Remote ischemic conditioning in the acute treatment of ischemic and hemorrhagic stroke: A systematic review and...

Remote ischemic conditioning, a low-cost, non-invasive therapy involving brief cycles of limb ischemia and reperfusion, may be a neuroprotective adjuvant or alternative to reperfusion therapies in acute ischemic stroke and may also have therapeutic effects in hemorrhagic stroke. This systematic review and meta-analysis evaluated the efficacy of remote ischemic conditioning in acute ischemic stroke and hemorrhagic stroke.

This review was conducted in accordance with Preferred Reporting for Systematic review and Meta-Analyses guidelines and was registered in PROSPERO (CRD42024549594). Literature searches were conducted on MEDLINE, Embase, and Web of Science from inception to 9 December 2025. Randomized controlled trials involving adults with acute ischemic stroke or hemorrhagic stroke were included in the study. We focused on functional outcomes; secondary measures included cerebral hemodynamics and neuroimaging. Outcomes were analyzed using the DerSimonian-Laird model, while study heterogeneity was evaluated using Cochran's Q.

Overall, 35 studies (6304 patients) were included. Functional outcomes were significantly better in acute ischemic stroke patients who received remote ischemic conditioning versus those who did not, as indicated by lower Modified Rankin Scale scores (standardized mean difference = -0.18, 95% confidence interval: -0.35 to -0.01, n = 11 studies) and higher odds for favorable (odds ratio = 1.28, 95% confidence interval: 1.05 to 1.57, n = 17 studies) and excellent (odds ratio = 1.27, 95% confidence interval: 1.06 to 1.51, n = 12 studies) outcomes; furthermore, post-treatment stroke severity (indicated by National Institutes of Health Stroke Scale scores) was also lower in acute ischemic stroke patients receiving remote ischemic conditioning (standardized mean difference = -0.64, 95% confidence interval: -0.96 to -0.31, n = 16 studies). The Modified Rankin Scale scores and outcomes were better when remote ischemic conditioning was initiated beyond 24 h, and the protocol involved bilateral application and/or use beyond 7 days. Favorable Modified Rankin Scale outcomes were only better in patients receiving remote ischemic conditioning without reperfusion.

Remote ischemic conditioning appears to improve functional and neurological outcomes in acute ischemic stroke patients. However, the quality of evidence is limited by regional generalizability (i.e. most studies came from China), small sample sizes, and methodological heterogeneity. We encourage future trials to include patients presenting beyond 4.5 h and to incorporate bilateral remote ischemic conditioning application and to extend remote ischemic conditioning use beyond 7 days. We also encourage studies to focus on patients who are not eligible for reperfusion therapy.