Reconsidering stroke management pathways: The role of microsurgical thrombectomy after failed endovascular therapy

Endovascular therapy (EVT) has revolutionized acute ischemic stroke (AIS) management in patients with large vessel occlusion (LVO). Yet, EVT fails to achieve recanalization in 10-20 % of cases. In selected patients with persistent vessel occlusion, viable brain tissue, and exhausted endovascular options, microsurgical thrombectomy (MST) may offer a rescue strategy. In this opinion paper, we present two illustrative cases demonstrating MST after EVT failure-one involving vessel injury during thrombectomy, the other a calcified embolus refractory to retrieval. In both cases, complete revascularization was achieved within 5.5-7 h from symptom onset, and both patients recovered to mRS 0-1 by 3 months. Initial NIHSS scores were 13 and 17, and preoperative imaging demonstrated LVO and poor collateral status, findings typically associated with poor prognosis under conservative management. These cases demonstrate that MST, when performed promptly by experienced teams, can result in favourable outcomes in otherwise high-risk scenarios. We argue for the structured integration of MST into modern stroke workflows and propose a research framework to evaluate its role. Multidisciplinary collaboration, standardized protocols, and prospective outcome monitoring are essential to ensure safe and effective implementation.