The EXTEND-IA trial aimed to evaluate the effectiveness of early endovascular thrombectomy with the Solitaire FR stent retriever in patients with ischemic stroke, compared to alteplase alone. The study found that endovascular therapy, initiated within 4.5 hours of stroke onset, significantly improved reperfusion rates, early neurologic recovery, and functional outcomes at 90 days. Patients in the endovascular-therapy group had a higher percentage of reperfusion at 24 hours (100% vs. 37%, P<0.001) and greater early neurologic improvement at 3 days (80% vs. 37%, P=0.002). Additionally, more patients in the endovascular-therapy group achieved functional independence at 90 days (71% vs. 40%, P=0.01). The trial was stopped early due to the clear efficacy demonstrated, and no significant differences were observed in rates of death or symptomatic intracerebral hemorrhage. The use of CT perfusion imaging to select patients with salvageable tissue and advanced devices improved the outcomes, highlighting the importance of early intervention and advanced imaging in ischemic stroke treatment.The EXTEND-IA trial aimed to evaluate the effectiveness of early endovascular thrombectomy with the Solitaire FR stent retriever in patients with ischemic stroke, compared to alteplase alone. The study found that endovascular therapy, initiated within 4.5 hours of stroke onset, significantly improved reperfusion rates, early neurologic recovery, and functional outcomes at 90 days. Patients in the endovascular-therapy group had a higher percentage of reperfusion at 24 hours (100% vs. 37%, P<0.001) and greater early neurologic improvement at 3 days (80% vs. 37%, P=0.002). Additionally, more patients in the endovascular-therapy group achieved functional independence at 90 days (71% vs. 40%, P=0.01). The trial was stopped early due to the clear efficacy demonstrated, and no significant differences were observed in rates of death or symptomatic intracerebral hemorrhage. The use of CT perfusion imaging to select patients with salvageable tissue and advanced devices improved the outcomes, highlighting the importance of early intervention and advanced imaging in ischemic stroke treatment.