Drug-coated balloons versus stenting for intracranial atherosclerotic stenosis: a meta-analysis

Background Intracranial atherosclerotic stenosis (ICAS) is a leading cause of ischemic stroke, often requiring endovascular treatment in cases refractory to medical therapy. Stent angioplasty is the most common intervention, but it carries risks such as restenosis and thromboembolic events. Drug-coated balloons or drug-eluting balloons (DCB/DEBs) have emerged as a promising alternative, delivering antiproliferative agents without permanent implantation. This study aims to compare clinical and procedural outcomes of DCB/DEBs versus stent angioplasty in patients with symptomatic ICAS. Methods A systematic review and meta-analysis was conducted according to PRISMA guidelines (PROSPERO: CRD42024616346). Six studies comprising 527 patients (233 DCB/DEB, 294 stenting) were included. Outcomes assessed included restenosis rates, periprocedural complications, and recurrent ischemic events. Results DCB/DEBs significantly reduced the risk of restenosis (RR 0.25; 95% CI 0.15 to 0.40; I²=0%) compared with stents. For periprocedural complications, no significant difference was observed (RR 0.65; 95% CI 0.32 to 1.33; I²=0%). In terms of recurrent ischemic events, DCB/DEBs were associated with a significant reduction (RR 0.30; 95% CI 0.13 to 0.67; I²=0%). Conclusion DCB/DEBs appear to offer significantly lower restenosis rates and fewer recurrent ischemic events compared with conventional stenting for symptomatic ICAS, without increasing periprocedural complications. While data on long-term outcomes remain limited, DCB/DEBs may represent a less invasive and potentially safer endovascular option. Further randomized trials are warranted to define its role in clinical practice.