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Stroke is the fifth leading cause of adult death and disability resulting in over $72 billion in annual cost. The two main types of strokes are ischemic and hemorrhagic strokes. The latter constitute 85% of the cases (Fisher et al., Handbook of clinical neurology. Elsevier B.V, 2009). The phrase “time is brain” was coined by Dr. Camilo Gomez to emphasize the importance of time when it comes to stroke (Gomez, J Stroke Cerebrovasc Dis 3:1–2, 1993). It is estimated that for every minute of delay in the treatment of ischemic stroke, 1.9 million cells die in the brain, and 13.8 million synapses and 12 kilometers of axonal fibers are lost (Gomez, J Stroke Cerebrovasc Dis 3:1–2, 1993).

Direct aspiration, a thrombectomy approach that originally evolved from a modified stent retriever-based technique, is now accepted as a frontline modality. We outline the evolution of thrombectomy techniques leading to ADAPT (A Direct Aspiration First-Pass Technique), as well as the current literature to support its use.

Carotid terminus occlusions have unique clinical and radiographic factors. Associated with more severe neurological deficits and a worse natural history, they may also manifest as “carotid pseudo-occlusion” on CT angiography. An approach utilizing direct aspiration of the thrombus is described.

Endovascular mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke patients with large vessel occlusions. The success of MT is mainly due to the development of new-generation devices that allow higher rates of successful revascularization with lower complications. In this chapter, we review the evolution of MT devices and technologies.