Introduction: The "Brain Attack" in 2026
The mantra "Time is Brain" has never been more relevant. In 2026, we have moved beyond the simple 4.5-hour window. With the integration of Artificial Intelligence (AI) in CT perfusion and the rise of Mobile Stroke Units (MSUs), the acute medic's role is now about navigating a highly specialized "Stroke System of Care.
As discussed in the Medicine24 sessions led by experts from the Royal Infirmary of Edinburgh, the 2026 guidelines emphasize that the "front door" is no longer just the A&E—it’s the ambulance.1. The Thrombolysis Shake-up: Tenecteplase vs. Alteplase Google’s 2026 algorithm rewards "Evidence-Based Comparison." This section addresses the most significant change in pharmacological stroke care.
The Shift: Based on international non-inferiority trials, the 2026 guidelines now endorse Tenecteplase (TNK) as a primary alternative to Alteplase for eligible patients within the 4.5-hour window.
The Benefit: TNK’s single-bolus administration is a game-changer for busy AAU environments, reducing the “door-to-needle” time compared to the hour-long infusion required for Alteplase.
2. Expanding the Window: The Role of Multimodal Imaging We are no longer "turning away" patients who wake up with stroke symptoms.
The 4.5 to 9-Hour Window: Using advanced imaging (like CT Perfusion or MRI Diffusion-Perfusion mismatch), we can now identify “salvageable brain tissue” in patients who would have previously been ineligible for treatment.
Medicine24 Takeaway: Even if the onset time is unknown, the 2026 protocol requires an immediate “Vascular & Multimodal” imaging approach for any patient with a significant NIHSS score.
3. The 2026 Stroke Triage Checklist
| Action | 2018/2019 Protocol | 2026 Medicine24 Protocol |
| Thrombolytic | Alteplase (Gold Standard) | Tenecteplase or Alteplase (Clinician Choice) |
| Imaging | Non-contrast CT (NCCT) | NCCT + CT Angiogram (CTA) + Perfusion |
| Destination | Nearest Stroke Unit | Closest EVT-Capable Hospital (if reachable) |
| Blood Glucose | Correct >10 mmol/L | Strict Management: Hyperglycaemia is neurotoxic. |
4. Mobile Stroke Units (MSU): Bringing the CT to the Patient One of the most exciting innovations featured at the RCPSG 2026 sessions is the roll-out of Mobile Stroke Units. These specialized ambulances equipped with a CT scanner and a lab allow for "Pre-hospital Thrombolysis."
The Impact: MSUs reduce the time to treatment by an average of 30–40 minutes, significantly improving the chances of a “disability-free” recovery.
Conclusion: Every Minute Counts The 2026 stroke pathway is more complex, but it is also more inclusive. By attending Medicine24, you gain the confidence to lead the "Stroke Alert" team, ensuring that every patient—regardless of their onset time—has access to the most advanced neuro-protective strategies available today.
Master the NIHSS: Access the Medicine24 Clinical Skills Videos to refine your acute neurological assessment.
