Endovascular therapy versus best medical treatment for symptomatic intracranial atherosclerotic stenosis: A systematic review and meta-analysis

Introduction: Evidence on endovascular therapy (EVT) for symptomatic intracranial stenosis (sICAS) from randomized-controlled clinical trials (RCTs) is conflicting. While prior RCTs on percutaneous transluminal angioplasty and stenting (PTAS) demonstrated harm or no benefit over best medical treatment (BMT), recent data suggest that submaximal balloon angioplasty with BMT may be superior to BMT alone. Patients and methods: A systematic review and meta-analysis of RCTs was conducted to evaluate the safety and efficacy of elective EVT plus BMT compared to BMT alone for sICAS. Results: Six RCTs (5 on PTAS and 1 on balloon-angioplasty) comprising 1606 patients were included. EVT increased the risk of any stroke or death (RR = 2.68; 95% CI: 1.72–4.19; I 2 = 0%), ischemic stroke within the territory of the qualifying artery (RR = 2.51; 95% CI: 1.36–4.61; I 2 = 0%), any ischemic stroke (RR = 1.99; 95% CI: 1.17–3.38; I 2 = 0%), intracranial hemorrhage (RR = 6.23; 95% CI: 1.92–20.2; I 2 = 0%), and mortality (RR = 3.52; 95% CI: 1.04–11.88; I 2 = 0%) within 30 days. No significant benefit from EVT was detected regarding the risk of any stroke or death (RR = 0.29, 95% CI: 0.06–1.38; I 2 = 68%), ischemic stroke in the territory of the qualifying artery (RR = 0.44, 95% CI: 0.14–1.33; I 2 = 59%) and mortality (RR = 0.49, 95% CI: 0.16–1.55; I 2 = 0%) beyond 30 days through 1 year. Discussion and conclusion: EVT is associated with adverse early outcomes, without reducing the risk of long-term stroke recurrence or mortality compared to BMT. Further research is warranted to identify high-risk subgroups who may benefit from EVT for sICAS and refine interventions to minimize periprocedural risks.