Delayed treatment of severe stroke: room for thrombectomy?

Large vessel occlusion stroke is a significant cause of disability and mortality. Mechanical thrombectomy (MT) has greatly improved outcomes when performed within 6 h of symptom onset. However, many patients present beyond this window, which limits treatment options. Studies show that up to 70% of stroke patients in the USA and 30-40% in Europe arrive after 6 h. Advanced imaging techniques, such as computed tomography perfusion and magnetic resonance imaging, can aid in identifying salvageable tissue (penumbra) and guide late thrombectomy decisions. Trials like DAWN and DEFUSE-3 demonstrated considerable benefits of MT up to 24 h post-stroke in selected patients. Recent research, including the MR CLEAN-LATE, SELECT2, and ANGEL-ASPECT trials, suggests potential advantages for patients with large ischaemic cores (ASPECTS 3-5) without the need for advanced imaging. Despite these advancements, challenges persist, such as identifying optimal candidates, reducing haemorrhagic risks, and managing complications like no-reflow phenomena. Future research aims to enhance patient selection, optimize treatment strategies, and investigate new pharmacological approaches. Endovascular therapy continues to progress, providing new treatment options for late-presenting stroke patients.