Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis: a meta-analysis of randomized controlled trials

Resumo

Background: Intracranial atherosclerotic stenosis (ICAS) is a leading cause of stroke worldwide, with a high risk of recurrence in patients with confirmed stroke and ≥ 70% stenosis. Dual antiplatelet therapy (DAPT) has proven to be more effective than monotherapy for ICAS. However, endovascular therapy (ET) has been explored for stroke prevention in ICAS patients. Therefore, we aim to perform a systematic review and meta-analysis in order to evaluate Conventional Medical Therapy (CMT) plus ET versus CMT in patients with ICAS.

Methods: We systematically searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing the two treatment regimens in patients with ICAS. Primary outcomes were all-cause mortality and any stroke or death within 30 days. Risk ratios (RRs) with 95% confidence intervals were calculated using a random effects model. R software (version 4.3.2) was used for statistical analyses.

Results: Five RCTs were included, comprising 1,491 patients, of whom 743 (49.8 %) received CMT plus ET. Any stroke or death within 30 days (RR = 2.73, 95% CI [1.74, 4.29], p < 0.0001, I2 = 0%) and all-cause mortality within 30 days (RR = 4.87, 95% CI [1.25, 18.96], p = 0.02, I2 = 0%) were significantly higher in patients treated with ET plus CMT compared with CMT alone.

Conclusion: This meta-analysis showed that CMT plus ET significantly increased the risk of stroke and all-cause mortality within 30 days compared with CMT alone. However, outcomes varied by technique: stenting was associated with higher early risk, whereas submaximal balloon angioplasty, as in the BASIS trial, suggested a possible long-term benefit.