Stroke is one of the leading causes of adult disability and mortality worldwide, and approximately 80 % of all strokes are due to ischemia [1, 2]. Acute ischemic stroke (AIS) is now considered a medical emergency that demands prompt intervention to prevent disability and death. Intravenous thrombolysis with recombinant tissue-plasminogen activator (rtPA) during the first hours after the onset of symptoms is now the first-line treatment for ischemic stroke [3–5]. However, IV thrombolysis is not as affective when there is occlusion of a relatively large artery. Alternative treatments such as intra-arterial thrombolysis or mechanical thrombectomy have been studied, with encouraging results [6– 14]. Randomized controlled trials have been published detailing the results of intra-arterial thrombolysis [15–18] but as of yet, there is no level 1 evidence regarding the efficacy of mechanical or stent-assisted thrombectomy. Of the intra-arterial therapeutic techniques, the most promising appears to be recanalization with stent-based mechanical thrombectomy devices. From all studies published, it has become clear that patient selection is going to be crucial for the ultimate success of active catheter intervention in stroke. MRI or CT perfusion imaging is the tool for this. Radiologists are thus going to play a key role in patient selection. This, and subsequent intra-arterial stroke therapies, requires an advanced skill set, with in-depth knowledge of anatomy, pathophysiology, and clinical findings/symptomatology, as well as advanced catheter and guide wire skills, including dedicated knowledge of microcatheters/ microwires, guiding catheters, and thrombectomy devices. In many cases, thrombectomy for stroke may require two skilled operators, as time is of the essence. If intra-arterial stroke management is going to expand in the coming years, many more interventionalists must be trained. We believe that this advanced skill set cannot be obtained by limited exposure to cerebral diagnostic angiography, industry-sponsored courses, simulator training, or observerships in stroke centers. The latter models often form the basis of so-called particular competence where medical specialists cherry-pick a technique, design an abbreviated training module, and assimilate it into their practice. Intraarterial stroke therapy requires imaging, clinical, cognitive, and extensive technical skills. It is our belief that there is a direct correlation between skill level and outcome for intraarterial stroke therapy. To avoid potentially grave patient consequences, patient safety demands that specialists perform these types of complex procedures. The unskilled must undergo rigorous curriculum-based training in approved training institutions associated with an assessment of competence before performing these procedures. Reaccreditation must be earned on a frequent basis. With all new endovascular therapies, there is often an initial rush by many specialties and institutions to get involved. However, this is probably not in the best interest of patients. Patients undergoing these therapies should be treated in designated stroke centers with access to a M. J. Lee (&) Department of Academic Radiology, Beaumont Hospital, Dublin 9, Ireland e-mail: mlee@rcsi.ie