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03-01-2024 | Cerebral Ischemia | Original Article

Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis

A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials

Authors: Joshua Y. P. Yeo, Chun En Yau, Natasha Yixuan Ong, Yao Hao Teo, Anil Gopinathan, Cunli Yang, Mingxue Jing, Joanna J. W. Yang, Ching-Hui Sia, Benjamin Yong Qiang Tan, Leonard Leong Litt Yeo

Published in: Clinical Neuroradiology | Issue 2/2024

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Abstract

Purpose: In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death.
Methods: Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies,  letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines.
Results: 7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28–3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41–66.45], I² = 0%) and death (RR = 5.41 [1.20–24.28], I² = 0%).
Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25–2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(–0.83 months; 95% CI: –1.30–0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11–2.32).
Conclusions and Relevance: There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks.
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Metadata
Title
Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis
A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials
Authors
Joshua Y. P. Yeo
Chun En Yau
Natasha Yixuan Ong
Yao Hao Teo
Anil Gopinathan
Cunli Yang
Mingxue Jing
Joanna J. W. Yang
Ching-Hui Sia
Benjamin Yong Qiang Tan
Leonard Leong Litt Yeo
Publication date
03-01-2024
Publisher
Springer Berlin Heidelberg
Published in
Clinical Neuroradiology / Issue 2/2024
Print ISSN: 1869-1439
Electronic ISSN: 1869-1447
DOI
https://doi.org/10.1007/s00062-023-01370-3