In acute ischemic stroke, rapid revascularization of the cerebral ‘penumbra volume’ is the key to better patient outcome. The largest and most proximal cerebral thrombotic artery occlusions can in most cases only be opened by intra-arterial intervention. The use of intra-arterial revascularization is rapidly expanding throughout Europe and North America, despite the risk for serious complications and the fact that the benefit of this treatment has not yet been proven in large, randomized clinical trials. Oslo University Hospital has performed approximately 60 intra-arterial procedures annually in acute ischemic stroke during the last few years. In this paper, we discuss important clinical and ethical aspects learned from our own experience. The future of intra-arterial cerebral revascularization will depend on an accurate preintervention patient selection.