For several years, the only therapy with proven efficacy for acute ischaemic stroke was alteplase, which is approved for use within 4. 5 h after stroke onset in many countries, but only within 3 h in the USA. However, the recanalisation rate with alteplase is modest. Several trials have shown substantial clinical benefit of neurothrombectomy within 6 h of ischaemic stroke onset, which has initiated a new era of acute stroke therapy. As neurothrombectomy becomes part of standard practice, additional trials will be needed to determine the best way to organise delivery of this care. Continuing clinical trials with several types of advanced MRI and CT imaging to enhance patient selection are investigating alteplase, other thrombolytic drugs, and novel endovascular devices, for use in later time periods from stroke onset. Consequently, the organisation and implementation of future dinical trials will need to adapt to what has been learned from the present generation of trials. The delivery of care to patients with acute stroke will also need to incorporate newly proven therapies, and much additional work is needed to maximise outcomes in as many patients as possible.
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