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Background Intracranial atherosclerotic stenosis of the distal middle cerebral artery branches is a clinically important cause of recurrent ischemic stroke. Management remains challenging, particularly in patients with recurrent symptoms despite optimal medical therapy. We report a case of symptomatic high-grade stenosis of the superior division of the MCA treated with percutaneous transluminal angioplasty and stenting (PTAS).Methods A 66-year-old woman presented with intermittent right-hand weakness, word-finding difficulty, and dysarthria of 10 days duration. Non-contrast computed tomography (CT) of the head demonstrated no acute infarction or hemorrhage. CT angiography revealed stenosis of the superior division of the left MCA. CT perfusion demonstrated hypoperfusion in the left rolandic territory. Magnetic resonance imaging (MRI) of the brain demonstrated diffusion restriction in the left corona radiata consistent with acute infarction. The patient was initiated on dual antiplatelet therapy (aspirin 325 mg daily and clopidogrel 75 mg daily) for secondary stroke prevention. Despite optimal medical management, she re-presented 3 days later with recurrent right-sided weakness and speech difficulties. Diagnostic cerebral angiography demonstrated approximately 70% stenosis of the superior division of the left MCA based on Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) criteria, with delayed distal branch filling of approximately 1.5 seconds. Given recurrent symptoms despite dual antiplatelet therapy, the patient underwent PTAS using EMERGE™ PTCA Dilatation Catheter (2x 8 mm, Boston Scientific in Maple Grove, Minnesota, USA) and Onyx Frontier™ drug-eluting stent (2 x 8 mm, Medtronic Inc, Santa Rosa, California, USA) from the superior division of the left MCA.Results The procedure was successfully performed without intra-procedural complications. Post-treatment angiography demonstrated improved luminal caliber with improvement of delayed filling noticed pre-procedurally. The patient demonstrated clinical stabilization with no recurrent acute ischemic stroke symptoms or symptomatic intracranial hemorrhage within 30 days post-procedurally.Conclusions Prior trials established aggressive medical management as the standard of care for symptomatic intracranial atherosclerotic stenosis, demonstrating superior outcomes compared with percutaneous transluminal angioplasty and stenting. However, a subset of patients continues to experience recurrent ischemic events despite maximal medical therapy, highlighting an unmet clinical need. This case illustrates that endovascular revascularization of symptomatic distal middle cerebral artery stenosis is technically feasible and can be performed with an acceptable safety profile in appropriately selected patients. Prospective, randomized trials are needed to identify patient selection criteria and to define the efficacy and safety of endovascular therapy in this challenging population.Disclosures G. Kaur: None. S. Gillani: None. H. Tolba: None. Z. St. Julien: None. B. Otvos: None.Abstract E-018 Figure 1