The high rate of recurrent strokes in patients with intracranial atherosclerotic disease (ICAS) despite medical therapy prompted intracranial angioplasty and/or stenting an adjunctive treatment option. The minute calibers of cerebral arteries, the relative paucity of supporting medial and adventitia layers, the presence of end-anastomosing perforator branches, and the vascular tortuosity from groin to head all demand specialized operative skills and dedicated tools. Since the stroke mechanism of ICAS is diverse, patient selection for endovascular treatment requires a sound understanding of the underlying pathophysiology. Patients with territorial cerebral hypo-perfusion associated with a high-grade steno-occlusive lesion may benefit most from endovascular revascularization. On the other hand, patients with atheromatous branch disease may stand a higher risk of perforator stroke from 'snow plowing' effect if angioplasty or stenting is inadvertently performed. A joint evaluation on the indication, procedural risks and benefits, and an individualized peri-operative care plan by a stroke neurologist and a neuro-interventionist is crucial prior to a procedure. Currently, the U.S. Food and Drug Administration approved Wingspan for patients who have developed two or more strokes despite aggressive medical management. The treatment indication will likely evolve in parallel with the advancement of endovascular techniques and our understanding of ICAS. © 2016 S. Karger AG, Basel. Copyright: All rights reserved.