Atherosclerotic stenosis of the major intracranial arteries is an important cause of ischemic stroke. Antiplatelet agents and aggressive management of atherosclerotic risk factors, including hypertension, should play a central role in the prevention of vascular events in patients with intracranial arterial stenosis. Angioplasty and stenting are also among current therapeutic options. A randomized controlled trial of intracranial stenting plus aggressive medical therapy versus aggressive medical therapy alone is needed to determine the optimal treatment for patients with severe symptomatic intracranial stenosis.