Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment

Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment Wen-feng Cao, An Wen, Xian-min Cao, Ling-feng Wu, Yong-liang Zhou, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4195871/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Patients with symptomatic intracranial arterial stenosis (sICAS) will likely face perioperative risks with stent placement and recurrence with medication. Simple balloon angioplasty (SBA), as a less invasive and safer alternative to stent placement, may offer an effective treatment option for sICAS. This study aimed to assess the perioperative safety of SBA compared to medication for sICAS. A retrospective analysis was conducted on sICAS patients admitted to the Department of Neurology, Jiangxi Provincial People's Hospital, between January 2020 and December 2021, within 60 days of onset. Patients with severe stenosis (70% to 99% rate), confirmed by cerebral angiography, were divided into medication and SBA groups. Demographic data, medical history, NIH Stroke Scale (NIHSS) scores at onset, responsible vessels, degree of vascular stenosis, postoperative residual stenosis rate, and any stroke or death within 30 days postoperatively were assessed. The study included 91 patients, with 51 in the medication group (38 males, mean age 58.06±1.58 years) and 40 in the SBA group (24 males, mean age 60.95±1.37 years). There were no significant differences in demographics, medical history, NIHSS scores, or degree of vascular stenosis (all P > 0.05). All SBA patients underwent successful balloon angioplasty, with 8 cases (20%) requiring a stent placement due to significant post-dilation stenosis regression or dissection affecting blood flow. Within 30 days postoperatively, 2 patients (3.9%) in the medication group experienced progressive stroke, while 3 patients (7.5%) in the SBA group experienced endpoint events, including 2 cases of new-onset infarction and 1 case of subarachnoid hemorrhage. There was no statistically significant difference in endpoint event occurrence between the groups (P > 0.05), and no deaths occurred. In conclusion, SAB in sICAS patients did not significantly increase the risk of stroke within 30 days postoperatively compared to medication treatment. Long-term efficacy warrants further investigation. Health sciences/Neurology/Neurological disorders/Cerebrovascular disorders Health sciences/Neurology/Neurological disorders/Stroke symptomatic intracranial atherosclerotic stenosis medical therapy balloon dilatation Perioperative Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Symptomatic intracranial atherosclerotic stenosis (sICAS) has a notably high incidence rate in China, ranging from 20–46% 1 . The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study, which compared warfarin (international normalized ratio 2–3) with aspirin (325-1,300 mg/day) in treating 569 patients with sICAS, revealed that within the first year of follow-up, the rates of any stroke or death were 17% (49/289) and 15% (42/280), respectively, for both groups. Additionally, the recurrence rate of ischemic stroke was as high as 22% during a 1.8-year follow-up 2 . In randomized controlled trials (RCT) such as the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT), the complication rates within 30 days after stenting were notably high at 14.7% and 24.1%, respectively. These rates exceed those associated with medical treatment (antiplatelet therapy with clopidogrel and aspirin, statin lipid-lowering therapy, blood pressure control, glucose reduction, and lifestyle guidance), which were 5.8% and 9.4%, respectively 3,4 . Typically, studies on the perioperative period of intracranial arterial stent placement have focused on the first 30 days after surgery, with stroke and death being the primary perioperative risks 5 . In patients with sICAS, the perioperative risks following stent placement were significantly higher than those associated with medical treatment. Both the SAMMPRIS and VISSIT studies were terminated early because of the significantly higher risk of stroke and death within 30 days after stent placement compared with the medical treatment group 3,4 . Therefore, reducing the perioperative risk of interventional treatment in patients with sICAS is crucial. Minimizing these risks can potentially benefit patients with sICAS. Current research findings suggest that despite aggressive medical treatment and intervention in the risk factors and lifestyle of patients with sICAS, the annual recurrence rate of stroke remains high, whereas the perioperative risks of stent placement are substantial 2–4 . Compared with the stent placement, balloon angioplasty without stent placement inside the vessel reduces stimulation to the vessel wall, lowers the risk of thrombus formation after stent placement, and minimizes the risk of stimulating the occlusion of the perforating arteries. This approach has been used to treat patients with sICAS 6,7 . However, the perioperative risks of simple balloon angioplasty compared with medical treatment remain unclear. This study aimed to compare the risk of stroke and death within 30 days between patients undergoing simple balloon angioplasty and those receiving medical treatment to identify a safer and more effective treatment method for sICAS. Methods A retrospective analysis was conducted on clinical data from patients who had experienced transient ischemic attacks or non-disabling ischemic strokes (mRS ≤ 2分) within 60 days at the Department of Neurology, Jiangxi Provincial People's Hospital, from January 2020 to December 2021. All patients underwent cerebral angiography, confirming severe stenosis (stenosis rate: 70%-99%). Based on whether they underwent balloon angioplasty, the eligible patients were divided into the medication treatment group and the balloon angioplasty group. Preoperative ischemic symptoms in the balloon angioplasty group remained stable for at least 7 days. Prior to obtaining informed consent, patients or their families were informed about the surgical risks. Inclusion criteria were as follows: ( 1 ) Age 18–85 years; ( 2 ) Ischemic stroke or transient ischemic attack within 60 days of onset; ( 3 ) Cerebral angiography confirmed major intracranial vessel involvement (intracranial segments of the internal carotid artery, middle cerebral artery, intracranial segments of the vertebral artery, and basilar artery), measured using the WASID method 8 , with stenosis severity ranging from 70–99% and vessel diameter ≥ 1.5 mm; ( 4 ) Preoperative modified Rankin Scale (mRS) score ≤ 2 points. Exclusion criteria were: ( 1 ) History of intracranial bleeding; ( 2 ) Uncontrolled hypertension before treatment, blood pressure > 185/110 mmHg; ( 3 ) Active bleeding or bleeding tendency; ( 4 ) Severe heart, liver, or kidney dysfunction; ( 5 ) Non-atherosclerotic causes of stenosis; ( 6 ) Hemoglobin < 100 g/L, platelet count < 100×10 9 /L, coagulation dysfunction, or uncontrollable bleeding factors; ( 7 ) Intolerance to antiplatelet drugs; ( 8 ) Incomplete clinical data or inability to cooperate with follow-up. Patients in the medical treatment group received dual antiplatelet therapy consisting of aspirin (100 mg/day), clopidogrel (75 mg/day), or ticagrelor (90 mg/day twice daily). Upon admission, all patients underwent CYP2C19 gene detection using polymerase chain reaction (PCR) with a fluorescence probe. If the patient does not carry the CYP2C19 loss-of-function allele, the treatment of choice is a combination of aspirin and clopidogrel. If a patient carries the CYP2C19 loss-of-function allele, the treatment of choice is a combination of aspirin and ticagrelor 9 . In the balloon angioplasty group, patients received a minimum of 7 days of dual antiplatelet therapy prior to the procedure. Anesthetic administration (local or general) was determined by the operator. The Seldinger technique was utilized for femoral artery puncture, and a 6F guiding catheter was employed, with the option of a 6F long sheath or an 8F guiding catheter plus an intermediate catheter. The microcatheter, guided by a 0.014-inch 2 m micro-guidewire, traversed the lesion to reach the distal end. After exchanging for a 3 m micro-guidewire, the microcatheter was carefully withdrawn. The chosen balloon (SacSpeed, Acandis, China; Gateway, Stryker, USA; Neuro RX, SinoMed, China) was advanced along the micro-guidewire to the lesion site. The balloon size was selected slightly smaller than the target vessel diameter (< 90% of the target vessel diameter), with a length covering the entire lesion and extending ≥ 2 mm beyond both ends. The balloon was slowly inflated once (30–60 s/atmospheric pressure), reaching nominal pressure, followed by a 1-minute dwell time and slow deflation (10 s/atmospheric pressure). If the remaining stenosis was more than 50%, a second or third dilation was considered, or a larger balloon was chosen. A follow-up angiogram was performed 15–20 minutes later, and the procedure was considered successful if the residual stenosis was less than 50%, the procedure is deemed successful. As a rescue strategy, stenting (APOLLP, MicroPort, China; Neuroform EZ, Stryker, USA; Enterprise, Johnson & Johnson, USA) may be used at the operator's discretion under the following conditions,: ( 1 ) residual stenosis rate ≥ 50%; ( 2 ) the occurrence of dissection at the lesion site with extended thrombolysis in cerebral infarction (eTICI) score < 3 10 . Clinical data collected from both groups included sex, age, medical history (hypertension, diabetes, hyperlipidemia, smoking and drinking, and history of stroke), NIH Stroke Scale (NIHSS) score at onset (total score ranging from 0 to 42) 11 , responsible vessels, degree of vascular stenosis, and treatment modalities (medical treatment, balloon angioplasty, and stent rescue treatment). Additionally, information on anesthesia methods, balloon size and length, post-treatment outcomes (including immediate residual stenosis rate), and postoperative follow-up status were also obtained. Patients underwent a 30-day follow-up involving a combination of outpatient visits, telephone communication, and hospital readmission. The observation period involves vigilant monitoring for any stroke-related events occurring within 30 days post-procedure. This includes ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and progressive stroke (defined as an increase of ≥ 2 points in the NIHSS score during the follow-up period) 12,13 . Additionally, mortality outcomes were documented and tracked. This study was approved by the local Research Ethics Committee (No: 2022-042) and adhered to the principles of the Declaration of Helsinki. Informed consent for data publication was obtained from the patients or their family members. Statistical Analysis Data analysis was conducted using SPSS 22.0 statistical software. The normal distribution of continuous data was visually assessed using graphs and histograms. Normally distributed continuous data are reported as mean ± standard deviation (x ± s), while non-normally distributed continuous data are presented as median and quartiles [ ༭ ( P 25 , P 75 )]. Group comparisons were performed using independent sample t-tests for normally distributed data or Mann-Whitney U tests for non-normally distributed data. Categorical data are expressed as frequencies and percentages (%). Group comparisons for categorical data were carried out using the χ2 test, continuous correction χ2 test, or Fisher's exact test, with statistical significance set at P < 0.05. Results A total of 91 patients were included in the study, comprising 62 males and 29 females, with an age range of 37 to 81 years and a mean age of (59.33 ± 1.08) years. The National Institutes of NIHSS score at onset was 2.33 (0–4). Medical history revealed 27 cases of smoking (29.7%), 16 of alcohol consumption (17.6%), 63 of hypertension (69.2%), 27 of diabetes (29.7%), 45 of hyperlipidemia (49.4%), and 15 of previous stroke (16.5%). As shown in Table 1 , the medication group included 51 cases, consisting of 38 males and 13 females, with ages ranging from 45 to 80 years and a mean age of (58.06 ± 1.58) years. The balloon angioplasty group comprised 40 cases, with 24 males and 16 females, aged between 37 to 81 years, and with a mean age of (60.95 ± 1.37) years. No statistically significant differences were observed between the two groups in terms of sex, age, medical history (hypertension, diabetes, hyperlipidemia, smoking, alcohol history, and stroke history), NIHSS score at onset, and degree of vascular stenosis (all P > 0.05). The predominant involvement of the responsible vessels in both groups was observed in the middle cerebral artery, with no statistically significant difference in the distribution of the responsible vessels between the two groups ( P > 0.05). Table 1 Comparison of baseline data between the two groups medical treatment group (n = 51) balloon angioplasty group (n = 40) Statistics P Age (y, x ± s) 58.06 ± 1.58 60.95 ± 1.37 1.339 0.184 Male, n (%) 38 (74.5) 60% ( 24 ) 2.174 0.140 Hypertension, n (%) 36 (70.6) 27 (67.5) 0.1 0.751 Diabetes mellitus, n (%) 12 (23.5) 15 (37.5) 2.097 0.148 Hyperlipidemia, n (%) 23(45.1) 22(55.0) 0.879 0.348 Prior stroke history, n (%) 7 (13.7) 8 (20.0) 0.641 0.423 Smoking, n (%) 11(21.6) 14(35.0) 2.03 0.154 alcohol consumption, n (%) 7(13.7) 9(22.5) 1.191 0.275 NIHSS at stroke onset 2.55 (0–4) 2.05 (0-3.75) -0.337 0.736 Responsible vessels, n (%) 0.895 Intracranial of ICA 6 (11.8) 3 (7.5) MCA 35 (68.6) 27 (67.5) BA 7 (13.7) 7 (17.5) V4 of the VA 3 (5.9) 3 (7.5) Stenosis degree, % 80.89 ± 1.76 77.40 ± 1.06 -1.453 0.150 NIHSS national institute of health stroke scores; ICA internal carotid artery; MCA middle cerebral artery; BA basilar artery; VA vertebral artery As shown in Table 2 , all patients in the balloon angioplasty group successfully underwent balloon dilation procedures, with 8 and 32 patients under local and general anesthesia, respectively. The time from the last onset to surgery was (18.28 ± 1.16) days, the target vessel diameter was (2.43 ± 0.087) mm, the selected balloon size was (2.23 ± 0.056) mm, and the balloon length was (13.75 ± 0.35) mm. Nine patients underwent stent salvage treatment, including eight cases with a residual stenosis rate of > 50% after balloon dilation and one case with the appearance of dissection and compromised distal blood flow (eTICI < 3) necessitating stent placement. Additionally, three patients underwent dissection after balloon dilation, but without a significant impact on distal blood flow (eTICI = 3) and did not undergo stent placement. The postoperative residual stenosis rate for all surgical patients was (24.7 ± 1.81)%. Table 2 The basic surgical characteristics of the balloon dilation group. Time from onset to intervention, days 18.28 ± 1.16 Anesthesia method Local anesthesia 20% (8/40) General anesthesia 80% (32/40) Target vessel diameter, mm 2.43 ± 0.087 Balloon angioplasty only 77.5% (31/40) Balloon size, mm 2.23 ± 0.056 Balloon length, mm 13.75 ± 0.35 Stent rescue 22.5% (9/40) Immediate restenosis after balloon dilation 8 Arterial dissection 1 Stenosis degree after intervention, % 24.7 ± 1.81% During the 30-day follow-up, two patients (3.9%) in the medication group exhibited symptomatic progression. In the balloon angioplasty group, three patients (7.5%) experienced endpoint events, with two patients developing new-onset infarction in the surgical vascular supply area and one case of subarachnoid hemorrhage. Statistical analysis revealed no significant difference in the occurrence of endpoint events between the two groups (χ2 = 0.078, P = 0.779). No deaths were reported in either group ( Figs. 1 –4 ) . Discussion In a comparison between Endovascular Therapy (ET) and conventional medical treatment for sICAS, ET posed an elevated risk of stroke and mortality, which was primarily attributed to increased early risk 14 . Precision medicine for the secondary prevention of acute ischemic stroke (AIS), particularly in patients carrying the CYP2C19 loss-of-function allele, demonstrated that the combination of enteric-coated aspirin and clopidogrel further mitigated the risk of recurrent stroke within 90 days compared with the combination of enteric-coated aspirin and clopidogrel 9 . This imposes heightened demands on ET for the treatment of sICAS, with a paramount emphasis on minimizing perioperative risks. The findings of this study revealed that in patients with sICAS (stenosis rate: 70–99%), there was no statistically significant difference in endpoint events within 30 days between balloon angioplasty and medical treatment. This observation may be associated with several factors: ( 1 ) Advancements in surgical materials: use of intermediate catheters is particularly notable. These catheters provide substantial support, reduce vascular irritation, and facilitate the smooth delivery of balloons and stents into target vessels. Consequently, this contributes to increased procedural success rates and diminished surgical risks 15 . ( 2 ) progressive expertise of neurointerventional practitioners: In contrast to the SAMMPRIS study, which mandated that operators should possess experience with over 20 intracranial arterial stenosis surgeries 3 , the standardization of acute large-vessel occlusion endovascular treatment since the release of major studies in 2015 16 has resulted in an annual caseload exceeding 100 cases at our institution. This has played a pivotal role in augmenting the operator's expertise. ( 3 ) optimal surgical timing: Research has indicated that an overly brief interval between stroke onset and surgery correlates with increased arterial plaque instability, intraoperative plaque detachment risk, and heightened postoperative hyperperfusion risk 17 . While the SAMMPRIS study randomized patients within 7 days of stroke onset with surgery performed within three working days after randomization 4 , the average surgical timing of our study was 18.28 days after the most recent ischemic stroke episode. The CASSISS study, which chose to conduct surgery 21 days after symptom onset, reported no significant increase in perioperative risk compared to medical treatment, with rates of 5.1% (9/176) and 2.2% (4/181), respectively. This observation may contribute to a reduction in perioperative complications 18 . In this investigation, the chosen balloon for simple balloon angioplasty exhibited a diameter of 91.8% of the target vessel's caliber (2.23/2.43), with an absolute disparity of 0.2 mm less than the target vessel. Previous studies frequently opted for balloons with diameters ranging around 70–80% of the target vessel 19 or 0.5 mm less than the target vessel 20 . The selection of enlarged balloons in this study can be ascribed to several primary reasons: ( 1 ) Measurement error: Current prevalent methods for measuring intracranial vascular stenosis involve the WASID and NASCET (the North American Symptomatic Carotid Endarterectomy Trial) approaches 21 . Researchers have also used optical coherence tomography (OCT) 22 . Nevertheless, these methods entail a certain degree of error, prompting the further exploration of more precise measurement techniques to facilitate accurate instrument selection for intravascular treatment. Prolonged stenosis of intracranial vessels can induce atrophy both proximally and distally, influencing the choice of balloon and stent sizes. ( 2 ) Changes in vessel lumen: Upon the occurrence of vascular stenosis, alterations in the vessel lumen manifest proximally and distally. This may arise from heightened blood flow velocity, causing distal vessel dilation, or reduced blood flow, resulting in constriction of the vessel lumen with escalating stenosis. These fluctuations can introduce inaccuracies in the measurements and affect the selection of surgical instruments. ( 3 ) Limitations in balloon size options: Currently available balloon sizes from diverse manufacturers often exhibit a minimum difference of 0.25 mm or 0.5 mm 20 . This constraint in the array of balloon specifications can influence the selection of an appropriately sized balloon. This study posits that utilizing the WASID method to gauge the degree and size of vascular stenosis and employing a balloon with a diameter of approximately 90% of the target vessel may represent a prudent and effective strategy for balloon angioplasty. Immediate postoperative dissection was observed in four cases (10%), with one case (2.5%) experiencing impeded stent placement due to the dissection. This may be linked to the preference for a slightly larger balloon. However, despite deploying a larger balloon, a notable rate of balloon recoil was observed, necessitating stent placement in eight cases (20%). Further investigation is imperative to determine the criteria for selecting an appropriate balloon that can mitigate the restenosis rate and minimize the incidence of dissection. Wang et al. conducted a systematic review to analyze three endovascular intervention methods for the treatment of patients with sICAS: Balloon angioplasty, balloon-mounted stenting, and self-expanding stent placement. The findings revealed that balloon angioplasty significantly reduced short-term risks of stroke and death compared to the latter two methods (perioperative or ≤ 3 months postoperative) 23 . A meta-analysis comparing medical treatment, stent placement, and balloon angioplasty for sICAS indicated that, during long-term follow-ups, balloon angioplasty might be the most effective method for preventing strokes and reducing mortality 24 . These results suggest that in the current clinical context, balloon angioplasty may be considered the optimal method for managing sICAS. Nevertheless, the application of balloon angioplasty in patients with sICAS has certain limitations: ( 1 ) Higher rate of late restenosis: After balloon angioplasty with balloon-mounted stent placement or self-expanding stent placement in sICAS patients, reported rates of restenosis range from 19.7–27.6% at 8–12 months postoperatively 25–27 . Limited data are available on restenosis rates after balloon angioplasty. Japanese researchers found that among 72 patients with sICAS who underwent balloon angioplasty, 31.9% (23/72) experienced restenosis during follow-up, ranging from 6 to 111 months postoperatively 28 . Another study focusing on 35 cases of severe stenosis in the sICAS with a high degree of eccentricity or stenosis close to perforating branches revealed that after balloon angioplasty, three out of 25 patients experienced significant vessel restenosis during an average follow-up of 16.3 months 19 . In a comparison between drug-coated balloon (DCB) angioplasty and conventional balloon angioplasty, the restenosis rate was significantly lower in the DCB group (5.3%, 2/38) than in the conventional balloon group (34.2%, 13/38) at an average follow-up of 6 months 29 , indicating a potentially promising treatment approach. ( 2 ) Some patients require stent rescue: In this study, all patients were initially planned for balloon angioplasty only (with stent backup). However, 22.5% (9/40) of the patients required stent rescue due to restenosis rates exceeding 50% or the occurrence of arterial dissection after balloon angioplasty. This observation was consistent with the findings of previous studies. The mechanism of immediate restenosis after balloon angioplasty was unclear in this study because of the small sample size, which prevented a statistical analysis. Research on coronary artery narrowing after isolated balloon angioplasty has indicated a higher rate of restenosis in arterial plaques exhibiting significant concentricity and fibrosis 30 . Research on restenosis after carotid endarterectomy for carotid artery stenosis has indicated a positive correlation between postoperative restenosis and the extent of macrophage infiltration and the size of the lipid core within the plaque 31 . In patients with restenosis following stent placement for vertebral artery intracranial segment stenosis, quantitative and qualitative analyses of plaque calcification using OCT revealed an association between restenosis and extensive calcification 32 . The mechanisms underlying restenosis after balloon angioplasty or stent placement in patients with sICAS remain unclear and require further investigation. Accurate identification of patients with a low restenosis rate following balloon angioplasty warrants further investigation in the academic research domain. Limitations While this study offers important findings regarding the safety and efficacy of simple balloon angioplasty compared to medical treatment for sICAS, it is important to acknowledge several limitations. Retrospective Design: The retrospective nature of this study introduces inherent biases and limitations. Data collection relied on medical records, which may have been incomplete or subject to documentation errors. Additionally, the lack of randomization may have led to selection bias and confounding variables. Small Sample Size: The sample size in this study was relatively small, comprising a total of 91 patients. A larger sample size would enhance the statistical power of the analysis and allow for more robust conclusions. Single-Center Study: This study was conducted at a single center, which may limit the generalizability of the findings. Variations in patient populations, treatment protocols, and healthcare practices across different institutions could affect the external validity of the results. Conclusion In summary, this study suggests that balloon angioplasty, when compared with medical treatment, does not significantly increase the risk of stroke or death within the first 30 days postoperatively in patients with sICAS. The long-term effectiveness of this intervention requires further investigation with extended follow-up. However, considering the retrospective nature of this study, confirming the safety profile requires validation using a large-sample RCT. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Jiangxi Provincial People's Hospital. The participants provided their written informed consent to participate in this study. Funding This work was supported by grant from Jiangxi Provincial Health Commission Foundation (NO. 202110007 and NO. 202310122). Author Contribution W.F.C. contributed to original draft preparation. A.W. provided review and editing. X.M.C. conducted data collection and statistical analysis. L.F.W., Y.L.Z, Z.B.X., W.R., Q.H.C., and H.W.W. performed interventional surgery. S.M.L. conceptualized the study. All authors contributed to manuscript revision, read and approved the submitted version. Data Availability The data analyzed in this study are available from the corresponding author upon reasonable request. The data include clinical information from patients admitted to the Department of Neurology, Jiangxi Provincial People's Hospital, from January 2020 to December 2021, who underwent simple balloon angioplasty or medication treatment for sICAS. The data encompass demographic characteristics, medical history, NIHSS scores, responsible vessels, degree of vascular stenosis, treatment modalities, anesthesia methods, balloon specifications, postoperative outcomes, and 30-day follow-up results. The data will be made available to researchers upon request to ensure transparency and reproducibility in our research findings. References Barnard, Z. R. & Alexander, M. J. Update in the treatment of intracranial atherosclerotic disease. Stroke Vasc Neurol 5, 59–64 (2020). Chimowitz, M. I. et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 352, 1305–1316 (2005). Chimowitz, M. I. et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 365, 993–1003 (2011). Zaidat, O. O. et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA 313, 1240–8 (2015). Fiorella, D. et al. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 38, 881–887 (2007). Turan, T. N. et al. Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee. Neurology 98, 486–498 (2022). Stapleton, C. J. et al. Neurosurgery 86, 755–762 (2020). Samuels, O. B., Joseph, G. J., Lynn, M. J., Smith, H. A. & Chimowitz, M. I. A standardized method for measuring intracranial arterial stenosis. AJNR Am J Neuroradiol 21, 643–646 (2000). Wang, Y. et al. Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. N Engl J Med 385, 2520–2530 (2021). Behme, D. et al. Validation of the extended thrombolysis in cerebral infarction score in a real world cohort. PLoS One 14, e0210334 (2019). Kwah, L. K. & Diong, J. National Institutes of Health Stroke Scale (NIHSS). J Physiother 60, 61 (2014). Zhang, H. & Zheng, L. Statistical analysis for efficacy of tirofiban combined with ozagrel in the treatment of progressive cerebral infarction patients out of thrombolytic therapy time window. Clinics (Sao Paulo) 76, e2728 (2021). Jiang, W.-J. et al. Symptomatic intracranial stenosis: cerebrovascular complications from elective stent placement. Radiology 243, 188–197 (2007). Luo, J. et al. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2, CD013267 (2023). Nayak, S. Mechanical Thrombectomy using Distal Access Catheters: Current Status and Future Prospects. J Neuroimaging 30, 754–761 (2020). Goyal, M. et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387, 1723–1731 (2016). Zhang, Y. et al. Early versus delayed stenting for intracranial atherosclerotic artery stenosis with ischemic stroke. J Neurointerv Surg 12, 274–278 (2020). Gao, P. et al. Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial. JAMA 328, 534–542 (2022). Wang, Y. et al. Primary Angioplasty without Stenting for Symptomatic, High-Grade Intracranial Stenosis with Poor Circulation. AJNR Am J Neuroradiol 39, 1487–1492 (2018). Marks, M. P. et al. Intracranial angioplasty without stenting for symptomatic atherosclerotic stenosis: long-term follow-up. AJNR Am J Neuroradiol 26, 525–530 (2005). Bash, S. et al. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol 26, 1012–1021 (2005). Feng, Y. et al. Correlation between intracranial vertebral artery stenosis diameter measured by digital subtraction angiography and cross-sectional area measured by optical coherence tomography. J Neurointerv Surg 13, 1002–1006 (2021). Wang, T. et al. Endovascular Therapy for Symptomatic Intracranial Artery Stenosis: a Systematic Review and Network Meta-analysis. Transl Stroke Res 13, 676–685 (2022). Peng, G. et al. Medical and Endovascular Treatments for Intracranial Atherosclerotic Stenosis: A Network Meta-Analysis. Transl Stroke Res (2021) doi: 10.1007/s12975-021-00957-7 . Ma, N. et al. Stenting for symptomatic intracranial arterial stenosis in China: 1-year outcome of a multicentre registry study. Stroke Vasc Neurol 3, 176–184 (2018). Zhou, K. et al. A Comparison of Safety and Effectiveness Between Wingspan and Neuroform Stents in Patients With Middle Cerebral Artery Stenosis. Front Neurol 12, 527541 (2021). Wang, Z.-L. et al. Outcomes of middle cerebral artery angioplasty and stenting with Wingspan at a high-volume center. Neuroradiology 58, 161–169 (2016). Ueda, T. et al. Long-Term Outcome of Balloon Angioplasty Without Stenting for Symptomatic Middle Cerebral Artery Stenosis. J Stroke Cerebrovasc Dis 27, 1870–1877 (2018). Zhang, J. et al. Drug-Coated Balloon Dilation Compared With Conventional Stenting Angioplasty for Intracranial Atherosclerotic Disease. Neurosurgery 87, 992–998 (2020). Virmani, R., Farb, A. & Burke, A. P. Coronary angioplasty from the perspective of atherosclerotic plaque: morphologic predictors of immediate success and restenosis. Am Heart J 127, 163–179 (1994). Hellings, W. E. et al. Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy. JAMA 299, 547–554 (2008). Xu, R. et al. Macrocalcification of intracranial vertebral artery may be related to in-stent restenosis: lessons learned from optical coherence tomography. J Neurointerv Surg 14, neurintsurg-2021-017913 (2022). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4195871","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":292164943,"identity":"6feffd39-e8bd-4971-b429-3af71ec58fd0","order_by":0,"name":"Wen-feng Cao","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Wen-feng","middleName":"","lastName":"Cao","suffix":""},{"id":292164944,"identity":"e2496b15-e9d9-4638-9580-2c9c5699edf8","order_by":1,"name":"An Wen","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"An","middleName":"","lastName":"Wen","suffix":""},{"id":292164945,"identity":"8163de52-f818-40ee-a891-410575f0cf5c","order_by":2,"name":"Xian-min Cao","email":"","orcid":"","institution":"Medical College of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Xian-min","middleName":"","lastName":"Cao","suffix":""},{"id":292164946,"identity":"3d333233-4f12-428c-b2df-edd5b7c7147b","order_by":3,"name":"Ling-feng Wu","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Ling-feng","middleName":"","lastName":"Wu","suffix":""},{"id":292164947,"identity":"40810f83-e4d2-486e-ad6a-f7b1b27f0dfe","order_by":4,"name":"Yong-liang Zhou","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Yong-liang","middleName":"","lastName":"Zhou","suffix":""},{"id":292164948,"identity":"e8a61c7e-3e63-4d90-a8aa-ec24ebe27db5","order_by":5,"name":"Zheng-bing Xiang","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Zheng-bing","middleName":"","lastName":"Xiang","suffix":""},{"id":292164949,"identity":"5261675c-9428-4e58-82e8-5011dc2697b0","order_by":6,"name":"Wei Rao","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Rao","suffix":""},{"id":292164950,"identity":"3e01cd27-ecde-47e6-b069-2dc59b60c06d","order_by":7,"name":"Quan-hong Chu","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Quan-hong","middleName":"","lastName":"Chu","suffix":""},{"id":292164951,"identity":"8bc94f78-e433-402f-b0b1-e4f79af0aed3","order_by":8,"name":"Wang-Wong Hang","email":"","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":false,"prefix":"","firstName":"Wang-Wong","middleName":"","lastName":"Hang","suffix":""},{"id":292164952,"identity":"8fd094e0-a0ae-408a-898c-cc67c5b9cb63","order_by":9,"name":"Shi-min Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDACZsYHQJJNjo29sfHhB+K0MBsAST5jfp7DzcYSRFoD0iKXOHNGepsADzEa+NuZGR8X/DJj3HDzYRuDBIOdnG4DAS0Sh5mZjWf2pTEb3E5se1DAkGxsdoCQNYf5j0nz9hxjA2ppN5BgOJC4jZAW+cPM7L95e/7zGNw82CbBQ4wWg8PMbMw8P9gkJGcwEqnFEOgXad4GNgN+nkRgIBsQ4Re584cZP/P8YatvYz/+8OGHCjs5wt4HAcY2uDuJUQ4Gf4hWOQpGwSgYBSMRAADxrz6/Emj+RwAAAABJRU5ErkJggg==","orcid":"","institution":"Jiangxi provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College)","correspondingAuthor":true,"prefix":"","firstName":"Shi-min","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-03-31 13:44:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4195871/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4195871/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55325483,"identity":"d81f4b58-d10e-4700-b357-fa2852c0fbb9","added_by":"auto","created_at":"2024-04-25 16:57:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":127964,"visible":true,"origin":"","legend":"\u003cp\u003eA 53-year-old male with a 3-year history of diabetes was hospitalized on July 3, 2021, presenting with a 2-day history of left-sided limb weakness and numbness. His NIHSS score at admission was 2 points (facial palsy 1 point, dysarthria 1 point). Diagnostic head MRI identified an acute infarction in the right cerebral hemisphere. On July 19 (after 18 days of stroke onset),the patient underwent a balloon angioplasty under general anesthesia to address severe stenosis in the M1 segment of the right MCA. The proximal lumen of the stenosis measured 2.5mm, with the narrowest part at 0.5mm, indicating an 80% stenosis degree \u003cstrong\u003e(Fig A)\u003c/strong\u003e. Following consecutive use of 2.0´15mm and 2.5´10mm balloons, a subsequent angiogram exhibited noticeable improvement in the stenosis\u003cstrong\u003e (Fig B)\u003c/strong\u003e. However, after a 10-minute observation period, there was observed restenosisat the stenotic site \u003cstrong\u003e(Fig C)\u003c/strong\u003e. Subsequently, a 2.5´10mm balloon-mounted stent (APOLLP, MicroPort, China) was deployed, effectively relieving the stenosis and achieving an eTICI grade of 3 \u003cstrong\u003e(Fig D)\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4195871/v1/c1caa5be51b2f09831cd31f3.png"},{"id":55324356,"identity":"daf9bf3f-0c59-4920-af65-d07ebe66bd8c","added_by":"auto","created_at":"2024-04-25 16:49:50","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":466595,"visible":true,"origin":"","legend":"\u003cp\u003eA 58-year-old male presented with sudden-onset right-sided weakness for 12 days and was admitted on November 4, 2021. Head MRI revealed a left pontine infarction, with an NIHSS score of 1 point at admission (attributed to dysarthria). On November 8th (after 16 days of stroke onset), the patient underwent a comprehensive basilar artery angioplasty procedure. Angiography identified severe stenosis in the basilar artery, characterized by a distal lumen of 2.9mm, the narrowest segment measuring 0.4mm, and an overall stenosis degree of 86.2%\u003cstrong\u003e (Fig A)\u003c/strong\u003e. Subsequent dilations were conducted using 1.5´15mm and 2.5´15mm balloons\u003cstrong\u003e (Fig B-C)\u003c/strong\u003e. Approximately 10% residual stenosis remained. Following a 15-minute observation period, a subsequent angiogram exhibited no significant restenosis \u003cstrong\u003e(Fig D)\u003c/strong\u003e, resulting in the attainment of eTICI grade 3.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4195871/v1/7a961cd3b78db84c0cb3a026.jpeg"},{"id":55324357,"identity":"49736707-5f0d-4014-b3e3-db797e7e352a","added_by":"auto","created_at":"2024-04-25 16:49:50","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":472184,"visible":true,"origin":"","legend":"\u003cp\u003eA 64-year-old female presented with acute-onset left-sided limb numbness, weakness, and slurred speech, prompting admission on March 7, 2020. The NIHSS score at admission was 5 (facial palsy 2, sensory deficits1, language impairment 1, dysarthria 1). Head MRI revealed an acute ischemic stroke adjacent to the right lateral ventricle. On March 25(after 19 days of stroke onset), cerebral angiography revealed severe stenosis with a distal diameter of 2.0mm, a narrowest segment of 0.5mm, and a stenosis degree of 75%\u003cstrong\u003e(Fig A)\u003c/strong\u003e. Subsequent dilation with a 1.5´15mm balloon led to an arterial dissection \u003cstrong\u003e(Fig B)\u003c/strong\u003e. A slow infusion of 5ml of tirofiban was administered through the artery, and after a 15-minute observation, the dissection showed improvement, achieving eTICI grade 3 blood flow \u003cstrong\u003e(Fig C-D)\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4195871/v1/6e510027425bf82f8d1483f5.jpeg"},{"id":55324359,"identity":"ebf7b459-2568-439c-a88c-cf35a788d63a","added_by":"auto","created_at":"2024-04-25 16:49:50","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":431937,"visible":true,"origin":"","legend":"\u003cp\u003eA 75-year-old male who was admitted on June 28, 2021, with a 22-day history of right-sided limb weakness. At admission, the NIHSS score was 0, and head MRI showed no evidence of acute infarction, leading to a diagnosis of transient ischemic attack (TIA). Subsequent cerebral angiography on June 30 revealed severe stenosis in the M1 segment of the right middle cerebral artery (MCA), characterized by a proximal lumen of 2.8mm, the narrowest part at 0.6mm, and a stenosis degree of 79% \u003cstrong\u003e(Fig A)\u003c/strong\u003e. An initial attempt at dilation was made using a 2.0´15mm balloon, resulting in satisfactory reconstruction of the stenosis \u003cstrong\u003e(Fig B)\u003c/strong\u003e. However, upon withdrawal of the microguidewire for a follow-up angiogram, an unexpected dissection in the MCA was observed\u003cstrong\u003e (Fig C)\u003c/strong\u003e. After a 10-minute observation, a subsequent angiogram indicated a more significant dissection, along with sluggish blood flow in the distal MCA\u003cstrong\u003e (Fig D)\u003c/strong\u003e, eTICI grade 2c. Consequently, a strategic decision was made to deploy a 3.0´13mm balloon-mounted stent (APOLLP, MicroPort, China). A follow-up angiogram demonstrated successful eTICI grade 3 \u003cstrong\u003e(Fig E)\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4195871/v1/c5647d7034e6b917f7b1a447.jpeg"},{"id":65682283,"identity":"5d26403b-e1c5-4bcd-b95c-2a10671761ec","added_by":"auto","created_at":"2024-10-01 09:02:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2022837,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4195871/v1/ce6d1eb1-5285-4614-afe9-bb1c1b18f2d5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSymptomatic intracranial atherosclerotic stenosis (sICAS) has a notably high incidence rate in China, ranging from 20\u0026ndash;46% \u003csup\u003e1\u003c/sup\u003e. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study, which compared warfarin (international normalized ratio 2\u0026ndash;3) with aspirin (325-1,300 mg/day) in treating 569 patients with sICAS, revealed that within the first year of follow-up, the rates of any stroke or death were 17% (49/289) and 15% (42/280), respectively, for both groups. Additionally, the recurrence rate of ischemic stroke was as high as 22% during a 1.8-year follow-up \u003csup\u003e2\u003c/sup\u003e. In randomized controlled trials (RCT) such as the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) and the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT), the complication rates within 30 days after stenting were notably high at 14.7% and 24.1%, respectively. These rates exceed those associated with medical treatment (antiplatelet therapy with clopidogrel and aspirin, statin lipid-lowering therapy, blood pressure control, glucose reduction, and lifestyle guidance), which were 5.8% and 9.4%, respectively \u003csup\u003e3,4\u003c/sup\u003e. Typically, studies on the perioperative period of intracranial arterial stent placement have focused on the first 30 days after surgery, with stroke and death being the primary perioperative risks \u003csup\u003e5\u003c/sup\u003e. In patients with sICAS, the perioperative risks following stent placement were significantly higher than those associated with medical treatment. Both the SAMMPRIS and VISSIT studies were terminated early because of the significantly higher risk of stroke and death within 30 days after stent placement compared with the medical treatment group \u003csup\u003e3,4\u003c/sup\u003e. Therefore, reducing the perioperative risk of interventional treatment in patients with sICAS is crucial. Minimizing these risks can potentially benefit patients with sICAS.\u003c/p\u003e \u003cp\u003eCurrent research findings suggest that despite aggressive medical treatment and intervention in the risk factors and lifestyle of patients with sICAS, the annual recurrence rate of stroke remains high, whereas the perioperative risks of stent placement are substantial \u003csup\u003e2\u0026ndash;4\u003c/sup\u003e. Compared with the stent placement, balloon angioplasty without stent placement inside the vessel reduces stimulation to the vessel wall, lowers the risk of thrombus formation after stent placement, and minimizes the risk of stimulating the occlusion of the perforating arteries. This approach has been used to treat patients with sICAS \u003csup\u003e6,7\u003c/sup\u003e. However, the perioperative risks of simple balloon angioplasty compared with medical treatment remain unclear. This study aimed to compare the risk of stroke and death within 30 days between patients undergoing simple balloon angioplasty and those receiving medical treatment to identify a safer and more effective treatment method for sICAS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective analysis was conducted on clinical data from patients who had experienced transient ischemic attacks or non-disabling ischemic strokes (mRS\u0026thinsp;\u0026le;\u0026thinsp;2分) within 60 days at the Department of Neurology, Jiangxi Provincial People's Hospital, from January 2020 to December 2021. All patients underwent cerebral angiography, confirming severe stenosis (stenosis rate: 70%-99%). Based on whether they underwent balloon angioplasty, the eligible patients were divided into the medication treatment group and the balloon angioplasty group. Preoperative ischemic symptoms in the balloon angioplasty group remained stable for at least 7 days. Prior to obtaining informed consent, patients or their families were informed about the surgical risks.\u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Age 18\u0026ndash;85 years; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Ischemic stroke or transient ischemic attack within 60 days of onset; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Cerebral angiography confirmed major intracranial vessel involvement (intracranial segments of the internal carotid artery, middle cerebral artery, intracranial segments of the vertebral artery, and basilar artery), measured using the WASID method \u003csup\u003e8\u003c/sup\u003e, with stenosis severity ranging from 70\u0026ndash;99% and vessel diameter\u0026thinsp;\u0026ge;\u0026thinsp;1.5 mm; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Preoperative modified Rankin Scale (mRS) score\u0026thinsp;\u0026le;\u0026thinsp;2 points. Exclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) History of intracranial bleeding; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Uncontrolled hypertension before treatment, blood pressure\u0026thinsp;\u0026gt;\u0026thinsp;185/110 mmHg; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Active bleeding or bleeding tendency; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Severe heart, liver, or kidney dysfunction; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Non-atherosclerotic causes of stenosis; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;100 g/L, platelet count\u0026thinsp;\u0026lt;\u0026thinsp;100\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L, coagulation dysfunction, or uncontrollable bleeding factors; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Intolerance to antiplatelet drugs; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Incomplete clinical data or inability to cooperate with follow-up.\u003c/p\u003e \u003cp\u003ePatients in the medical treatment group received dual antiplatelet therapy consisting of aspirin (100 mg/day), clopidogrel (75 mg/day), or ticagrelor (90 mg/day twice daily). Upon admission, all patients underwent CYP2C19 gene detection using polymerase chain reaction (PCR) with a fluorescence probe. If the patient does not carry the CYP2C19 loss-of-function allele, the treatment of choice is a combination of aspirin and clopidogrel. If a patient carries the CYP2C19 loss-of-function allele, the treatment of choice is a combination of aspirin and ticagrelor \u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the balloon angioplasty group, patients received a minimum of 7 days of dual antiplatelet therapy prior to the procedure. Anesthetic administration (local or general) was determined by the operator. The Seldinger technique was utilized for femoral artery puncture, and a 6F guiding catheter was employed, with the option of a 6F long sheath or an 8F guiding catheter plus an intermediate catheter. The microcatheter, guided by a 0.014-inch 2 m micro-guidewire, traversed the lesion to reach the distal end. After exchanging for a 3 m micro-guidewire, the microcatheter was carefully withdrawn. The chosen balloon (SacSpeed, Acandis, China; Gateway, Stryker, USA; Neuro RX, SinoMed, China) was advanced along the micro-guidewire to the lesion site. The balloon size was selected slightly smaller than the target vessel diameter (\u0026lt;\u0026thinsp;90% of the target vessel diameter), with a length covering the entire lesion and extending\u0026thinsp;\u0026ge;\u0026thinsp;2 mm beyond both ends. The balloon was slowly inflated once (30\u0026ndash;60 s/atmospheric pressure), reaching nominal pressure, followed by a 1-minute dwell time and slow deflation (10 s/atmospheric pressure). If the remaining stenosis was more than 50%, a second or third dilation was considered, or a larger balloon was chosen. A follow-up angiogram was performed 15\u0026ndash;20 minutes later, and the procedure was considered successful if the residual stenosis was less than 50%, the procedure is deemed successful. As a rescue strategy, stenting (APOLLP, MicroPort, China; Neuroform EZ, Stryker, USA; Enterprise, Johnson \u0026amp; Johnson, USA) may be used at the operator's discretion under the following conditions,: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) residual stenosis rate\u0026thinsp;\u0026ge;\u0026thinsp;50%; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the occurrence of dissection at the lesion site with extended thrombolysis in cerebral infarction (eTICI) score\u0026thinsp;\u0026lt;\u0026thinsp;3 \u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eClinical data collected from both groups included sex, age, medical history (hypertension, diabetes, hyperlipidemia, smoking and drinking, and history of stroke), NIH Stroke Scale (NIHSS) score at onset (total score ranging from 0 to 42) \u003csup\u003e11\u003c/sup\u003e, responsible vessels, degree of vascular stenosis, and treatment modalities (medical treatment, balloon angioplasty, and stent rescue treatment). Additionally, information on anesthesia methods, balloon size and length, post-treatment outcomes (including immediate residual stenosis rate), and postoperative follow-up status were also obtained. Patients underwent a 30-day follow-up involving a combination of outpatient visits, telephone communication, and hospital readmission.\u003c/p\u003e \u003cp\u003eThe observation period involves vigilant monitoring for any stroke-related events occurring within 30 days post-procedure. This includes ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and progressive stroke (defined as an increase of \u0026ge;\u0026thinsp;2 points in the NIHSS score during the follow-up period) \u003csup\u003e12,13\u003c/sup\u003e. Additionally, mortality outcomes were documented and tracked.\u003c/p\u003e \u003cp\u003e This study was approved by the local Research Ethics Committee (No: 2022-042) and adhered to the principles of the Declaration of Helsinki. Informed consent for data publication was obtained from the patients or their family members.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis was conducted using SPSS 22.0 statistical software. The normal distribution of continuous data was visually assessed using graphs and histograms. Normally distributed continuous data are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s), while non-normally distributed continuous data are presented as median and quartiles [\u003cem\u003e༭\u003c/em\u003e(\u003cem\u003eP\u003c/em\u003e\u003csub\u003e25\u003c/sub\u003e, \u003cem\u003eP\u003c/em\u003e\u003csub\u003e75\u003c/sub\u003e)]. Group comparisons were performed using independent sample t-tests for normally distributed data or Mann-Whitney U tests for non-normally distributed data. Categorical data are expressed as frequencies and percentages (%). Group comparisons for categorical data were carried out using the χ2 test, continuous correction χ2 test, or Fisher's exact test, with statistical significance set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 91 patients were included in the study, comprising 62 males and 29 females, with an age range of 37 to 81 years and a mean age of (59.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08) years. The National Institutes of NIHSS score at onset was 2.33 (0\u0026ndash;4). Medical history revealed 27 cases of smoking (29.7%), 16 of alcohol consumption (17.6%), 63 of hypertension (69.2%), 27 of diabetes (29.7%), 45 of hyperlipidemia (49.4%), and 15 of previous stroke (16.5%).\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the medication group included 51 cases, consisting of 38 males and 13 females, with ages ranging from 45 to 80 years and a mean age of (58.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58) years. The balloon angioplasty group comprised 40 cases, with 24 males and 16 females, aged between 37 to 81 years, and with a mean age of (60.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37) years. No statistically significant differences were observed between the two groups in terms of sex, age, medical history (hypertension, diabetes, hyperlipidemia, smoking, alcohol history, and stroke history), NIHSS score at onset, and degree of vascular stenosis (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The predominant involvement of the responsible vessels in both groups was observed in the middle cerebral artery, with no statistically significant difference in the distribution of the responsible vessels between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of baseline data between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedical treatment group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eballoon angioplasty group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60% (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.751\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior stroke history, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ealcohol consumption, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS at stroke onset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.55 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.05 (0-3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsible vessels, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial of ICA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (68.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eV4 of the VA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStenosis degree, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNIHSS\u003c/em\u003e national institute of health stroke scores; \u003cem\u003eICA\u003c/em\u003e internal carotid artery; \u003cem\u003eMCA\u003c/em\u003e middle cerebral artery; \u003cem\u003eBA\u003c/em\u003e basilar artery; \u003cem\u003eVA\u003c/em\u003e vertebral artery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, all patients in the balloon angioplasty group successfully underwent balloon dilation procedures, with 8 and 32 patients under local and general anesthesia, respectively. The time from the last onset to surgery was (18.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16) days, the target vessel diameter was (2.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.087) mm, the selected balloon size was (2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.056) mm, and the balloon length was (13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35) mm. Nine patients underwent stent salvage treatment, including eight cases with a residual stenosis rate of \u0026gt;\u0026thinsp;50% after balloon dilation and one case with the appearance of dissection and compromised distal blood flow (eTICI\u0026thinsp;\u0026lt;\u0026thinsp;3) necessitating stent placement. Additionally, three patients underwent dissection after balloon dilation, but without a significant impact on distal blood flow (eTICI\u0026thinsp;=\u0026thinsp;3) and did not undergo stent placement. The postoperative residual stenosis rate for all surgical patients was (24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81)%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe basic surgical characteristics of the balloon dilation group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from onset to intervention, days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAnesthesia method\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20% (8/40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80% (32/40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarget vessel diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalloon angioplasty only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.5% (31/40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalloon size, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalloon length, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent rescue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5% (9/40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediate restenosis after balloon dilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStenosis degree after intervention, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the 30-day follow-up, two patients (3.9%) in the medication group exhibited symptomatic progression. In the balloon angioplasty group, three patients (7.5%) experienced endpoint events, with two patients developing new-onset infarction in the surgical vascular supply area and one case of subarachnoid hemorrhage. Statistical analysis revealed no significant difference in the occurrence of endpoint events between the two groups (χ2\u0026thinsp;=\u0026thinsp;0.078, P\u0026thinsp;=\u0026thinsp;0.779). No deaths were reported in either group \u003cb\u003e(\u003c/b\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;4\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn a comparison between Endovascular Therapy (ET) and conventional medical treatment for sICAS, ET posed an elevated risk of stroke and mortality, which was primarily attributed to increased early risk \u003csup\u003e14\u003c/sup\u003e. Precision medicine for the secondary prevention of acute ischemic stroke (AIS), particularly in patients carrying the CYP2C19 loss-of-function allele, demonstrated that the combination of enteric-coated aspirin and clopidogrel further mitigated the risk of recurrent stroke within 90 days compared with the combination of enteric-coated aspirin and clopidogrel \u003csup\u003e9\u003c/sup\u003e. This imposes heightened demands on ET for the treatment of sICAS, with a paramount emphasis on minimizing perioperative risks. The findings of this study revealed that in patients with sICAS (stenosis rate: 70\u0026ndash;99%), there was no statistically significant difference in endpoint events within 30 days between balloon angioplasty and medical treatment. This observation may be associated with several factors: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Advancements in surgical materials: use of intermediate catheters is particularly notable. These catheters provide substantial support, reduce vascular irritation, and facilitate the smooth delivery of balloons and stents into target vessels. Consequently, this contributes to increased procedural success rates and diminished surgical risks\u003csup\u003e15\u003c/sup\u003e. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) progressive expertise of neurointerventional practitioners: In contrast to the SAMMPRIS study, which mandated that operators should possess experience with over 20 intracranial arterial stenosis surgeries \u003csup\u003e3\u003c/sup\u003e, the standardization of acute large-vessel occlusion endovascular treatment since the release of major studies in 2015 \u003csup\u003e16\u003c/sup\u003e has resulted in an annual caseload exceeding 100 cases at our institution. This has played a pivotal role in augmenting the operator's expertise. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) optimal surgical timing: Research has indicated that an overly brief interval between stroke onset and surgery correlates with increased arterial plaque instability, intraoperative plaque detachment risk, and heightened postoperative hyperperfusion risk \u003csup\u003e17\u003c/sup\u003e. While the SAMMPRIS study randomized patients within 7 days of stroke onset with surgery performed within three working days after randomization \u003csup\u003e4\u003c/sup\u003e, the average surgical timing of our study was 18.28 days after the most recent ischemic stroke episode. The CASSISS study, which chose to conduct surgery 21 days after symptom onset, reported no significant increase in perioperative risk compared to medical treatment, with rates of 5.1% (9/176) and 2.2% (4/181), respectively. This observation may contribute to a reduction in perioperative complications \u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this investigation, the chosen balloon for simple balloon angioplasty exhibited a diameter of 91.8% of the target vessel's caliber (2.23/2.43), with an absolute disparity of 0.2 mm less than the target vessel. Previous studies frequently opted for balloons with diameters ranging around 70\u0026ndash;80% of the target vessel \u003csup\u003e19\u003c/sup\u003e or 0.5 mm less than the target vessel \u003csup\u003e20\u003c/sup\u003e. The selection of enlarged balloons in this study can be ascribed to several primary reasons: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Measurement error: Current prevalent methods for measuring intracranial vascular stenosis involve the WASID and NASCET (the North American Symptomatic Carotid Endarterectomy Trial) approaches \u003csup\u003e21\u003c/sup\u003e. Researchers have also used optical coherence tomography (OCT) \u003csup\u003e22\u003c/sup\u003e. Nevertheless, these methods entail a certain degree of error, prompting the further exploration of more precise measurement techniques to facilitate accurate instrument selection for intravascular treatment. Prolonged stenosis of intracranial vessels can induce atrophy both proximally and distally, influencing the choice of balloon and stent sizes. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Changes in vessel lumen: Upon the occurrence of vascular stenosis, alterations in the vessel lumen manifest proximally and distally. This may arise from heightened blood flow velocity, causing distal vessel dilation, or reduced blood flow, resulting in constriction of the vessel lumen with escalating stenosis. These fluctuations can introduce inaccuracies in the measurements and affect the selection of surgical instruments. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Limitations in balloon size options: Currently available balloon sizes from diverse manufacturers often exhibit a minimum difference of 0.25 mm or 0.5 mm \u003csup\u003e20\u003c/sup\u003e. This constraint in the array of balloon specifications can influence the selection of an appropriately sized balloon. This study posits that utilizing the WASID method to gauge the degree and size of vascular stenosis and employing a balloon with a diameter of approximately 90% of the target vessel may represent a prudent and effective strategy for balloon angioplasty. Immediate postoperative dissection was observed in four cases (10%), with one case (2.5%) experiencing impeded stent placement due to the dissection. This may be linked to the preference for a slightly larger balloon. However, despite deploying a larger balloon, a notable rate of balloon recoil was observed, necessitating stent placement in eight cases (20%). Further investigation is imperative to determine the criteria for selecting an appropriate balloon that can mitigate the restenosis rate and minimize the incidence of dissection.\u003c/p\u003e \u003cp\u003eWang et al. conducted a systematic review to analyze three endovascular intervention methods for the treatment of patients with sICAS: Balloon angioplasty, balloon-mounted stenting, and self-expanding stent placement. The findings revealed that balloon angioplasty significantly reduced short-term risks of stroke and death compared to the latter two methods (perioperative or \u0026le;\u0026thinsp;3 months postoperative) \u003csup\u003e23\u003c/sup\u003e. A meta-analysis comparing medical treatment, stent placement, and balloon angioplasty for sICAS indicated that, during long-term follow-ups, balloon angioplasty might be the most effective method for preventing strokes and reducing mortality \u003csup\u003e24\u003c/sup\u003e. These results suggest that in the current clinical context, balloon angioplasty may be considered the optimal method for managing sICAS. Nevertheless, the application of balloon angioplasty in patients with sICAS has certain limitations: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Higher rate of late restenosis: After balloon angioplasty with balloon-mounted stent placement or self-expanding stent placement in sICAS patients, reported rates of restenosis range from 19.7\u0026ndash;27.6% at 8\u0026ndash;12 months postoperatively \u003csup\u003e25\u0026ndash;27\u003c/sup\u003e. Limited data are available on restenosis rates after balloon angioplasty. Japanese researchers found that among 72 patients with sICAS who underwent balloon angioplasty, 31.9% (23/72) experienced restenosis during follow-up, ranging from 6 to 111 months postoperatively \u003csup\u003e28\u003c/sup\u003e. Another study focusing on 35 cases of severe stenosis in the sICAS with a high degree of eccentricity or stenosis close to perforating branches revealed that after balloon angioplasty, three out of 25 patients experienced significant vessel restenosis during an average follow-up of 16.3 months \u003csup\u003e19\u003c/sup\u003e. In a comparison between drug-coated balloon (DCB) angioplasty and conventional balloon angioplasty, the restenosis rate was significantly lower in the DCB group (5.3%, 2/38) than in the conventional balloon group (34.2%, 13/38) at an average follow-up of 6 months \u003csup\u003e29\u003c/sup\u003e, indicating a potentially promising treatment approach. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Some patients require stent rescue: In this study, all patients were initially planned for balloon angioplasty only (with stent backup). However, 22.5% (9/40) of the patients required stent rescue due to restenosis rates exceeding 50% or the occurrence of arterial dissection after balloon angioplasty. This observation was consistent with the findings of previous studies.\u003c/p\u003e \u003cp\u003eThe mechanism of immediate restenosis after balloon angioplasty was unclear in this study because of the small sample size, which prevented a statistical analysis. Research on coronary artery narrowing after isolated balloon angioplasty has indicated a higher rate of restenosis in arterial plaques exhibiting significant concentricity and fibrosis \u003csup\u003e30\u003c/sup\u003e. Research on restenosis after carotid endarterectomy for carotid artery stenosis has indicated a positive correlation between postoperative restenosis and the extent of macrophage infiltration and the size of the lipid core within the plaque \u003csup\u003e31\u003c/sup\u003e. In patients with restenosis following stent placement for vertebral artery intracranial segment stenosis, quantitative and qualitative analyses of plaque calcification using OCT revealed an association between restenosis and extensive calcification \u003csup\u003e32\u003c/sup\u003e. The mechanisms underlying restenosis after balloon angioplasty or stent placement in patients with sICAS remain unclear and require further investigation. Accurate identification of patients with a low restenosis rate following balloon angioplasty warrants further investigation in the academic research domain.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eWhile this study offers important findings regarding the safety and efficacy of simple balloon angioplasty compared to medical treatment for sICAS, it is important to acknowledge several limitations. Retrospective Design: The retrospective nature of this study introduces inherent biases and limitations. Data collection relied on medical records, which may have been incomplete or subject to documentation errors. Additionally, the lack of randomization may have led to selection bias and confounding variables. Small Sample Size: The sample size in this study was relatively small, comprising a total of 91 patients. A larger sample size would enhance the statistical power of the analysis and allow for more robust conclusions. Single-Center Study: This study was conducted at a single center, which may limit the generalizability of the findings. Variations in patient populations, treatment protocols, and healthcare practices across different institutions could affect the external validity of the results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, this study suggests that balloon angioplasty, when compared with medical treatment, does not significantly increase the risk of stroke or death within the first 30 days postoperatively in patients with sICAS. The long-term effectiveness of this intervention requires further investigation with extended follow-up. However, considering the retrospective nature of this study, confirming the safety profile requires validation using a large-sample RCT.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of Jiangxi Provincial People's Hospital. The participants provided their written informed consent to participate in this study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by grant from Jiangxi Provincial Health Commission Foundation (NO. 202110007 and NO. 202310122).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eW.F.C. contributed to original draft preparation. A.W. provided review and editing. X.M.C. conducted data collection and statistical analysis. L.F.W., Y.L.Z, Z.B.X., W.R., Q.H.C., and H.W.W. performed interventional surgery. S.M.L. conceptualized the study. All authors contributed to manuscript revision, read and approved the submitted version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data analyzed in this study are available from the corresponding author upon reasonable request. The data include clinical information from patients admitted to the Department of Neurology, Jiangxi Provincial People's Hospital, from January 2020 to December 2021, who underwent simple balloon angioplasty or medication treatment for sICAS. The data encompass demographic characteristics, medical history, NIHSS scores, responsible vessels, degree of vascular stenosis, treatment modalities, anesthesia methods, balloon specifications, postoperative outcomes, and 30-day follow-up results. The data will be made available to researchers upon request to ensure transparency and reproducibility in our research findings.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarnard, Z. R. \u0026amp; Alexander, M. J. Update in the treatment of intracranial atherosclerotic disease. Stroke Vasc Neurol 5, 59\u0026ndash;64 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChimowitz, M. I. \u003cem\u003eet al.\u003c/em\u003e Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 352, 1305\u0026ndash;1316 (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChimowitz, M. I. \u003cem\u003eet al.\u003c/em\u003e Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 365, 993\u0026ndash;1003 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaidat, O. O. \u003cem\u003eet al.\u003c/em\u003e Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA 313, 1240\u0026ndash;8 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiorella, D. \u003cem\u003eet al.\u003c/em\u003e US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke 38, 881\u0026ndash;887 (2007).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuran, T. N. \u003cem\u003eet al.\u003c/em\u003e Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee. Neurology 98, 486\u0026ndash;498 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStapleton, C. J. \u003cem\u003eet al.\u003c/em\u003e Neurosurgery 86, 755\u0026ndash;762 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuels, O. B., Joseph, G. J., Lynn, M. J., Smith, H. A. \u0026amp; Chimowitz, M. I. A standardized method for measuring intracranial arterial stenosis. AJNR Am J Neuroradiol 21, 643\u0026ndash;646 (2000).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, Y. \u003cem\u003eet al.\u003c/em\u003e Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. N Engl J Med 385, 2520\u0026ndash;2530 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehme, D. \u003cem\u003eet al.\u003c/em\u003e Validation of the extended thrombolysis in cerebral infarction score in a real world cohort. PLoS One 14, e0210334 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwah, L. K. \u0026amp; Diong, J. National Institutes of Health Stroke Scale (NIHSS). J Physiother 60, 61 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, H. \u0026amp; Zheng, L. Statistical analysis for efficacy of tirofiban combined with ozagrel in the treatment of progressive cerebral infarction patients out of thrombolytic therapy time window. Clinics (Sao Paulo) 76, e2728 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang, W.-J. \u003cem\u003eet al.\u003c/em\u003e Symptomatic intracranial stenosis: cerebrovascular complications from elective stent placement. Radiology 243, 188\u0026ndash;197 (2007).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo, J. \u003cem\u003eet al.\u003c/em\u003e Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2, CD013267 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayak, S. Mechanical Thrombectomy using Distal Access Catheters: Current Status and Future Prospects. J Neuroimaging 30, 754\u0026ndash;761 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoyal, M. \u003cem\u003eet al.\u003c/em\u003e Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387, 1723\u0026ndash;1731 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, Y. \u003cem\u003eet al.\u003c/em\u003e Early versus delayed stenting for intracranial atherosclerotic artery stenosis with ischemic stroke. J Neurointerv Surg 12, 274\u0026ndash;278 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao, P. \u003cem\u003eet al.\u003c/em\u003e Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial. JAMA 328, 534\u0026ndash;542 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, Y. \u003cem\u003eet al.\u003c/em\u003e Primary Angioplasty without Stenting for Symptomatic, High-Grade Intracranial Stenosis with Poor Circulation. AJNR Am J Neuroradiol 39, 1487\u0026ndash;1492 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarks, M. P. \u003cem\u003eet al.\u003c/em\u003e Intracranial angioplasty without stenting for symptomatic atherosclerotic stenosis: long-term follow-up. AJNR Am J Neuroradiol 26, 525\u0026ndash;530 (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBash, S. \u003cem\u003eet al.\u003c/em\u003e Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol 26, 1012\u0026ndash;1021 (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng, Y. \u003cem\u003eet al.\u003c/em\u003e Correlation between intracranial vertebral artery stenosis diameter measured by digital subtraction angiography and cross-sectional area measured by optical coherence tomography. J Neurointerv Surg 13, 1002\u0026ndash;1006 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, T. \u003cem\u003eet al.\u003c/em\u003e Endovascular Therapy for Symptomatic Intracranial Artery Stenosis: a Systematic Review and Network Meta-analysis. Transl Stroke Res 13, 676\u0026ndash;685 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng, G. \u003cem\u003eet al.\u003c/em\u003e Medical and Endovascular Treatments for Intracranial Atherosclerotic Stenosis: A Network Meta-Analysis. Transl Stroke Res (2021) doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12975-021-00957-7\u003c/span\u003e\u003cspan address=\"10.1007/s12975-021-00957-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa, N. \u003cem\u003eet al.\u003c/em\u003e Stenting for symptomatic intracranial arterial stenosis in China: 1-year outcome of a multicentre registry study. Stroke Vasc Neurol 3, 176\u0026ndash;184 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, K. \u003cem\u003eet al.\u003c/em\u003e A Comparison of Safety and Effectiveness Between Wingspan and Neuroform Stents in Patients With Middle Cerebral Artery Stenosis. Front Neurol 12, 527541 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, Z.-L. \u003cem\u003eet al.\u003c/em\u003e Outcomes of middle cerebral artery angioplasty and stenting with Wingspan at a high-volume center. Neuroradiology 58, 161\u0026ndash;169 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUeda, T. \u003cem\u003eet al.\u003c/em\u003e Long-Term Outcome of Balloon Angioplasty Without Stenting for Symptomatic Middle Cerebral Artery Stenosis. J Stroke Cerebrovasc Dis 27, 1870\u0026ndash;1877 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, J. \u003cem\u003eet al.\u003c/em\u003e Drug-Coated Balloon Dilation Compared With Conventional Stenting Angioplasty for Intracranial Atherosclerotic Disease. Neurosurgery 87, 992\u0026ndash;998 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVirmani, R., Farb, A. \u0026amp; Burke, A. P. Coronary angioplasty from the perspective of atherosclerotic plaque: morphologic predictors of immediate success and restenosis. Am Heart J 127, 163\u0026ndash;179 (1994).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHellings, W. E. \u003cem\u003eet al.\u003c/em\u003e Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy. JAMA 299, 547\u0026ndash;554 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu, R. \u003cem\u003eet al.\u003c/em\u003e Macrocalcification of intracranial vertebral artery may be related to in-stent restenosis: lessons learned from optical coherence tomography. J Neurointerv Surg 14, neurintsurg-2021-017913 (2022).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"symptomatic intracranial atherosclerotic stenosis, medical therapy, balloon dilatation, Perioperative","lastPublishedDoi":"10.21203/rs.3.rs-4195871/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4195871/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Patients with symptomatic intracranial arterial stenosis (sICAS) will likely face perioperative risks with stent placement and recurrence with medication. Simple balloon angioplasty (SBA), as a less invasive and safer alternative to stent placement, may offer an effective treatment option for sICAS. This study aimed to assess the perioperative safety of SBA compared to medication for sICAS. A retrospective analysis was conducted on sICAS patients admitted to the Department of Neurology, Jiangxi Provincial People's Hospital, between January 2020 and December 2021, within 60 days of onset. Patients with severe stenosis (70% to 99% rate), confirmed by cerebral angiography, were divided into medication and SBA groups. Demographic data, medical history, NIH Stroke Scale (NIHSS) scores at onset, responsible vessels, degree of vascular stenosis, postoperative residual stenosis rate, and any stroke or death within 30 days postoperatively were assessed. The study included 91 patients, with 51 in the medication group (38 males, mean age 58.06±1.58 years) and 40 in the SBA group (24 males, mean age 60.95±1.37 years). There were no significant differences in demographics, medical history, NIHSS scores, or degree of vascular stenosis (all P \u003e 0.05). All SBA patients underwent successful balloon angioplasty, with 8 cases (20%) requiring a stent placement due to significant post-dilation stenosis regression or dissection affecting blood flow. Within 30 days postoperatively, 2 patients (3.9%) in the medication group experienced progressive stroke, while 3 patients (7.5%) in the SBA group experienced endpoint events, including 2 cases of new-onset infarction and 1 case of subarachnoid hemorrhage. There was no statistically significant difference in endpoint event occurrence between the groups (P \u003e 0.05), and no deaths occurred. In conclusion, SAB in sICAS patients did not significantly increase the risk of stroke within 30 days postoperatively compared to medication treatment. Long-term efficacy warrants further investigation.","manuscriptTitle":"Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-25 16:49:45","doi":"10.21203/rs.3.rs-4195871/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e259126f-97b7-420c-9f2c-4b809f803c16","owner":[],"postedDate":"April 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30779012,"name":"Health sciences/Neurology/Neurological disorders/Cerebrovascular disorders"},{"id":30779013,"name":"Health sciences/Neurology/Neurological disorders/Stroke"}],"tags":[],"updatedAt":"2024-10-01T08:54:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-25 16:49:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4195871","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4195871","identity":"rs-4195871","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}