Abstract
Background: Artificial Intelligence as a Medical Device (AIaMD) introduces regulatory, methodological, ethical, and clinical challenges that are not fully addressed by traditional device trial frameworks. Given rapidly evolving and jurisdiction-specific guidance, a consolidated mapping of trial design expectations and regulatory requirements is needed. Objective: To map regulatory requirements and clinical trial design approaches for AIaMD across major jurisdictions and to identify key methodological and implementation gaps relevant to adaptive/continuously learning systems. Methods: A scoping review was conducted in accordance with the PRISMA-ScR reporting guideline. Peer-reviewed literature (2017-2025) was searched in PubMed, Embase, Web of Science, and the Cochrane Library. Gray literature was identified from major regulators and policy bodies (FDA, EMA, MHRA, PMDA, WHO, CDSCO). Eligible records addressed AIaMD clinical evaluation, trial design, regulatory pathways, post-market surveillance, or reporting standards. Data were charted using a predefined extraction framework and synthesized descriptively with thematic analysis across regulatory, methodological, ethical, and clinical implementation domains. Results: Included sources demonstrate substantial heterogeneity in evidence expectations and AI-specific pathways across jurisdictions. Recurrent themes include the need for predefined change management, performance monitoring and drift controls, dataset representativeness and bias evaluation, transparency and versioning, cybersecurity, and real-world evidence integration. Reporting frameworks (SPIRIT-AI, CONSORT-AI, MI-CLAIM) are frequently cited as mechanisms to improve reproducibility and regulatory readiness. Conclusions: Evidence and regulatory expectations for AIaMD remain fragmented. Harmonization of terminology, trial design principles, and post-market governance-supported by standardized reporting-would improve clinical validity, safety assurance, and scalability across regions. This review has several limitations. As a scoping synthesis, it prioritizes breadth of coverage rather than quantitative meta-analysis. Included sources vary in methodological rigor and reporting detail, and evolving regulatory guidance may change rapidly over time. Nevertheless, integrating peer-reviewed and regulatory evidence provides a comprehensive overview of current expectations and emerging gaps. In conclusion, effective evaluation of AIaMD requires a shift from static, one-time validation toward continuous lifecycle oversight that integrates adaptive trial designs, transparent reporting standards, bias surveillance, and structured post-market monitoring. Regulatory heterogeneity currently poses significant barriers to multinational development; however, coordinated adoption of standardized evidence frameworks and collaborative governance mechanisms may reduce duplication while preserving patient safety. By translating methodological principles into operational guidance, this review aims to support regulators, sponsors, and clinical investigators in designing trials that are both scientifically rigorous and practically implementable for continuously learning systems.