Past, Present, and Future of Mechanical Thrombectomy in Acute Ischemic Stroke: Expanding the Horizons of Endovascular Stroke Care

Mechanical thrombectomy has transformed the management of acute ischemic stroke caused by large vessel occlusion, evolving from early intra-arterial thrombolysis and first-generation devices into a Class I, Level A standard of care in anterior circulation stroke. Landmark randomized trials and pooled analyses have demonstrated robust improvements in functional independence with early-window, late-window, posterior circulation, and now large-core thrombectomy. Recent large-core trials show that carefully selected patients with substantial baseline infarction can still derive meaningful benefit from endovascular therapy, challenging traditional exclusion thresholds. In contrast, randomized medium- and distal-vessel occlusion (MeVO/DVO) studies to date have been neutral, emphasizing the need for more refined patient selection and dedicated small-vessel devices. Ongoing platform trials, advances in devices and combined techniques, and AI-enabled workflow optimization are poised to further expand the horizons of mechanical thrombectomy, particularly in resource-limited settings and previously undertreated stroke populations.