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Background Whether endovascular recanalization (ER) plus medical treatment reduces the risk of stroke or death compared with medical treatment alone in patients with symptomatic nonacute intracranial artery occlusion (sNAIAO) is uncertain. Purpose To compare clinical outcomes following ER plus medical treatment versus medical treatment alone in patients with sNAIAO. Materials and Methods This multicenter, prospective cohort study enrolled consecutive participants with sNAIAO at six comprehensive stroke centers in China from January 2020 to October 2023. The primary outcome was any stroke or death within 30 days after enrollment or ischemic stroke in the same region as the qualifying artery between 30 days and 1 year after enrollment. The difference in the primary outcome between groups was assessed by using Kaplan-Meier analysis with log-rank testing. Results Of the 436 participants included in the final analysis (median age, 57 years; IQR, 50-65 years; 322 male and 114 female participants), 288 underwent medical treatment alone, and 148 underwent ER plus medical treatment (hereafter, the ER group). Compared with medical treatment alone, ER plus medical treatment increased the incidence of the primary outcome (adjusted hazard ratio [aHR], 2.80; 95% CI: 1.55, 5.08; P < .001). Within 30 days of enrollment, the risk of stroke or death was greater in the ER group than in the medical group (aHR, 21.74; 95% CI: 5.00, 95; P < .001). Between 30 days and 1 year after enrollment, there was no evidence of a difference between groups in the incidence of ischemic stroke in the territory of the qualifying artery (aHR, 0.62; 95% CI: 0.24, 1.62; P = .33). Conclusion In patients with sNAIAO, medical treatment alone was associated with better clinical outcomes compared with ER plus medical treatment. The observed higher event rate in the ER group suggested potential procedure-related risks. © RSNA, 2026 Supplemental material is available for this article. See also the editorial by Chaudhary and Wilseck in this issue.