Submaximal Angioplasty for Severe Intracranial Atherosclerotic Stenosis: Benefit of Revascularization at Last

Intracranial atherosclerotic stenosis is a leading cause of stroke with a significant risk of recurrent ischemic events despite aggressive medical management. The longstanding benefits of percutaneous angioplasty and stenting in coronary artery disease, where atherosclerosis is the overarching cause in nearly all cases, provided a compelling rationale for exploring similar interventions in intracranial atherosclerotic stenosis. However, 3 percutaneous angioplasty and stenting randomized trials showed negative or neutral results. The recent BASIS trial (Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis) was the first randomized trial in intracranial atherosclerotic stenosis to demonstrate the benefits of endovascular treatment, suggesting that submaximal balloon angioplasty might be in the sweet spot between mitigating early complications and securing long-term efficacy. These findings represent a significant advancement in the field, reinvigorating the goal of effective revascularization as a viable secondary prevention approach for intracranial atherosclerotic stenosis. However, several uncertainties still need to be addressed before the widespread implementation of angioplasty in clinical practice.