Systematic Review and Meta-Analysis on Rescue Stenting for Large-Vessel Occlusion due to Underlying Intracranial Atherosclerotic Stenosis (ICAS)

BACKGROUND: Large-vessel occlusion due to intracranial atherosclerotic stenosis often leads to failed or unstable reperfusion after mechanical thrombectomy. Rescue intracranial stenting is increasingly used, but its benefit-to-risk profile remains unclear. Prior systematic reviews have frequently pooled different rescue strategies and heterogeneous cohorts, limiting inference on the independent risk-benefit profile of stenting in ICAS-LVO.

PURPOSE: To quantify the efficacy and safety of rescue stenting in ICAS-LVO.

DATA SOURCES: Comparative studies evaluating permanent rescue stenting for ICAS-LVO during mechanical thrombectomy from January 1, 2020, through October 31, 2025, were searched in PubMed, EMBASE, Scopus, and the Web of Science.

STUDY SELECTION: Eight comparative studies encompassing 1,901 patients with confirmed large-vessel occlusion due to intracranial atherosclerotic stenosis (654 treated with rescue stenting and 1,247 managed with a no-stent strategy) were included.

DATA ANALYSIS: We evaluated 90-day functional independence (mRS 0-2), successful reperfusion (TICI ≥2b), symptomatic intracranial haemorrhage, and mortality; when available, we also extracted data by stent type. Meta-analysis was performed using a random-effects model.

DATA SYNTHESIS: Eight studies (1901 patients; 654 stented, 1247 controls) were included. Rescue stenting was associated with higher odds of 90-day functional independence (mRS 0-2) (OR 1.61; 95% CI 1.13-2.29) and successful reperfusion (TICI ≥2b) (OR 2.47; 95% CI 1.55-3.93). Mortality was not significantly different (OR 0.74; 95% CI 0.45-1.22), and symptomatic intracranial haemorrhage was not significantly increased (OR 1.25; 95% CI 0.81-1.95). In stent-type subgroup analyses, no apparent differences were observed between self-expanding and balloon-mounted stents for functional or safety outcomes.

LIMITATIONS: Evidence is limited by the small number of included studies and their observational nature, with potential confounding by indication and selection bias; heterogeneity was moderate for the functional outcome and substantial for mortality; symptomatic haemorrhage definitions varied, and event counts were limited.

CONCLUSIONS: In large-vessel occlusion due to intracranial atherosclerotic stenosis, rescue stenting is associated with higher reperfusion rates and improved 90-day functional outcomes without a statistically significant increase in symptomatic haemorrhage, while any mortality benefit remains uncertain. The certainty of the evidence is low, and randomized data are needed to confirm causality and optimize patient selection.