Written by Peter Liu
Spoon Feed
For patients with TIA or stroke due to severe (70-99%) symptomatic intracranial atherosclerotic stenosis (sICAS) of the major intracranial arteries, submaximal balloon angioplasty may become a first-line therapy option based on the BASIS trial. Current first-line therapy will remain medical management, with catheter-based interventions such as submaximal balloon angioplasty and intracranial artery stenting reserved for patients with stroke recurrence on maximal medical therapy until a larger multinational study can be completed.
Synopsis
The BASIS trial investigated the effectiveness of submaximal balloon angioplasty combined with aggressive medical management versus medical management alone for symptomatic intracranial atherosclerotic stenosis (sICAS) in a randomized clinical setting. Conducted across 31 Chinese centers, the trial included 501 patients aged 35–80 with recent ischemic events and significant arterial stenosis. Results indicated a significantly lower incidence of stroke and death in the angioplasty group compared to the medical-only group on 12-month follow-up (4.4% vs. 13.5%). While angioplasty demonstrated a short-term risk of complications, the trial supports its potential as a viable treatment for sICAS. [AI-generated]
Stents for the heart, balloon angioplasty for the brain?
For patients with acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) with stenting has become the standard, surpassing simple balloon angioplasty. However, in cases of symptomatic intracranial atherosclerotic stenosis (sICAS) — the brain’s equivalent of ACS — endovascular treatments have had limited success outside of mechanical thrombectomy for large vessel occlusions. Historically, intracranial angioplasty, with or without stenting, has not shown clear benefits and is associated with higher 30-day complication rates, including intracranial hemorrhage (ICH) and death.
The recent BASIS trial examined submaximal balloon angioplasty as a potential first-line option for severe sICAS, but it highlighted persistent concerns. The intervention group had higher 30-day complications including all-cause mortality and stroke even though mortality and stroke were lower in the intervention arm at the one year mark. Notably, the only vascular death in the study occurred in the angioplasty group from ICH. Conducted exclusively in China, the trial may reflect regional differences in ICAS, which is more common in Asian populations and may differ pathophysiologically from Western ICAS. Currently, endovascular treatments for sICAS remain second-line, reserved for patients with recurrent stroke despite optimal medical therapy, until further studies validate the BASIS findings across diverse populations.
Source
Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis: The BASIS Randomized Clinical Trial. JAMA. 2024 Oct 1;332(13):1059-1069. doi: 10.1001/jama.2024.12829. PMID: 39235816; PMCID: PMC11378071.
