Remote Ischemic Conditioning in the Acute Treatment of Ischemic and Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundRemote ischemic conditioning (RIC), a low-cost, non-invasive therapy involving brief cycles of limb ischemia and reperfusion, may be a neuroprotective adjuvant or alternative to reperfusion therapies in acute ischemic stroke (AIS) and may also have therapeutic effects in hemorrhagic stroke (HS). This systematic review and meta-analysis evaluated the efficacy of RIC in AIS and HS.MethodsThis review was conducted in accordance with PRISMA guidelines and was registered in PROSPERO (CRD42024549594). Literature searches were conducted on MEDLINE, Embase, and Web of Science from inception to December 9, 2025. Randomized controlled trials (RCTs) involving adults with AIS or HS were included in the study. We focused on functional outcomes; secondary measures included cerebral hemodynamics and neuroimaging. Outcomes were analyzed using the DerSimonian-Laird model, while study heterogeneity was evaluated using Cochran's Q.ResultsOverall, 35 studies (6,304 patients) were included. Functional outcomes were significantly better in AIS patients who received RIC versus those who did not, as indicated by lower modified Ranking Scale (mRS) scores (SMD=-0.18, 95%CI -0.35 to -0.01, n=11 studies) and higher odds for favourable (OR=1.28, 95%CI 1.05 to 1.57, n=17 studies) and excellent (OR=1.27, 95%CI 1.06 to 1.51, n=12 studies) outcomes; furthermore, post-treatment stroke severity (indicated by NIHSS scores) was also lower in AIS patients receiving RIC (SMD=-0.64, 95%CI -0.96 to -0.31, n=16 studies). MRS scores and outcomes were better when RIC was initiated beyond 24 hours, and the protocol involved bilateral application and/or use beyond seven days. Favourable mRS outcomes were only better in patients receiving RIC without reperfusion.ConclusionRIC appears to improve functional and neurological outcomes in AIS patients. However, the quality of evidence is limited by regional generalizability (i.e, most studies came from China), small sample sizes, and methodological heterogeneity. We encourage future trials to include patients presenting beyond 4.5 hours and to incorporate bilateral RIC application and to extend RIC use beyond seven days. We also encourage studies to focus on patients who are not eligible for reperfusion therapy.