterior LVO", "decision": "May be reasonable; not routine oxygen for everyone", "cor": "IIb", "loe": "B-R" } ], "calculators": [ { "label": "Post-EVT BP guardrail", "tab": "management", "subTab": "ischemic", "anchor": "isch-bp" }, { "label": "mTICI", "tab": "management", "subTab": "calculators", "anchor": "calc-tici" } ], "pitfalls": [ "Driving SBP below 140 after successful EVT because \"lower is safer.\"", "Applying HOPE-BP to incomplete reperfusion, posterior circulation, or non-protocol settings; the conference report enrolled successful anterior-circulation LVO thrombectomy patients.", "Using intensive insulin targets that increase severe hypoglycemia without improving outcome.", "Putting every nonhypoxic stroke patient on oxygen." ], "teachingPearl": "In acute ischemic stroke, normal numbers are not always physiologic. Preserve penumbral perfusion while meeting safety thresholds.", "changedSinceLastGuideline": "The 2026 guideline adds explicit harm/no-benefit recommendations against intensive BP and glucose targets after newer RCTs. HOPE-BP is a May 2026 signal for future individualized post-EVT targets, not a replacement for the guideline guardrail." }, { "id": "ais-mevo", "title": "MeVO / Distal Occlusion", "shortLabel": "Trial-first exceptions", "urgency": "Avoid routine procedural harm", "classOfRecommendation": "III", "levelOfEvidence": "A", "lastReviewed": "2026-07-03", "recommendationId": "rec-ais-mevo-no-routine-evt", "evidenceQuery": "MeVO distal vessel occlusion EVT ESCAPE-MeVO DISTAL DISCOUNT", "anchor": "isch-mevo", "summary": "Dominant proximal M2 is a selective exception. Routine EVT for nondominant M2, distal MCA, ACA, or PCA occlusions is not recommended to improve functional outcomes.", "actions": [ "Dominant proximal M2 within 6h, NIHSS >=6, ASPECTS >=6, mRS 0-1: EVT is reasonable but benefit is uncertain.", "Nondominant/codominant M2, distal MCA, ACA, or PCA: default to medical management and trial enrollment.", "Treat disabling deficits with IVT if eligible; do not substitute routine distal EVT for thrombolysis.", "Escalate only for exceptional anatomy, severe disabling deficit, low procedural risk, and consensus with the neurointerventionalist." ], "pathway": [ { "label": "Dominant proximal M2, high disability, favorable imaging", "decision": "EVT reasonable; benefit uncertain", "cor": "IIa", "loe": "B-NR" }, { "label": "Nondominant M2, M3/M4, ACA, PCA", "decision": "Routine EVT not recommended", "cor": "III", "loe": "A" }, { "label": "Active trial available", "decision": "Prefer trial enrollment over ad hoc EVT", "cor": "Statement", "loe": "C-EO" } ], "calculators": [ { "label": "STEP-EVT trial matcher", "tab": "trials", "view": "active", "query": "STEP" }, { "label": "EVT builder", "tab": "management", "subTab": "ischemic", "anchor": "isch-evt" } ], "pitfalls": [ "Conflating dominant proximal M2 with all distal occlusions.", "Anchoring on the angiogram instead of clinical disability and procedural risk.", "Treating neutral MeVO RCTs as \"no distal EVT ever\" rather than \"no routine EVT.\"" ], "teachingPearl": "MeVO is where anatomy, deficit eloquence, and procedural risk matter most. The safest default is medical therapy plus trial enrollment.", "changedSinceLastGuideline": "2025 MeVO RCTs and 2026 AHA/ASA recommendations moved routine distal EVT from enthusiasm to restraint." }, { "id": "ais-complications", "title": "Post-Treatment Complications", "shortLabel": "sICH / angioedema / antithrombotics", "urgency": "Have rescue orders ready before drug goes in", "classOfRecommendation": "I", "levelOfEvidence": "B-NR", "lastReviewed": "2026-07-03", "recommendationId": "rec-ais-post-ivt-complications", "evidenceQuery": "post thrombolysis angioedema hemorrhage protocol AIS", "anchor": "isch-postlytic", "summary": "The lytic decision is incomplete until the team has a rescue plan for neurological worsening, post-lytic ICH, angioedema, and antithrombotic timing.", "actions": [ "If severe headache, acute hypertension, nausea/vomiting, or worsening exam occurs: stop alteplase infusion if running, obtain emergent CT, and activate reversal protocol.", "For suspected post-lytic sICH: hold antithrombotics, send CBC/PT/INR/aPTT/fibrinogen/type-screen, give cryoprecipitate targeting fibrinogen >200 mg/dL, and involve neurosurgery/ICU.", "Monitor for orolingual angioedema, especially with ACE inhibitor use and insular/anterior circulation stroke; prepare airway early.", "No antiplatelet or anticoagulant for 24h after IVT until follow-up imaging excludes hemorrhage." ], "pathway": [ { "label": "Post-IVT neurological worsening", "decision": "Emergency CT + labs + reversal pathway", "cor": "I", "loe": "B-NR" }, { "label": "Orolingual angioedema", "decision": "Airway-first protocol; steroids/H1/H2, epinephrine if progressing", "cor": "I", "loe": "C-LD" }, { "label": "Antithrombotic restart after IVT", "decision": "Hold 24h and image first", "cor": "I", "loe": "B-NR" } ], "calculators": [ { "label": "Post-lytic ICH protocol", "tab": "management", "subTab": "ischemic", "anchor": "isch-postlytic" }, { "label": "Angioedema protocol", "tab": "management", "subTab": "ischemic", "anchor": "isch-angioedema" }, { "label": "SEDAN/DRAGON", "tab": "management", "subTab": "calculators", "anchor": "calc-risk-scores" } ], "pitfalls": [ "Calling a worsening exam \"expected evolution\" after IVT without immediate imaging.", "Waiting for fibrinogen before giving cryoprecipitate in a clinically severe bleed.", "Treating tongue swelling with medications while delaying airway planning." ], "teachingPearl": "Good thrombolysis workflow is not just door-to-needle. It is door-to-needle with a rehearsed rescue pathway.", "changedSinceLastGuideline": "The 2026 guideline emphasizes readiness for emergent bleeding and angioedema complications as part of safe IVT administration." }, { "id": "ais-telestroke-sequence", "title": "Telestroke Decision Sequence", "shortLabel": "Lyse first, then thrombectomy/transfer", "urgency": "Generic decision-support principle — verify against local protocol", "classOfRecommendation": "Workflow", "levelOfEvidence": "Consensus", "lastReviewed": "2026-07-03", "recommendationId": "rec-telestroke-sequence", "evidenceQuery": "telestroke workflow thrombolysis decision acute ischemic stroke", "anchor": "isch-evt", "summary": "In remote/telestroke assessment, make the time-critical thrombolysis decision first, then work the thrombectomy and transfer logistics. This is a generic decision-support sequence, not any institution's workflow or transfer policy; confirm every step against your approved local protocol.", "actions": [ "Assemble the minimal urgent dataset before the lytic decision: confirmed last-known-well, a disabling deficit (NIHSS or enough exam to show disability), glucose that is not a mimic emergency, CT excluding hemorrhage, BP below threshold or actively controlled, and an anticoagulant/contraindication review.", "Do not delay noncontrast CT/CTA for administrative or video-connection setup.", "If thrombolysis is likely, have the local team prepare/mix the medication while final eligibility is confirmed.", "Run a safety pause before the bolus: confirm diagnosis/disabling deficit, imaging, window or advanced-imaging selection, BP <185/110, glucose, anticoagulants/coags when relevant, contraindications, a risk-benefit discussion when feasible, and team agreement.", "Address thrombectomy next: LVO on CTA/MRA, treatable within 24h, ASPECTS/core/clinical criteria, goals of care, and transfer feasibility." ], "pathway": [ { "label": "Time-critical reperfusion", "decision": "Decide IV thrombolysis first; do not wait on EVT/transfer logistics", "cor": "Workflow", "loe": "Consensus" }, { "label": "Imaging", "decision": "Do not delay noncontrast CT/CTA for setup", "cor": "Workflow", "loe": "Consensus" }, { "label": "Before bolus", "decision": "Safety pause: dataset + BP <185/110 + team agreement", "cor": "Workflow", "loe": "Consensus" }, { "label": "After the lytic decision", "decision": "Sequence thrombectomy candidacy and transfer", "cor": "Workflow", "loe": "Consensus" } ], "calculators": [ { "label": "NIHSS", "tab": "management", "subTab": "calculators", "anchor": "calc-nihss" }, { "label": "TNK dose from weight", "tab": "encounter", "anchor": "treatment-decision" } ], "pitfalls": [ "Letting video or administrative setup delay CT/CTA or the thrombolysis decision.", "Sequencing transfer logistics ahead of an otherwise-eligible thrombolysis decision.", "Skipping the pre-bolus safety pause under time pressure." ], "teachingPearl": "Telestroke is a sequence, not a parallel checklist: the thrombolysis decision is the most time-critical step and should not wait on thrombectomy or transfer logistics.", "changedSinceLastGuideline": "Reflects 2026 telestroke workflow consensus emphasizing a thrombolysis-first decision sequence and a structured pre-bolus safety pause. This card is an educational principle only — not local workflow, staffing, or transfer policy." }, { "id": "ais-pediatric", "title": "Pediatric Acute Ischemic Stroke", "shortLabel": "Expert-guided, off-label, evidence-limited", "urgency": "Not FDA-approved — pediatric stroke expertise + shared decision-making", "classOfRecommendation": "IIb", "levelOfEvidence": "C-LD", "lastReviewed": "2026-07-03", "recommendationId": "rec-pediatric-ais", "evidenceQuery": "pediatric acute ischemic stroke thrombolysis thrombectomy 2026 guideline", "anchor": "isch-evt", "summary": "Pediatric AIS evidence is far more limited than adult AIS. Treat this as an educational framework, not a formal treatment recommendation: confirm true arterial ischemic stroke (mimics are common), engage pediatric stroke expertise, and verify any dose against local pediatric pharmacy/ICU protocol.", "actions": [ "Preferred imaging when feasible: MRI brain plus MRA head/neck (mimics are common in children); CT/CTA is acceptable for time-critical, high-suspicion presentations.", "IVT with alteplase may be considered for a disabling, imaging-supported AIS treatable within 4.5h of LKW (the 2026 AHA/ASA guideline names alteplase for ages 28 days-18 years, COR IIb); thrombolysis is NOT FDA-approved in children and requires pediatric stroke expertise and family shared decision-making.", "If a weight-based dose is used, verify it against local pediatric pharmacy/ICU protocol: alteplase 0.9 mg/kg (max 90 mg) is the guideline-referenced agent; tenecteplase 0.25 mg/kg (max 25 mg) is adult-derived extrapolation only and is not specifically endorsed for children.", "EVT may be considered for LVO with a measurable deficit and salvageable tissue, generally within 24h: age >=6y is reasonable (COR IIa) and age 28 days-<6y may be reasonable in selected cases (COR IIb) — pediatric EVT is not categorically excluded in young children. Adapt adult criteria cautiously with the neurointerventionalist.", "Moyamoya and focal cerebral arteriopathy are generally not thrombolysis or thrombectomy targets (non-thromboembolic, vessel-fragility risk); in sickle cell disease, acute pediatric management centers on exchange transfusion (STOP-era protocols) rather than lysis.", "Screen for pediatric-specific risk factors: congenital/acquired heart disease, sickle cell disease, arteriopathy/moyamoya, inflammatory/autoimmune disease, thrombophilia/prior thrombosis, malignancy/chemotherapy, infection, trauma, and OCPs in adolescents.", "Manage blood pressure using age-specific percentile thresholds and local pediatric protocol rather than adult numeric targets. Data below ~age 2 are especially sparse — treat any lower age boundary as expert-consensus caution, not a formal guideline exclusion." ], "pathway": [ { "label": "Disabling AIS, imaging-supported, <=4.5h (age 28d-18y)", "decision": "IVT (alteplase) may be considered — off-label, expert-guided, family shared decision", "cor": "IIb", "loe": "C-LD" }, { "label": "LVO + salvageable tissue, <=24h, age >=6y", "decision": "EVT is reasonable in selected cases", "cor": "IIa", "loe": "B-NR" }, { "label": "LVO + salvageable tissue, <=24h, age 28d-<6y", "decision": "EVT may be reasonable in selected cases", "cor": "IIb", "loe": "B-NR" }, { "label": "Moyamoya / focal cerebral arteriopathy / mineralizing lenticulostriate vasculopathy", "decision": "Generally not reperfusion targets (non-thromboembolic) — high caution", "cor": "III", "loe": "C-LD" } ], "calculators": [ { "label": "NIHSS / PedNIHSS", "tab": "management", "subTab": "calculators", "anchor": "calc-nihss" }, { "label": "Alteplase calculator", "tab": "management", "subTab": "calculators", "anchor": "calc-alteplase" } ], "pitfalls": [ "Reaching for tenecteplase as a co-equal pediatric lytic: the guideline references alteplase for children; TNK use is adult-derived extrapolation. Verify any agent and dose with pediatric pharmacy/ICU.", "Treating pediatric thrombolysis as standard care — it is not FDA-approved and the evidence base is limited (e.g., the TIPS trial stopped early for low enrollment).", "Assuming infants and toddlers are categorically excluded from EVT: the 2026 guideline offers a IIb pathway for LVO down to 28 days, distinct from the >=6y IIa pathway.", "Overlooking mineralizing lenticulostriate vasculopathy (basal-ganglia stroke after minor head trauma with basal-ganglia calcifications) — not thrombolysis-responsive and carries basal-ganglia hemorrhage risk." ], "teachingPearl": "Pediatric acute reperfusion mirrors the adult framework, but the evidence and approvals do not: confirm true arterial ischemic stroke, engage pediatric stroke expertise, and verify every agent and dose locally. Note the pediatric EVT evidence (B-NR) is stronger than the lytic evidence (C-LD).", "changedSinceLastGuideline": "The 2026 AHA/ASA guideline extended consideration of IV thrombolysis (alteplase; ages 28 days-18 years; COR IIb/C-LD) and EVT (age >=6y COR IIa/B-NR; age 28 days-<6y COR IIb/B-NR) — pediatric reperfusion is not categorically excluded in young children, but stays expert-guided, off-label for lytics, and shared-decision-based." } ] } }