The Extend-IA multicenter randomized trial conducted in Australia and New Zealand included patients with a confirmed anterior circulation occlusion who received IV alteplase (0.9 mg/kg) within 4.5 hours of symptom onset. All patients received CT perfusion imaging and we’re excluded if the completed infarct volume exceeded 70 mL. Patients received thrombectomy with the Solitaire FR or supportive treatment. Originally planned for 100 patients, the trial was stopped after 70 patients due to efficacy in the interventional arm across all endpoints. Revascularization success (100% versus 37%, p <0.001), early neurological improvement > 8 NIHSS points at 3 days (80% versus 37%, p < 0.002), and 3 month functional outcome (mRS 0-2: 71% versus 41%, p <0.01) were all superior in the endovascular arm. The Extend-IA trial affirms Class IA evidence in multiple trials supporting mechanical thrombectomy in large vessel occlusion and IV alteplase; it further introduced the potential value of perfusion imaging to screen for completed infarct.