Medical and Endovascular Treatments for Intracranial Atherosclerotic Stenosis: A Network Meta-Analysis

Abstract

Medical treatment and endovascular therapy are widely used for intracranial atherosclerotic stenosis, but the best treatment strategy remains uncertain. The goal of this study was to compare the safety and effectiveness of medical treatment, stenting, and primary balloon angioplasty (PBA). We searched PubMed, MEDLINE, and EMBASE for trials comparing these three treatments for intracranial stenosis up to December 24, 2020. We performed a network meta-analysis with randomeffects models. The primary outcome was any stroke or death during a long-term follow-up. Secondary outcomes included ischemic stroke, intracranial hemorrhage, and death. This network meta-analysis included 14 trials with 1520 participants. No significant difference was found between the three groups in the primary outcome, while PBA was probably the best treatment according to the ranking plot. Medical treatment had significantly lower rate of any stroke or death (odds ratio (OR), 0.31; 95% CI, 0.17-0.56), ischemic stroke (OR, 0.43; 95% CI, 0.23-0.81), and intracranial hemorrhage (OR, 0.12; 95% CI, 0.02-0.71) within 30 days than stenting but did not differ from PBA. The ranking plot demonstrated that PBA was also most likely to rank the highest for ischemic stroke during the long-term follow-up and beyond 30 days, although no significant difference was identified. Medical treatment had lower risk of any stroke or death within 30 days than stenting but did not differ from PBA. All the treatments had similar effects on the prevention of long-term stroke, while PBA had the highest probability of being the most effective.

Balloon angiopLasty for intracranial Atherosclerotic minor Stroke/TIA (BLAST): study protocol for a multicenter prospective cohort study

“…The incidence rate was lower than that reported in previous studies (SAMMPRIS, 14.7% within 30 days and 19.7% within 1 year; VISSIT, 24.1% within 30 days and 36.2% within 1 year; and CASSIS, 5.1% within 30 days and 8% within 1 year). Previous meta-analyses have also suggested that SBA and medical therapy have similar short-term outcomes; however, SBA may better prevent long-term stroke recurrence (12). Thus, we hypothesized that SBA plus medical therapy may outperform medical therapy alone in patients with minor stroke/ TIA with ICAS within 1 week of onset who are at a high risk of recurrence.…”

“…Over the past 20 years, several trials have investigated stent placement combined with medical therapy in this population; however, the results have been neutral, and the risk of recurrent stroke remains high (9)(10)(11). Compared with stenting, submaximal balloon angioplasty (SBA) could be a safer and simpler intervention that may be an effective strategy for preventing recurrent stroke (12,13). For example, prior meta-analysis found that the incidence of stroke or death within 30 days after SBA was 3-4.9% (14,15), and the one-year stroke occurrence rate was 5% (15), which was lower than that of stent placement (9)(10)(11).…”

Safety Assessment of Symptomatic Intracranial Atherosclerotic Stenosis: A Comparison between Sole Balloon Angioplasty and Medical Treatment

“…The ndings revealed that balloon angioplasty signi cantly reduced short-term risks of stroke and death compared to the latter two methods (perioperative or ≤ 3 months postoperative) 23 . A meta-analysis comparing medical treatment, stent placement, and balloon angioplasty for sICAS indicated that, during long-term follow-ups, balloon angioplasty might be the most effective method for preventing strokes and reducing mortality 24 . These results suggest that in the current clinical context, balloon angioplasty may be considered the optimal method for managing sICAS.…”

Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS): protocol of a prospective, multicentre, randomised, controlled trial

“…7 Three recent meta-analyses all suggested that submaximal balloon angioplasty may be a potentially promising intervention for sICAS. [8][9][10] However, compared with medical therapy, the long-term effectiveness of balloon angioplasty, including recurrent stroke and restenosis of target vessels, is still unknown. Therefore, we designed the BASIS trial to investigate a new perspective on endovascular treatment for sICAS.…”

“…Moreover, several previous meta-analyses also proved the safety and efficacy of balloon angioplasty for sICAS, which suggested that balloon angioplasty alone may be potentially promising for sICAS. [8][9][10] To date, limited evidence is available from randomised controlled trials (RCTs) to determine the safety and efficacy of balloon angioplasty for patients with sICAS. Hence, we designed the Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS) RCT to explore whether balloon angioplasty plus AMM is superior to AMM alone in patients with sICAS.…”