Intravenous thrombolysis improves long term functional outcomes in acute ischemic stroke. A select proportion of patients treated with thrombolysis experience rapid early neurological recovery, a powerful predictor of favourable long term outcomes. There is increased interest to augment early neurological recovery by endovascular therapy or by adjuvant intravenous thrombolytics. However, incomplete understanding of the physiological mechanisms of early recovery has hampered a unified approach to monitor and to triage patients for invasive therapy. This review aims to examine the current understanding and insights gained from recent studies concerning early recovery and to inform the design of future studies.