Angiography remains the standard imaging modality for evaluating vascular disease and guiding endovascular interventions; however, its limited spatial resolution restricts visualization of vessel wall pathology and therapeutic devices. Over the past decade, intravascular optical coherence tomography (OCT) has emerged as a transformative tool in coronary artery disease. OCT provides three-dimensional, high-resolution imaging of coronary arteries, enabling assessment of vessel wall microstructure, plaque composition, lumen geometry, and stent deployment. This level of detail has advanced the understanding of coronary pathology and contributed to improved outcomes in percutaneous coronary interventions. Major cardiology societies now recommend the use of intravascular imaging, including OCT, for complex coronary interventions with level 1A evidence.OCT is now expanding beyond the coronary vasculature, with growing interest in its potential role in neurointerventional surgery. While limited use of OCT has been reported in the neurovasculature, the characteristics of a coronary OCT device prevent routine use in intracranial arteries. A new generation of intravascular OCT technology has been developed for the tortuous and complex anatomy of cerebral vessels. Early clinical experience has investigated its safety, feasibility, and utility for intracranial vascular imaging. Neuro-dedicated OCT technology could represent a significant advancement in cerebrovascular imaging, offering insights beyond the capabilities of current modalities, with the potential to improve current understanding of neurovascular pathology and refine diagnostic and therapeutic strategies. Successful translation of OCT into neurointervention, however, also requires establishing principles for image interpretation to assess neurovascular disease and therapeutic devices. This article aims to provide guidance for interpreting OCT imaging of intracranial arteries. In addition, it reviews applications of OCT in neurointervention and describes the development of neuro-specific OCT technology.