MEANINGFUL advancement in the successful treatment of intracranial atherosclerotic disease is a major issue facing neurologists. Already at least the third leading cause of death and much morbidity, the relative prevalence of cerebrovascular disease in the population is expected to increase with longer survival and the effects of multiple disease processes. Parallelling the overall growth of neurology and its transition from a largely diagnostic to a mixed diagnostic-therapeutic specialty, the efforts to select and appropriately treat patients with cerebrovascular disorders have had increased success owing to a greater understanding of vascular biology, identification of risk factors, and the introduction of technology for noninvasive imaging and newer treatment modalities. Despite the excitement over novel treatment available through endovascular methods, there must be the restraint of cautiously evaluating and welcoming new treatment approaches, while still attempting to identify the best therapeutic interventions.