Endovascular thrombectomy for acute ischemic stroke: evolving patient selection, procedural strategies, and...

Endovascular thrombectomy (EVT) has transformed the treatment of acute ischemic stroke caused by large-vessel occlusion; however, its expanding indications require increasingly precise patient selection and procedural execution. This mini-review summarizes contemporary issues in EVT that go beyond the original early-window anterior-circulation paradigm. Current evidence supports the use of EVT for selected anterior-circulation large-vessel occlusion, late-window stroke, large-core infarction, and basilar artery occlusion, while more marginal scenarios-including a very low Alberta Stroke Program Early CT Score (ASPECTS), minor stroke with large-vessel occlusion, presentations beyond 24 h, prestroke disability, and medium-vessel occlusion-require individualized assessment. Recent randomized trials have tempered enthusiasm for routine thrombectomy in medium-vessel occlusion, emphasizing the need to distinguish technical accessibility from meaningful clinical benefit, particularly when eloquent brain regions are involved. Procedural strategy has also shifted from simple recanalization toward high-quality, tissue-effective reperfusion, with attention to the access route, device selection, first-pass effect, reperfusion grade, tandem lesions, intracranial atherosclerotic disease, anesthesia, antithrombotic use, and blood-pressure management. Adjunctive therapies, especially intra-arterial thrombolysis after successful, incomplete, or failed reperfusion, remain promising but should be employed selectively rather than as a routine practice. Overall, the future of EVT lies in disciplined precision: selecting patients for whom reperfusion is likely to be beneficial, optimizing procedural quality, and developing adjunctive strategies that convert angiographic success into durable functional recovery.