Impact of enhanced external counterpulsation treatment on cerebral blood flow and functional outcomes in ischemic stroke patients: a systematic review and meta-analysis

Enhanced external counterpulsation (EECP) is a noninvasive circulatory support device that has been shown to improve perfusion in cardiovascular diseases; however, its effectiveness in ischemic stroke is yet to be explored. This systematic review and meta-analysis were proposed to evaluate the effectiveness of EECP on cerebral blood flow (CBF) and other functional outcomes in ischemic stroke patients. PubMed, CNKI, Web of Science, Embase, CINAHL, Wangfang, Chinese Medicine and Sinomed databases were searched up to June 2025. Studies evaluating the effect of EECP on CBF, daily living activities, disability degree and neurological impairment. Data were pooled using RStudio (version 4.5.1) with both a common-effect model and a Hartung-Knapp (HK) random-effects model, applying the generic inverse variance method. Fifteen studies comprising 506 participants were included. While the common-effect model suggested a statistically significant improvement in CBF, this effect was no longer significant after applying the more conservative HK adjustment (MD = 0.15; 95% CI: -0.13 to 0.44; P = 0.1485). This indicates that current evidence supports a possible, but not definitive, effect of EECP on CBF. EECP showed significant improvement in daily living activities (MD = 23.53; 95% CI: 14.65-32.40; P = 0.0002), disability degree (MD = -1.88; 95% CI: -2.64 to -1.11; P = 0.0009) and neurological function (MD = -5.42; 95% CI: -8.90 to -1.94; P = 0.0060). High heterogeneity was observed across outcomes. Overall, EECP shows promising potential as an adjunct rehabilitation therapy for ischemic stroke, particularly in improving functional outcomes. However, the non-significant CBF findings under the HK model and the substantial heterogeneity highlight the need for rigorously designed, high-quality studies to better define EECP's clinical efficacy and optimal treatment protocols.