[Ethical Issues in Mechanical Thrombectomy for Acute Ischemic Stroke]

Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion, and its indications have expanded substantially over the past decade. Recent randomized controlled trials (RCTs) have extended eligibility to patients presenting in extended time windows, those with large ischemic cores, and other populations previously considered unsuitable for intervention. However, the expansion of MT indications has also raised important ethical challenges. Patients with AIS often lack decision-making capacity, requiring physicians to balance respect for patient autonomy with the principles of beneficence, nonmaleficence, and justice under severe time constraints. Moreover, RCTs have enrolled highly selected populations, and evidence remains limited for many patients encountered in clinical practice. This review discusses ethical issues related to MT across clinical contexts involving treatment beyond conventional time windows, large ischemic cores, medium or distal vessel occlusions, futile recanalization, active malignancy, and prestroke disability. Representative cases illustrate situations in which ethical considerations extend beyond guideline recommendations. Whenever possible, treatment decisions should incorporate each patient's premorbid functional status, values, anticipated quality of life, procedural risks, and expected neurological recovery. Continued evidence generation in understudied populations will be essential to support the ethically sound, patient-centered application of MT.