Cerebrovascular disease is a common cause of disability and death, representing an important and growing burden in societies with aging populations. Appropriate use of neuroimaging resources in the elderly is especially important since clinical information may be difficult to obtain, and disease patterns may not be straightforward in these patients. Unenhanced computed tomography (CT) is well established for initial imaging evaluation of both hemorrhagic and ischemic stroke patients, but magnetic resonance imaging (MRI) has advantages for assessing ischemic stroke subtypes when diffusion-weighted imaging and MR angiography are used in combination. Vascular imaging methods such as MR angiography and CT angiography have an increasing role and often replace invasive digital subtraction angiography in screening or initial assessment of aneurysms and steno-occlusive disease. Ultrasonography is useful for non-invasive bedside monitoring. A high index of suspicion is needed to diagnose cerebral venous thrombosis, with judicious use of confirmatory CT or MR venography. Endovascular neurointerventional techniques are minimally invasive alternatives to treat aneurysm, carotid stenosis, and acute ischemic stroke. Recent developments in thrombolysis and thrombectomy have the potential to improve management options in elderly patients. These advances are also driving research initiatives to apply physiological imaging to measure cerebral perfusion, in order to identify more patients with salvageable brain tissue at risk and to improve patient outcome. Arterial spin labelling perfusion techniques that do not require contrast injection can be helpful in patients with renal impairment. In patients with contraindications for MRI, multimodal CT studies that include CT angiography and perfusion have additional advantages of better scanner availability and shorter study times, with ionizing radiation being of secondary importance among the elderly. With the variety of diagnostic imaging and image-guided therapeutic options, good communication between radiologists and clinicians provides individualized options to elderly patients, so that challenges may be met by faster, safer, and more clinically useful information.