Elucidating the benefit of drug-eluting stent for symptomatic intracranial atherosclerotic stenosis: Meta-analysis of randomized controlled trials

Background: Intracranial atherosclerotic stenosis (ICAS) is a major global cause of stroke. Patient with high risk of recurring strokes despite standard medication therapy usually needs aggressive medical treatment such as self-expanding and balloon-expandable stents. Drug-eluting stents (DESs), with anti-vascular endothelial cell proliferation drugs, aim to inhibit smooth muscle cells proliferation and migration, providing a promising alternative to standard bare metal stents (BMS). This study compared the advantages and safety of DES to BMS in symptomatic ICAS patients. Methods: A comprehensive search was conducted through PubMed, Cochrane Central Register of Controlled Trials, and Science Direct in May 2024, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized trials comparing DES and BMS for symptomatic intracranial and vertebral artery stenosis were included in the study. Meta-analysis was carried out by RevMan software to analyze and odds ratio (OR) for primary and secondary outcomes. Results: Three randomized controlled trials ( n = 491) were included in the study. DES significantly reduced instent restenosis (ISR) compared to BMS (OR 0.26, 95% confidence interval [CI]: 0.16–0.45, P < 0.00001) and lowered the risk of ischemic stroke in the target vessel (OR 0.20, 95% CI: 0.06–0.65, P = 0.008). No significant difference was observed in all-cause mortality (OR 0.80, 95% CI: 0.21–3.02, P = 0.74) or technical success rates. Symptomatic ISR within 1 year was markedly lower with DES (OR 0.09, 95% CI: 0.01–0.73, P = 0.02). Conclusion: Intravascular DES is more effective than BMS in lowering risk of ISR and incidence of ischemic stroke in symptomatic ICAS.