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Introduction Restenosis following bare-metal stent (BMS) implantation remains a major limitation of endovascular treatment for symptomatic intracranial atherosclerotic stenosis (sICAS) and contributes to recurrent ischemic events. Drug-coated balloons (DCBs) inhibit neointimal hyperplasia without leaving a permanent implant and may reduce restenosis risk. We performed a systematic review and meta-analysis comparing the efficacy and safety of DCB versus BMS in patients with sICAS.Methods A systematic search of PubMed, Embase, and Web of Science identified comparative studies evaluating DCB versus BMS for sICAS. Randomized controlled trials (RCTs) and comparative observational studies were included. The primary endpoint was angiographic restenosis. Secondary endpoints included symptomatic restenosis and recurrent ischemic events. Random-effects meta-analysis using the Hartung-Knapp-Sidik-Jonkman method was performed to estimate pooled odds ratios (OR) with 95% confidence intervals (CI). Between-study heterogeneity was assessed using I 2 statistics.Results Six studies (2 RCTs and 4 comparative observational studies) comprising 647 patients (DCB: 293; BMS: 354) were included. DCB significantly reduced angiographic restenosis compared with BMS (25/293 vs 114/354; OR 0.21, 95% CI 0.12-0.35; P=0.0006; I2=0%), representing a 79% relative reduction in odds. Recurrent ischemic events were also significantly lower in the DCB group (11/327 vs 45/386; OR 0.27, 95% CI 0.17-0.42; P=0.0007; I2=0%). Symptomatic restenosis demonstrated a favorable trend toward DCB (4/162 vs 20/196; OR 0.25, 95% CI 0.05-1.24; P=0.07; I2=0%), though statistical significance was not reached. Across all outcomes, heterogeneity was minimal, indicating consistent treatment effects across study designs and centers.Conclusion In patients with symptomatic intracranial atherosclerotic stenosis, drug-coated balloon angioplasty is associated with significantly lower rates of angiographic restenosis and recurrent ischemic events compared with bare-metal stenting, with highly consistent effects across studies. Although symptomatic restenosis reduction did not reach statistical significance, the magnitude of effect favored DCB. These findings support DCB as a promising endovascular strategy for sICAS and warrant further multicenter randomized evaluation against contemporary medical management.Disclosures W. Luo: None. W. Lee: None. T. QM Tran: None. R. Correia Maciel: None. E. Raz: None. R. Regenhardt: None. A. Dmytriw: None.Abstract P-006 Figure 1