Stroke is the second most frequent cause of death and third most frequent cause of combined death and disability globally, with 12.2 million incident cases of stroke, 143 million disability-adjusted life-years, and 6.5 million deaths in 2019.1 Nearly 87% of strokes are ischemic, and the remainder are hemorrhagic.2 Large vessel occlusions (LVOs) account for 24%–46% of all acute ischemic strokes (AIS).3 Since the publication of landmark trials demonstrating the superiority of endovascular mechanical thrombectomy (EVT) over medical therapy for anterior circulation LVO in 2015,4, 5, 6, 7, 8 EVT has been increasingly utilized.9,10 Approximately 6%–12% of people with ischemic strokes are eligible for EVT.11,12

EVT represents a unique intervention given its efficacy when used appropriately for an emergent, deadly condition. Moreover, treatment paradigms are rapidly changing as more data regarding the indications for EVT are released. EVT stands to become a widely generalizable treatment for patients with intracranial occlusions. These factors necessitate an approach determine who to treat, and perhaps more importantly, who not to treat. The field of ethics provides such a framework by allowing clinicians to understand why certain decisions are correct and others are wrong. In particular, neurosurgeons, neurointerventionalists, neuroradiologists, and neurologists must understand how to balance and address ethical considerations. Here, we delineate the application of foundational bioethical principles and narrative ethics to EVT, highlight salient and distinctive ethical issues in EVT, and develop an ethical framework to guide responsible use of EVT for people with stroke. Of note, this manuscript is focused on clinical ethics, meaning routine procedures, rather than research ethics, meaning investigative uses of EVT.