A decade after the US Food and Drug Administration (FDA) approved intravenous tissue plasminogen activator for treatment of acute ischemic stroke, the public health impact of this treatment on stroke outcome remains limited. The extremely small time window for treatment and very low recanalization rates in large artery strokes are its major shortcomings. Endovascular therapies for the treatment of acute stroke have rapidly evolved during this time period and may overcome these limitations. FDA approval of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) concentric retriever in August 2004 for the treatment of occluded brain arteries has spurred trials of newer devices for mechanical thrombolysis in acute stroke. At present, there are two major National Institutes of Health-sponsored randomized controlled trials testing endovascular treatments in acute stroke. In this article, we provide an experience-guided review of the current approach to the endovascular treatment of acute ischemic stroke and current evidence for various strategies. We first emphasize the key aspects of patient selection, including the increasingly central role of perfusion/diffusion imaging. The technical aspects of chemical, mechanical, ultrasound-based, and multimodal approaches are provided along with the authors' own experiences. Most of the endovascular modalities tested in clinical trials show recanalization rates in the range of 50% to 65%. However, no one modality is clearly superior. In practice, multimodal treatment strategy is often employed to achieve rapid recanalization of occluded cerebral vessels and minimize chances of hemorrhage. This may become the standard of care in the future.