Advances in endovascular thrombectomy of acute ischemic stroke

Acute ischaemic stroke (AIS) from large vessel occlusion (LVO) is a major global cause of death and disability.Endovascular thrombectomy (EVT) has revolutionized its treatment, yet nearly half of patients remain functionally dependent, highlighting the need to optimize the entire care pathway. This thesis addresses critical evidence gaps through multicenter randomized trials.
In the pre-procedural phase, the DIRECT-MT trial challenged routine bridging intravenous thrombolysis before EVT. Direct EVT was non-inferior to bridging therapy for selected Chinese population, suggesting that omitting intravenous thrombolysis may be safe and efficient in selected patients presenting directly to EVT-capable centers, simplifying workflows without compromising clinical outcomes.
In the intra-procedural phase, the PROTECT-MT trial demonstrated that balloon guide catheters resulted in worse functional outcomes and longer procedure times compared with conventional guide catheters, prompting re-evaluation of their routine use.
In the post-procedural phase, the ENCHANTED2/MT trial showed that intensive blood pressure lowering (systolic ≤120 mmHg) after successful reperfusion caused harm, supporting a more permissive management strategy.
Collectively, these findings advocate for streamlined pre-procedural preparation, evidence-based device selection, and conservative post-procedural blood pressure management. Future trials should focus on personalized strategies to further close the gap between successful reperfusion and functional recovery.