The past decade has seen a significant change in the treatment of acute ischemic stroke (AIS). There has been a paradigm shift from a predominantly conservative approach to administration of intravenous thrombolytics and to endovascular thrombectomy. These treatment strategies have been backed by multiple randomized clinical trials. Current evidence suggests that endovascular thrombectomy in the form of stent retriever and/or suction aspiration should be first-line therapy for patients with intracranial large vessel occlusion. The most important aspect for successful outcomes is proper patient selection using clinical and imaging criteria. In this chapter, we follow the evolution of endovascular treatment for acute ischemic stroke and comprehensively discuss the various nuances for proper patient selection.