This meta-analysis aims to compare the efficacy of drug-eluting stents (DES) and bare metal stents (BMS) in treating intracranial atherosclerotic stenosis (ICAS).

Evidence supports the efficacy of DES over BMS in the setting of extracranial atherosclerotic stenosis (ECAS). The utility of DES in ICAS has not been established.

Electronic databases MEDLINE (PubMed), Embase, and Cochrane Library were queried from inception up till November 2022 using a structured search strategy. The inclusion criteria included observational and randomized studies which compared patients diagnosed with either symptomatic or asymptomatic, ECAS or ICAS in whom outcomes were compared between groups receiving DES or BMS. Subjects had a minimum of 50% arterial stenosis at baseline. Primary outcomes included overall in-stent restenosis (ISR) and symptomatic ISR. Secondary outcomes included incidence of stroke beyond thirty days of intervention. Study quality and risk of bias was reported using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Statistical analysis was conducted with Review Manager 5.4. Effect size was expressed as Risk Ratio with a 95% confidence interval (CI). Heterogeneity was determined using I² index, with values greater than 50% indicating significant heterogeneity. 

15 studies were eligible for analysis and featured 1857 lesions of which 872 were stented by DES. DES significantly reduced the incidence of overall ISR for patients with ICAS (0.31 [95% CI: 0.16 – 0.59]) and ECAS (0.55 [95% CI: 0.33 – 0.91]). The incidence of symptomatic ISR was significantly reduced in patients with ECAS (0.15 [95% CI: 0.03 – 0.61]). A single study reported symptomatic ISR as an outcome in ICAS (0.07 [95% CI: 0.00 – 1.15]). The incidence of stroke after 30 days of intervention was significantly reduced by DES (0.34 [95% CI: 0.18 – 0.64]).

Our meta-analysis extends the efficacy of DES in reducing overall ISR among patients with intracranial atherosclerosis.