Background: Intracranial atherosclerotic stenosis (ICAS) is a leading cause of ischemic stroke, with elevated recurrence risk. The efficacy and safety of endovascular treatment (EVT) versus conventional medical therapy (CMT) remain controversial. Methods: We searched PubMed, Embase, Web of Science, and CENTRAL for RCTs comparing EVT + CMT versus CMT alone for sICAS. Primary outcomes: any stroke/death, ischemic stroke, death, ICH, TIA within 30 days. Secondary outcomes: these events beyond 30 days through 1 year and over the entire follow-up. Results: Six RCTs (1641 patients) were included. Within 30 days, EVT increased any stroke/death (RR = 2.31; 95% CI: 1.57 - 3.39), ischemic stroke (RR = 1.97; 95% CI: 1.22 - 3.19), ICH (RR = 10.55; 95% CI: 2.90 - 38.38), death (RR = 4.96; 95% CI: 1.28 - 19.21); TIA showed no difference (RR = 0.87; 95% CI: 0.33 - 2.27). From 30 days to 1 year, EVT reduced any stroke/death (RR = 0.10; 95% CI: 0.03 - 0.37); ischemic stroke (RR = 0.49; 95% CI: 0.21 - 1.11) and death (RR = 0.34; 95% CI: 0.08 - 1.40) showed no difference. Over entire follow-up, EVT increased any stroke/death (RR = 1.49; 95% CI: 1.12 - 1.99) and ICH (RR = 5.89; 95% CI: 1.55 - 22.44), reduced ischemic stroke (RR = 0.52; 95% CI: 0.33 - 0.83); death (RR = 1.57; 95% CI: 0.77 - 3.19) and TIA (RR = 0.68; 95% CI: 0.36 - 1.27) showed no difference. Conclusion: Current evidence does not support routine EVT for sICAS. EVT may increase 30-day stroke, death, and ICH risks without a clear long-term benefit. Further high-quality RCTs are warranted.
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