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Advances in mechanical thrombectomy techniques have resulted in improved, recanalization and functional outcomes in acute stroke, as demonstrated in recent, randomized trials comparing mechanical thrombectomy with thrombolysis. In conjunction with the technological advancements in thrombectomy devices, there has been better appreciation of stricter patient selection criteria for endovascular therapy based on pre-procedural imaging, including clot location, infarct volume, and penumbral territory at risk. Pre-procedural imaging performed to assess suitability for endovascular therapy commonly provides information on clot characteristics, such as clot location, length, density, and susceptibility, which can influence and may predict the efficacy of intravenous and endovascular treatments. The purpose of this review is to evaluate the role of clot imaging in acute large vessel occlusion strokes and discuss the relevance of clot imaging to thrombolytic and endovascular therapy.