Efficacy of Remote Ischemic Conditioning in Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Introduction Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability worldwide. Despite significant advances in reperfusion therapies, such as intravenous thrombolysis and mechanical thrombectomy, many patients do not achieve optimal recovery, and secondary brain injury remains a major therapeutic challenge. Remote ischemic conditioning (RIC) has emerged as a promising neuroprotective strategy to reduce infarct size and improve outcomes. However, the results from clinical trials investigating RIC's efficacy in AIS have been inconsistent. This meta-analysis aims to evaluate the overall efficacy and safety of RIC in AIS, assessing its effects on infarct size, functional recovery, and secondary outcomes. Methods A comprehensive systematic search was conducted across multiple electronic databases, including PubMed, Cochrane Library, Web of Science, Embase, and ClinicalTrials.gov, up to September 2025. Randomized controlled trials (RCTs) assessing RIC in AIS patients were included, with studies that compared RIC with sham, placebo, or standard care. Two independent reviewers assessed study eligibility, data extraction, and quality using the Cochrane Risk of Bias tool. Pooled analyses were performed using a random-effects model. Primary outcomes included functional recovery (mRS 0-1, mRS 0-2), neurological outcomes (NIHSS), stroke recurrence, and mortality. Heterogeneity was assessed with the I 2 statistic, and publication bias was analyzed using funnel plots. Results A total of 25 randomized controlled trials (RCTs) involving 13,084 patients were included in this analysis, with 6,433 patients in the remote ischemic conditioning (RIC) group and 6,615 in the control group. The mean age of participants was 66.32±5 years, with 61.9% male participants. The average duration of RIC treatment was 9.5 ± 2 days, and the mean follow-up time was 20.3±7 months. For functional independence (mRS 0-1), the pooled log odds ratio (OR) was 0.36 95% CI: 0.15, 0.56, suggesting a significant benefit of RIC, although substantial heterogeneity was observed (I 2 = 78.6%). For mRS 0-2, the pooled log OR was 0.36 95% CI: -0.04, 0.75, which was not statistically significant, with high heterogeneity (I 2 = 86.2%). Regarding neurological outcomes, the pooled mean difference for NIHSS scores was -0.46 95% CI: -1.13, 0.22, showing no significant improvement in RIC-treated patients, and very high heterogeneity (I 2 = 95.9%) was observed. The pooled mean difference for stroke recurrence was -21.49 95% CI: -65.16, 22.19, indicating no significant effect of RIC, with extreme heterogeneity (I 2 = 99.2%). For mortality, the pooled log risk ratio (RR) was -0.07 95% CI: -0.34, 0.19, suggesting no significant benefit in terms of reducing mortality, with no heterogeneity (I 2 = 0%). Conclusion This meta-analysis suggests that RIC may offer modest benefits in improving functional outcomes (mRS 0-1) in AIS patients, but the evidence remains inconsistent across other clinical endpoints such as broader functional recovery, neurological improvement, stroke recurrence, and mortality. The substantial heterogeneity across the trials points to significant variability in study protocols, patient characteristics, and outcome measures. While RIC presents as a promising, non-invasive, and cost-effective adjunctive therapy, further large-scale, well-designed RCTs with standardized treatment protocols are needed to establish its definitive clinical utility and identify the patient subgroups most likely to benefit from this intervention