The EXTEND-IA trial evaluated the effectiveness of endovascular thrombectomy with the Solitaire FR stent retriever compared to alteplase alone in patients with ischemic stroke and proximal cerebral arterial occlusion. The study enrolled 70 patients (35 in each group) who had evidence of salvageable brain tissue and an ischemic core of less than 70 ml on CT perfusion imaging. Patients were randomized to receive either endovascular thrombectomy or alteplase alone. The trial was stopped early due to efficacy. The endovascular-therapy group had significantly higher reperfusion at 24 hours (100% vs. 37%) and greater early neurologic improvement (80% vs. 37%) at 3 days compared to the alteplase-only group. Functional outcomes at 90 days were also better in the endovascular-therapy group, with more patients achieving functional independence (71% vs. 40%). There were no significant differences in mortality or symptomatic intracerebral hemorrhage between the groups. The study used CT perfusion imaging to select patients with salvageable tissue, which improved the accuracy of patient selection. The use of advanced imaging techniques allowed for better identification of patients who could benefit from endovascular therapy. The trial demonstrated that early endovascular thrombectomy with the Solitaire FR stent retriever improved reperfusion, early neurologic recovery, and functional outcomes in patients with ischemic stroke and proximal cerebral arterial occlusion. The results suggest that endovascular therapy is more effective than alteplase alone in this patient population. The study was funded by the Australian National Health and Medical Research Council and others.The EXTEND-IA trial evaluated the effectiveness of endovascular thrombectomy with the Solitaire FR stent retriever compared to alteplase alone in patients with ischemic stroke and proximal cerebral arterial occlusion. The study enrolled 70 patients (35 in each group) who had evidence of salvageable brain tissue and an ischemic core of less than 70 ml on CT perfusion imaging. Patients were randomized to receive either endovascular thrombectomy or alteplase alone. The trial was stopped early due to efficacy. The endovascular-therapy group had significantly higher reperfusion at 24 hours (100% vs. 37%) and greater early neurologic improvement (80% vs. 37%) at 3 days compared to the alteplase-only group. Functional outcomes at 90 days were also better in the endovascular-therapy group, with more patients achieving functional independence (71% vs. 40%). There were no significant differences in mortality or symptomatic intracerebral hemorrhage between the groups. The study used CT perfusion imaging to select patients with salvageable tissue, which improved the accuracy of patient selection. The use of advanced imaging techniques allowed for better identification of patients who could benefit from endovascular therapy. The trial demonstrated that early endovascular thrombectomy with the Solitaire FR stent retriever improved reperfusion, early neurologic recovery, and functional outcomes in patients with ischemic stroke and proximal cerebral arterial occlusion. The results suggest that endovascular therapy is more effective than alteplase alone in this patient population. The study was funded by the Australian National Health and Medical Research Council and others.