Vascular lesions of the central nervous system such as aneurysms, arteriovenous malformations, tumors, and fistulas are responsible for the majority of intracranial hemorrhages seen in the United States. Microneurosurgical techniques have enabled neurosurgeons to effectively manage the majority of these lesions. Over the past 15 years, microcatheter based treatment modalities have evolved which permit access of the distal intracranial and spinal circulation by percutaneous cannulation of the femoral artery or vein. Technologic developments in polymer science and advances in hydrophilic coatings have produced microcatheters less than 1 mm in diameter capable of reaching deep within the nidus of arteriovenous malformations or into the body of a cerebral aneurysm. Numerous thrombogenic devices are available that can be delivered through microcatheters to permanently occlude cerebral vascular abnormalities. Catheter technology perfected in the coronary circulation for the management of atherosclerotic disease has been used to treat similar lesions of the extracranial and intracranial cerebral circulation. Cerebral circulation angioplasty for vasospasm has become an accepted technique, and superselective drug delivery is growing in popularity. This chapter reviews the recent literature in vascular and endovascular neurosurgery in an attempt to familiarize the reader with recent advances in the management of cerebrovascular disease.