Are we close to the twilight of IV thrombolysis for acute ischemic stroke patients with large vessel occlusion?

Endovascular treatment (EVT) has revolutionized acute stroke management, but defining precisely when and in which patients to use this therapy remains challenging. The spectacular efficacy of EVT follows 2 decades of acute stroke research, which focused initially on IV thrombolysis (IVT) and then on EVT, in parallel with the development of new endovascular devices. In the first years after the publication of the National Institute of Neurological Disorders and Stroke study in 1995,² few alternatives to IVT were available. At the time, stroke specialists focused on determining the time window during which IVT could benefit patients. Because it is so that the shorter the time from onset to needle, the more favorable the outcome, process development focused on optimizing stroke triage and emergency room management for acute patients. However, despite remarkable efforts in the organization of stroke centers, the number of patients who could benefit from IVT stalled. Selection of patients, using perfusion and diffusion imaging beyond the 4.5-hour time window, only marginally increased the number of potential candidates for IVT. After several unsuccessful trials, recent studies have demonstrated the benefit of EVT in patients with proximal vessel occlusion following, in most cases, the administration of IVT within 4.5 hours of symptoms.³ Based on new devices for thrombectomy and thromboaspiration, these consistent results have led to a complete reevaluation of EVT as the only acute therapy beyond 4.5 hours of symptoms onset, or in a seemingly counterintuitive approach, even without prior administration of IVT within 4.5 hours of onset.