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Review
. 2025 Sep;10(3):655-664.
doi: 10.1177/23969873251324863. Epub 2025 Mar 13.

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

Maria-Ioanna Stefanou  1   2 , Evangelos Panagiotopoulos  1 , Lina Palaiodimou  1 , Aikaterini Theodorou  1 , George Magoufis  3   4 , Stavros Spiliopoulos  4 , Apostolos Safouris  1   5 , Odysseas Kargiotis  5 , Klearchos Psychogios  1   5 , Tatiana Sidiropoulou  6 , Frantzeska Frantzeskaki  7 , Panayiotis D Mitsias  8 , Katharina Feil  2   9 , Annerose Mengel  2   9 , Marios Themistocleous  10 , Ulf Ziemann  2   9 , Georgios Tsivgoulis  1
Affiliations
Review

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

Maria-Ioanna Stefanou et al. Eur Stroke J. 2025 Sep.

Abstract

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; I2 = 0%), ischemic stroke within the territory of the qualifying artery (RR = 2.51; 95% CI: 1.36-4.61; I2 = 0%), any ischemic stroke (RR = 1.99; 95% CI: 1.17-3.38; I2 = 0%), intracranial hemorrhage (RR = 6.23; 95% CI: 1.92-20.2; I2 = 0%), and mortality (RR = 3.52; 95% CI: 1.04-11.88; I2 = 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; I2 = 68%), ischemic stroke in the territory of the qualifying artery (RR = 0.44, 95% CI: 0.14-1.33; I2 = 59%) and mortality (RR = 0.49, 95% CI: 0.16-1.55; I2 = 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.

Keywords: Endovascular therapy; intracranial stenosis; percutaneous transluminal angioplasty and stenting; stroke; submaximal balloon angioplasty.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Graphical abstract
Graphical abstract
Figure 1.
Figure 1.
PRISMA flowchart diagram presenting the selection of eligible studies.
Figure 2.
Figure 2.
Forest plot comparing the risk of any stroke or death within 30 days in EVT and control group.
Figure 3.
Figure 3.
(a) Forest plot comparing the risk of ischemic stroke in the territory of the qualifying artery within 30 days in EVT and control group and (b) forest plot comparing the risk of any ischemic stroke within 30 days in EVT and control group.
Figure 4.
Figure 4.
Forest plot comparing the risk of intracranial hemorrhage within 30 days in EVT and control group.
Figure 5.
Figure 5.
Forest plot comparing the risk of death within 30 days in EVT and control group.
See this image and copyright information in PMC

References

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