Rajamani Kumar, Chaturvedi Seemant
Comprehensive Stroke Program, Department of Neurology, Wayne State University, Detroit, MI 48201, USA.
Curr Drug Targets. 2007 Jul;8(7):860-6. doi: 10.2174/138945007781077391.
The last 15 years have witnessed a resurgence of the role of surgical options for prevention of ischemic stroke. The landmark randomized trials including NASCET and ECST were published and explored the role of carotid endarterectomy in this regard. Patients with high grade stenosis of the internal carotid artery (> or = 70%) with prior TIA or minor non disabling stroke in the same territory were shown to have significant benefit of the procedure compared to best medical treatment. Benefit was comparatively less in patients with moderate grade stenosis of the ICA (50-69%). Surgical treatment of patients with <50% stenosis of the ICA resulted in worse outcomes compared to medical therapy and is consequently not recommended. These studies also standardized the method for measuring the degree of ICA stenosis. The ACAS and ACST studies attempted to resolve the rather vexing issue of surgical treatment of patients with asymptomatic ICA stenosis. The risk benefit ratio in asymptomatic patients is low and depends to a large extent on a low perioperative complication rate. Studies have also attempted to identify the best medical treatment in the perioperative period during CEA. Low dose aspirin has been shown to be beneficial, but the role of statins and betablockers is promising but yet uncertain. Ischemic stroke is a common complication after CABG. In this regard surgeons have differed in their approaches to performing CEA, some preferring to do it during the bypass surgery, while others prefer a two staged procedure. The surgical treatment of complete carotid occlusion by EC-IC bypass surgery has also enjoyed renewed interest and results of the COSS study are awaited keenly. The EC-IC bypass surgical procedure is also beneficial in moya-moya disease.
过去15年见证了手术治疗在预防缺血性卒中方面作用的复兴。包括北美症状性颈动脉内膜切除术试验（NASCET）和欧洲颈动脉外科试验（ECST）在内的具有里程碑意义的随机试验相继发表，探讨了颈动脉内膜切除术在这方面的作用。与最佳药物治疗相比，同侧颈内动脉严重狭窄（≥70%）且既往有短暂性脑缺血发作（TIA）或轻度非致残性卒中的患者接受该手术显示出显著益处。颈内动脉中度狭窄（50%-69%）的患者获益相对较少。颈内动脉狭窄<50%的患者手术治疗与药物治疗相比结果更差，因此不推荐。这些研究还规范了测量颈内动脉狭窄程度的方法。无症状性颈内动脉狭窄患者的手术治疗这一相当棘手的问题在无症状颈动脉粥样硬化研究（ACAS）和无症状颈动脉外科试验（ACST）中得到了探讨。无症状患者的风险效益比很低，且在很大程度上取决于低围手术期并发症发生率。研究还试图确定颈动脉内膜切除术围手术期的最佳药物治疗方法。低剂量阿司匹林已被证明有益，但他汀类药物和β受体阻滞剂的作用虽有前景但仍不确定。缺血性卒中是冠状动脉旁路移植术（CABG）后的常见并发症。在这方面，外科医生在进行颈动脉内膜切除术的方法上存在差异，一些人倾向于在搭桥手术期间进行，而另一些人则倾向于分两阶段进行。通过颅外-颅内（EC-IC）旁路手术治疗完全性颈动脉闭塞也重新受到关注，人们热切期待慢性闭塞性脑血管病研究（COSS）的结果。EC-IC旁路手术在烟雾病中也有益处。
