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Intracranial atherosclerotic stenosis (ICAS) represents a major cause of stroke worldwide. Despite optimal medical treatment, a considerable proportion of patients with high-grade (70–99%) symptomatic ICAS continue to experience recurrent strokes. The pivotal randomized controlled trials (RCTs) for neurointerventional therapy, including SAMMPRIS,1 2 VISSIT,3 and CASSISS,4 compared stenting versus medical therapy, and all yielded negative results.5 The potential long-term benefits of stenting over medical therapy have failed to outweigh the perioperative risks. Recently, CASSISS reported its 7-year long-term results. Even over a prolonged period, stenting did not demonstrate additional advantages beyond those achieved with medical therapy.6 Nevertheless, promising evidence emerged from the BASIS trial, which explored the novel concept of suboptimal angioplasty as a strategy to potentially minimize perioperative risks in symptomatic ICAS patients.7 In light of the history of negative trials and the persistent challenge of recurrent strokes in a group of patients managed with maximal medical therapy, the critical question remains: what is the future direction for designing a successful neurointerventional trial for ICAS?