BackgroundGroundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for.AimThis standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO.MethodThe SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels.ResultsThis SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care.ConclusionsThe challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.