Intravascular Optical Coherence Tomography for Neuroendovascular Intervention: Applications, Devices, and Future Directions

Background/Objectives: Intravascular optical coherence tomography (OCT) is a near-infrared light-based imaging modality with an axial resolution approaching 10 µm, roughly tenfold finer than intravascular ultrasound. Although OCT is established in coronary practice, its use in the cerebral circulation has been limited by catheter crossing profile, vessel tortuosity, and the need to clear blood from the vascular lumen during acquisition. In this narrative review, we summarize the physical principles of OCT, its plaque-characterization criteria and their histologic validation, the coronary evidence base, the imaging hardware available for intracranial use, and the reported clinical applications across intracranial atherosclerotic disease, intracranial aneurysms treated with flow diverters, carotid disease and carotid webs, arterial dissection, and venous and thromboembolic disease. We also discuss the technical barriers that limit routine neuroendovascular use. Methods: MEDLINE and PubMed were searched from inception through 1 September 2026 for English-language reports of intravascular OCT in human or animal cervical and intracranial vessels; study selection was not systematic. Results: The evidence base is composed largely of preclinical models, small human feasibility series, and case reports; no randomized or large-scale clinical outcome data exist. OCT has been feasible in selected cerebrovascular series, but the pooled evidence comes largely from extracranial carotid studies and does not establish its performance in intracranial vessels. Dedicated neurovascular probes have recently entered clinical study. In the coronary circulation, randomized evidence supports intravascular imaging-guided stent implantation and OCT-defined plaque features are associated with events; corresponding benefits have not been established intracranially. Conclusions: Intravascular OCT resolves the cerebral arterial wall and endoluminal devices in detail, but its safety and clinical benefit in neuroendovascular practice require further study. Prospective studies are needed to determine whether OCT findings change management and improve patient outcomes.