Should baseline mRS serve as a gatekeeper for stroke thrombectomy? A commentary on the 2026 AHA/ASA guidelines for the early management of acute ischemic stroke

The recently published 2026 American Heart Association/American Stroke Association (AHA/ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke include a patient selection algorithm for endovascular thrombectomy (EVT) eligibility.1 For adult patients, four key factors were included – site of occlusion, time from last known well, Alberta Stroke Program Early CT Score (ASPECTS), and baseline modified Rankin Scale (mRS).1 While the first three factors are well justified, we believe the inclusion of baseline mRS warrants careful examination and that the field would benefit from an honest reflection on how a flawed and unvalidated metric became a key factor determining access to one of the most effective treatments in modern medicine.