Intracranial atherosclerotic disease (ICAD) is the most common proximate 
mechanism of ischemic stroke worldwide. Approximately half of those affected are 
Asians. For diagnosis of ICAD, intra-arterial angiography is the gold standard 
to identify extent of stenosis. However, noninvasive techniques including 
transcranial ultrasound and MRA are now emerging as reliable modalities to 
exclude moderate to severe (50%-99%) stenosis. Little is known about measures 
for primary prevention of the disease. In terms of secondary prevention of 
stroke due to intracranial atherosclerotic stenosis, aspirin continues to be the 
preferred antiplatelet agent although clopidogrel along with aspirin has shown 
promise in the acute phase. Among Asians, cilostazol has shown a favorable 
effect on symptomatic stenosis and is of benefit in terms of fewer bleeds. 
Moreover, aggressive risk factor management alone and in combination with dual 
antiplatelets been shown to be most effective in this group of patients. 
Interventional trials on intracranial atherosclerotic stenosis have so far only 
been carried out among Caucasians and have not yielded consistent results. Since 
the Asian population is known to be preferentially effected, focused trials need 
to be performed to establish treatment modalities that are most effective in 
this population.