Redrawing the Limits of Thrombectomy: Dose, Damage, and Delay

Endovascular thrombectomy has transformed the treatment of large vessel occlusion stroke. But as its use expands, important questions remain about where its boundaries lie. In this episode of Voice of Stroke, we explore three recent studies examining patient selection and treatment intensity at the margins of thrombectomy practice. This episode discusses: • The CHOICE-2 trial and adjunctive intra-arterial alteplase after successful thrombectomy • Whether ischaemic core volume may refine patient selection beyond ASPECTS in large-core stroke • The AURORA pooled analysis examining the role of time in imaging-selected patients treated in the extended 6–24-hour window Featuring discussion of recent research published in JAMA, Stroke, and Neurology. Written by: Robert Hurford, Voice of Stroke Podcast Editor, and Linxin Li, Voice of Stroke Editor-in-Chief. Read the full transcript here References ·      Renú A, Fernández-Couto MD, de la Riva P, et al. Adjunctive Intra-Arterial Alteplase After Successful Thrombectomy for Acute Ischemic Stroke: The CHOICE-2 Randomized Clinical Trial. JAMA. 2026. ·      Jiang X, Zhao Z, Zhang Y, et al. Intra-arterial thrombolysis following endovascular recanalization for large vessel occlusion stroke: a systematic review and meta-analysis. Neurology. 2025. ·      Kim H, Ryu WS, Inoue M, et al. Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS. Stroke. 2026.  ·      Sarraj A, Hassan AE, Abraham MG, et al. Endovascular thrombectomy for large ischemic stroke across ischemic injury and penumbra profiles. JAMA. 2024. ·      Sarraj A, Thomalla G, Yoshimura S, et al. Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS). Lancet. 2026. ·      Nogueira RG, Jovin TG, Lansberg MG, et al. Time to Treatment in Stroke Thrombectomy and Outcomes in the Extended Time Window: A Meta-Analysis. Neurology. 2026.