<![CDATA[Background: Intracranial atherosclerotic disease (ICAD) is a major cause of recurrent ischemic stroke despite optimized aggressive medical management. Over the last decade, intracranial balloon angioplasty (IBA)—including submaximal angioplasty and drug-coated balloon (DCB)—has emerged as a “leave-nothing-behind” strategy that may lower restenosis and recurrent events compared with stenting. Objective: To evaluate the effectiveness and safety of IBA as secondary prevention for patients with symptomatic intracranial atherosclerotic stenosis (sICAS) and to compare outcomes with aggressive medical therapy and/or stenting. Method: We conducted a PRISMA-guided systematic literature review across Scopus, PubMed, and ProQuest (2015–2025). From 199 records (Scopus 78; PubMed 21; ProQuest 100), titles/abstracts were screened, full texts assessed, and data extracted in duplicate using a standardized form. Seventeen studies (RCT, prospective/retrospective cohorts, and systematic reviews/meta-analyses) were included for qualitative synthesis. Result: Across included studies, IBA—particularly submaximal angioplasty combined with modern medical therapy—reduced 30-day stroke/death and 12-month recurrent stroke versus medical therapy alone in eligible sICAS. DCB consistently showed lower restenosis and minimal residual stenosis versus conventional stenting without a safety penalty, while overall periprocedural complication rates with conservative dilation were low. Conclusion: Evidence from the 17 included publications supports IBA—both submaximal and DCB—as a safe and effective option for secondary prevention in carefully selected sICAS. Longer-term multicenter RCTs are warranted to standardize technique (target residual stenosis, inflation parameters) and confirm superiority over stenting or medical therapy alone. Keywords: intracranial balloon angioplasty; submaximal angioplasty; drug-coated balloon; secondary prevention; sICAS.]]>
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