Bin Aziz Khalid, Alhathlol Hussam, Bin Aziz Fahad, Alshammari Mohammed, Alhefdhi Mohammed Ali, Alrasheed Abdulrahman M, Alfayez Nawwaf, Alhowaish Thamer S
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia.
King Abdullah International Medical Research Center, Riyadh 11481, Saudi Arabia.
Clin Pract. 2025 Jun 19;15(6):113. doi: 10.3390/clinpract15060113.
Intracranial atherosclerotic stenosis (ICAS) is a significant cause of ischemic stroke worldwide, with high recurrence rates despite optimal medical therapy. While endovascular stenting has been proposed as an adjunctive treatment, its clinical benefit remains controversial as a first line therapy. To evaluate the efficacy and safety of stenting plus medical therapy (STN+MT) compared to medical therapy alone (MT) in patients with symptomatic ICAS through a systematic review and meta-analysis of randomized controlled trials (RCTs). : We systematically searched PubMed, Web of Science, the Cochrane Library, Embase, Scopus, and EBSCO for RCTs comparing STN+MT with MT in adult patients with symptomatic ICAS. Primary outcomes included transient ischemic attack (TIA), stroke, intracerebral hemorrhage (ICH), and death at 30 days and 1 year. Pooled risk ratios with 95% confidence intervals were calculated using random-effects or fixed-effects models as appropriate. Meta-regression was conducted to assess effect modification by study-level characteristics. : Four trials comprising 990 patients were included. STN+MT was associated with significantly higher 30-day risk of stroke and ICH compared to MT alone. No significant differences in TIA, stroke, ICH, or death were found at 1 year. Meta-regression revealed no significant effect modifiers, suggesting consistent findings across subgroups. : Our meta-analysis consolidates the evidence that intracranial stenting as a first line therapy offers no significant advantage over medical therapy in preventing stroke in symptomatic ICAS, while it does pose added early risks. This holds true across different trials, patient demographics, and clinical scenarios examined. The consistency of this message across multiple RCTs provides a high level of evidence to guide practice. At present, aggressive medical therapy alone should be the default management for most patients. Endovascular intervention should be reserved for clinical trial settings or carefully selected salvage cases, until and unless new evidence emerges to change the risk-benefit calculus such as the promising use of balloon angioplasty in the BASIS trial.
颅内动脉粥样硬化性狭窄（ICAS）是全球缺血性卒中的一个重要原因，尽管进行了最佳药物治疗，但其复发率仍很高。虽然血管内支架置入术已被提议作为辅助治疗，但作为一线治疗，其临床益处仍存在争议。通过对随机对照试验（RCT）进行系统评价和荟萃分析，评估支架置入术联合药物治疗（STN+MT）与单纯药物治疗（MT）相比，对有症状ICAS患者的疗效和安全性。：我们系统检索了PubMed、Web of Science、Cochrane图书馆、Embase、Scopus和EBSCO，以查找比较STN+MT与MT治疗有症状ICAS成年患者的RCT。主要结局包括30天和1年时的短暂性脑缺血发作（TIA）、卒中、脑出血（ICH）和死亡。根据情况使用随机效应或固定效应模型计算95%置信区间的合并风险比。进行Meta回归以评估研究水平特征的效应修正。：纳入了四项试验，共990例患者。与单纯MT相比，STN+MT的30天卒中风险和ICH风险显著更高。1年时在TIA、卒中、ICH或死亡方面未发现显著差异。Meta回归显示无显著的效应修饰因素，表明各亚组的结果一致。：我们的荟萃分析证实了以下证据：在预防有症状ICAS患者的卒中方面，颅内支架置入术作为一线治疗并不比药物治疗有显著优势，同时它确实带来了额外的早期风险。在不同的试验、患者人口统计学特征和所研究的临床场景中都是如此。这一信息在多个RCT中的一致性为指导实践提供了高水平的证据。目前，对于大多数患者，默认的治疗方法应是积极的单纯药物治疗。血管内介入治疗应保留用于临床试验环境或经过仔细挑选的挽救性病例，除非有新的证据出现改变风险效益计算，例如在BASIS试验中球囊血管成形术的应用前景良好。
