Timely reperfusion of brain ischaemic tissue is the main therapeutic target for acute stroke. In the last few decades many recanalisation strategies have been studied by randomised controlled trials (RCTs), including intravenous (IV), intra-arterial (IA), and combined approaches. Clinical research is addressed to identify the drug associated with the better reperfusion properties and the lower rate of side-effects. To date, according to current evidence-based guidelines, IV tissue plasminogen activator (tPA) is the only approved treatment for acute ischaemic stroke (AIS) within 4.5 hours from onset. Other IV thrombolytics, such as tenecteplase and desmoteplase, have shown promising results in preliminary RCTs and are currently being investigated to produce further evidence. Endovascular catheter-based treatments (including IA administration of thrombolytics or mechanical thrombectomy) have quite inferior feasibility, being performed only by stroke-trained interventional neuroradiologists. Until a few months ago, many trials had investigated the safety and efficacy of endovascular techniques compared with IV tPA without consistent results, limiting their application to patients with contraindications or poor response to IV tPA. More recently, the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN), Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE), and Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-arterial (EXTEND-IA) trial results have demonstrated the superiority of endovascular procedures associated with standard care in AIS due to proximal arterial occlusion in the anterior cerebral circulation. These data are going to change the current decision-making process and the care pathway in AIS patients.
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