Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke 
worldwide and represents a significant health problem. The pathogenesis and 
natural history of ICAD are poorly understood, and rigorous treatment paradigms 
do not exist as they do for extracranial atherosclerosis. Currently, the best 
treatment for ICAD remains aspirin therapy, but many patients who are placed on 
aspirin continue to experience recurrent strokes. As microsurgical and 
endovascular techniques continue to evolve, the role of extracranial to 
intracranial bypass operations and stenting are increasingly being reconsidered. 
We performed a PubMed review of the English literature with a particular focus 
on treatment options for ICAD and present evidence-based data for the role of 
surgery and stenting in ICAD against medical therapy alone.