Patients with symptomatic intracranial atherosclerotic disease (ICAD) have a high risk of recurrent stroke and secondary prevention in these patients remains a challenge. Aggressive medical management of vascular risk factors is safe and effective for most high risk patients, but the role of endovascular and surgical therapies still remain uncertain. Future studies may identify novel therapeutic strategies for patients with ICAD, but aggressive risk factor control remains the mainstay of evidenced-based treatment at this time.