To compare the efficacy and safety of stenting plus medical therapy (STN + MT) versus medical therapy alone (MT) in patients with symptomatic ICAS through a systematic review and meta-analysis of randomized controlled trials (RCTs).

A comprehensive search of PubMed, Embase, Web of Science, the Cochrane Library, Scopus, and EBSCO was conducted to identify RCTs evaluating STN + MT versus 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 (RRs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models as appropriate. Meta-regression analyses assessed potential study-level effect modifiers.

Four RCTs encompassing 990 patients met inclusion criteria. Compared with MT alone, STN + MT was associated with a significantly higher 30-day risk of stroke and ICH. At 1 year, no significant differences were observed in TIA, stroke, ICH, or mortality between groups. Meta-regression identified no significant effect modifiers, indicating consistent results across trials and patient subgroups.

This meta-analysis reinforces that intracranial stenting as a first-line strategy provides no added long-term benefit over aggressive medical therapy while conferring greater early procedural risk. Current evidence supports medical therapy as the default management for most patients with symptomatic ICAS. Endovascular intervention should remain limited to research settings or carefully selected rescue cases until further data.