CEREBROVASCULAR DISEASE: Edited by Ralph Sacco and Tatjana RundekCurrent diagnosis and management of symptomatic intracranial atherosclerotic diseasePrabhakaran, Shyama; Romano, Jose G.bAuthor Information aRush University Medical Center, Chicago, Illinois bUniversity of Miami, Miller School of Medicine, Miami, Florida, USA Correspondence to Jose G. Romano, MD, Associate Professor of Clinical Neurology, Director, Cerebrovascular Division, University of Miami, Miller School of Medicine, 1120 NW 14th Street, Suite 1357, Miami, FL 33136, USA. Tel: +1 305 243 2336; fax: +1 305 243 7081; e-mail: email@example.com Current Opinion in Neurology: February 2012 - Volume 25 - Issue 1 - p 18-26 doi: 10.1097/WCO.0b013e32834ec16b Buy Metrics Abstract Purpose of review Intracranial atherosclerotic disease (IAD) is likely the most common cause of stroke world-wide and is associated with a very high risk of recurrence. It results in cerebral ischemia due to a variety of mechanisms, including artery-to-artery embolism, hemodynamic failure, and occlusion of penetrating arteries. New imaging modalities focused on physiological consequences of IAD have become available and recent treatment trials have been completed. Recent findings We review the traditional imaging modalities, emphasizing the advantages and limitations of each method, and discuss the novel physiological approaches that interrogate physiological process to indicate specific mechanisms of ischemia. These allow deeper understanding of the pathophysiological processes that underlie IAD-related ischemia. The key findings of recent therapeutic trials are reviewed, including the landmark randomized studies showing advantage of antiplatelet agents and risk factor modification, and a significant risk of complications with endovascular approaches. Summary Current evidence argues for aggressive medical management and suggests caution with interventional treatments. We propose that mechanistic information will further refine the risk assessment of patients with IAD to offer targeted therapy. © 2012 Lippincott Williams & Wilkins, Inc.