Abstract The treatment for acute ischemic stroke is a delicate matter, especially since time relapse from ictus to treatment is of vital importance for the outcome. The constantly evolving treatment options aim towards achieving high revascularization rates and limit the time in order to prevent irreversible damage to the brain tissue. Although becoming more clear, predictors of positive outcome and selection of patients to receive endovascular treatment remains unproven. Promising results are seen when selection is based on imaging to determine still viable tissue and the localization of the occlusion. Furthermore it is known that revascularization is associated with improved outcomes, however it is still unclear which method, if any, is ideal and might be proven superior against the presently preferred medical treatment. The main goal of this review is to discuss available therapies for acute ischemic stroke and criteria that will help identifying patients who might benefit from them. In order to find selection criteria and decide whether endovascular treatment is superior to medical more randomized controlled studies are needed.