Stroke is the third leading cause of death and a leading cause of severe long-term disability worldwide. It costs the world's economy billions of dollars each year in physician services, hospital costs, lost wages and decreased productivity. Rapid advances in medical technology have resulted in an explosion of treatment strategies in the management of acute ischemic stroke. Each clinical scenario presents unique challenges related to risks and benefits of therapy. In this article, we review the evolution of endovascular therapy in acute ischemic stroke, discuss the latest advances, challenges and controversies in the field and speculate on the future of this therapy.