Objective: Post-procedure monitoring in a neurointensive care unit (NICU) after neurointerventional procedures is conventional at most centers. However, NICU resources are scarce and costly. The purpose of this study was to determine whether an intermediate care step-down unit could be a safe and cost-effective alternative to the NICU for patients after uncomplicated neurointerventional procedures. Methods: A retrospective review was undertaken of 127 consecutive patients over a 3-year period undergoing elective neurointerventional procedures including treatment of intracranial aneurysms, tumors, arteriovenous malformations and dural arteriovenous fistulas. Seventyone patients were admitted to a step-down unit and 56 patients were admitted to the NICU. Endpoints were post-procedural complications, hospital costs and length of stay. Patients admitted to the step-down unit were compared with patients admitted to the NICU. Results Patients admitted to the step-down unit did not have more complications than patients admitted to the NICU. Two patients admitted to the step-down unit had neurological complications after the procedure which were immediately recognized by nursing staff and adequately managed. The mean (SD) total cost per patient was $19 299 ($6955) for patients admitted to the step-down unit and $22 716 ($8052) for patients admitted to the NICU, resulting in a statistically significant cost saving for patients admitted to the step-down unit of $3417 (p=0.012). The mean (SD) total cost less procedural costs per patient was $8442 ($4062) for patients in the step-down unit and $10 631 ($4727) for those admitted to the NICU, which was also statistically significant (p=0.005). Length of stay averaged 21.7 h for patients admitted to the step-down unit and 24.9 h for those admitted to the NICU (p=0.016). Conclusions A step-down unit is a safe and costeffective alternative to the NICU for patients undergoing elective neurointerventional procedures.