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Introduction: Cognitive decline after transient ischemic attacks (TIA) or stroke is common. Evaluation with the Montreal Cognitive Assessment (MoCA) tool has shown a decrease in cognitive scores in more than 30% of patients at 1 year. We hypothesize that indirect revascularization with EDAS plus intensive medical management (IMM) would decrease the rate of decline.Methods: This is a prospective study of EDAS plus IMM in symptomatic patients with intracranial arterial stenosis of more than 70%. Patients had MoCA evaluations at baseline, 1 month, 6 months, and 12 months after EDAS. Differences in MoCA at baseline and follow-up were compared using mixed model repeated measures ANOVA.Results: Thirty-one patients with no aphasia or neglect were included. Mean age was 48.3 +/- 16.6 years. Twenty-one were females (70%). The mean MoCA scores at baseline and 12-months were 23.6 +/- 4.3 and 25.5 +/- 4.1, respectively. MoCA ≥ 1 improvement was seen in 78.9% at 12 months. However, differences in MoCA scores at these time points did not reach statistical significance (p= 0.49, Fig. 1). Only 9% of patients had a decline of ≥2 MoCA points at 12 months. These results are comparable to the twelve month MoCA data from the SAMMPRIS trial, which showed a mean MoCA for IMM of 25.4 +/- 3.73 and for percutaneous angioplasty and stenting (PTAS) of 25.6 +/- 3.89. The rate of decline of MoCA scores after EDAS plus IMM was significantly less than the reported natural history after TIA or strokes outside the SAMMPRIS trial (9% vs. 30%, p=0.03).Conclusion: Compared to historical data, the decline in MoCA scores after TIA and stroke was lower in patients treated with EDAS plus maximum medical therapy and has similar effects to those reported in the SAMMPRIS IMM and PTAS groups.