Endovascular therapy for acute ischemic stroke: From a decade of trials to the next frontier

Over the past decade, endovascular therapy (EVT) has transformed the management of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Building on the pivotal randomized controlled trials (RCTs) of 2015, subsequent evidence has refined indications, extended time windows, and advanced technical approaches. Yet, overall outcomes remain modest, with only half of patients achieving functional independence at 90 days. This has spurred efforts to expand EVT to new subgroups, including patients with medium-distal occlusions and mild deficits while optimizing workflows such as direct-to-angiosuite triage and tailored technical strategies. Recent RCTs have also revisited intra-arterial thrombolysis. Beyond revascularization, emerging research explores peri- and post-reperfusion targets, particularly anti-inflammatory and thromboinflammatory pathways. Collectively, these efforts reflect a paradigm shift, from reperfusion alone toward a broader, physiology-informed strategy aimed at improving functional recovery. Ten years on, EVT continues to evolve, promising greater precision, safety, and impact across AIS care.