Endovascular therapy vs. conventional medical treatment for symptomatic intracranial atherosclerotic stenosis: an updated meta-analysis of randomized controlled trials

Symptomatic intracranial atherosclerotic stenosis is a common cause of ischemic stroke, with high recurrence rates despite medical management. The present study investigated the short-term and long-term outcomes of endovascular therapy (ET) versus conventional medical therapy (CMT) in intracranial atherosclerotic stenosis (sICAS) management. We conducted a systematic review and meta-analysis. Searches were performed in PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), SCOPUS, and Embase. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. PROSPERO ID: (CRD42024601551). Five RCTs involving 1,531 patients were included, with 743 in the ET + CMT group and 748 in the CMT group. ET was associated with increased odds of short-term mortality or stroke (OR, 3.19; 95% CI 1.96, 5.19, P < 0.01), including higher risks of mortality (OR, 4.35; 95% CI 1.23, 15.35, P = 0.02), ischemic stroke (OR, 2.26; 95% CI 1.34, 3.82, P < 0.01), and hemorrhagic stroke (OR, 10.74; 95% CI 2.52, 45.90, P < 0.01), but no difference between both groups in transient ischemic attack (OR, 0.87; 95% CI 0.32, 2.34, P = 0.78). For long-term outcomes, no significant differences were observed. However, ET significantly increased long-term hemorrhagic stroke risk (OR, 5.14; 95% CI 1.48, 17.77, P < 0.01). In patients with ischemic stroke due to sICAS, ET plus CMT has increased the risk of all-cause mortality, ischemic stroke, and hemorrhagic stroke compared to CMT alone. Hence, current evidence does not support adjuvant ET for patients with sICAS.