Angioplasty and Stenting vs Aggressive Medical Management in Intracranial Atherosclerotic Stenosis: Updated Meta-Analysis of RCTs
Abdulaziz Boqaeid1, Mohammed Alqahtani1, Muna Alnamlah1, Shatha Alqurashi2, Muhnnad Asiri1, Ahmed Alkhiri2, Fawaz Alotaibi1, Adel Alhazzani1, Fahad Al-Ajlan3
1Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, 2College of Medicine, King Saud bin Abdulaziz for Health Sciences, Jeddah, Saudi Arabia, 3King Faisal Specialist Hospital and Research Center
Objective:
Our objective was to conduct an updated meta-analysis of RCTs examining stenting and angioplasty with aggressive medical management compared to aggressive medical management alone in patients with ICAS.
Background:
Previous randomized clinical trials (RCTs) did not establish the superiority of stenting and angioplasty over aggressive medical management for patients with symptomatic intracranial atherosclerotic stenosis (ICAS). However, a recent Chinese RCT (BASIS) has suggested potential benefits of angioplasty
Design/Methods:
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We searched PubMed, Medline, and Cochrane databases for RCTs. The Primary outcome was composite rates of stroke or death within 30-days. Surrogate outcome included composite rates of stroke or death at 1-year. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model.
Results:
Five RCTs, comprising a total of 1,491 patients with ICAS, were included in this meta-analysis. The stent and angioplasty arm included 743 patients (49.8%), while 748 patients (50.2%) received aggressive medical management alone. Within 30 days, the rates of stroke or death were higher in the stent and angioplasty arm (OR 2.48 [95% CI 1.54-4.00]; p<0.01; I2=0%). No significant difference between the groups was observed when evaluating rates of stroke or death at 1 year (OR 1.20 [95% CI 0.58-2.46]; p=0.63; I2=75%). Subgroup analysis based on the main intervention performed (stent with angioplasty vs. angioplasty alone) indicated the superiority of aggressive medical management in rates of stroke or death within 30 days over both approaches. However, angioplasty alone exhibited lower composite rates at 1 year compared to aggressive medical management (OR 0.33 [95% CI 0.14-0.75]; p=0.008
Conclusions:
This meta-analysis does not support stenting and angioplasty as a standard treatment for the wider symptomatic ICAS patient group. There is a need for further RCTs with safer devices and larger cohorts.
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