Endovascular thrombectomy for acute stroke: evolving eligibility criteria and adjunct therapies

Endovascular thrombectomy is the standard treatment for ischaemic stroke, a leading cause of disability worldwide. Randomised trials in the past decade have expanded eligibility criteria to include broader patient populations, such as those with large ischaemic core stroke. However, many patients still have poor outcomes despite high rates of macrovascular reperfusion, underscoring the need for strategies that go beyond restoring large-vessel flow. Intra-arterial thrombolysis and cytoprotective agents are under investigation for their potential to reduce secondary complications during and after endovascular thrombectomy. These strategies target key mechanisms such as microvascular obstruction, excitotoxicity, oxidative stress, and inflammation. Their effectiveness depends on aligning the mechanism of action with the patient's underlying pathophysiology. Despite years of promising results limited by constrained clinical translation in cytoprotective trials, recent trials have provided hope and insights, helping to define crucial factors for translational success. Incorporating these lessons into refined inclusion criteria and future studies has the potential to transform our approach to caring for patients at the greatest risk of poor clinical outcomes, including severe disability or death.