Jeffrey A. Switzer, DO Medical College of Georgia, 1122 15th Street, Augusta, GA 30912, USA.
Curr Treat Options Neurol. 2007 Nov;9(6):451-62. doi: 10.1007/s11940-007-0046-x.
Atherosclerotic narrowing of the proximal internal carotid artery is an important mechanism in ischemic stroke. Optimal medical management of internal carotid stenosis includes antiplatelet agent and statin administration, blood pressure reduction, weight control, and smoking cessation. Decisions regarding the use of invasive procedures to treat carotid disease--specifically carotid endarterectomy and carotid angioplasty and stenting--must weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks. Clinical trials evaluating the benefits of carotid endarterectomy were conducted before widespread use of statins and newer blood pressure-lowering agents such as angiotensin-receptor blockers; it is unclear what impact this may have had on trial results. Regardless, carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis. Conversely, the benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity. Currently, there is a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease. Selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed may still benefit from endovascular management. However, it is unlikely that asymptomatic patients or symptomatic patients with moderate stenosis considered at high risk for endarterectomy would benefit from any intervention.
颈内动脉起始部粥样硬化性狭窄是缺血性脑卒中的重要发病机制。颈内动脉狭窄的最佳药物治疗包括抗血小板药物和他汀类药物的应用、降压、控制体重和戒烟。决定是否采用有创手段治疗颈动脉疾病（具体包括颈动脉内膜切除术和颈动脉血管成形术及支架置入术），必须权衡同侧缺血性脑卒中的长期风险降低与即刻干预风险。评估颈动脉内膜切除术获益的临床试验在他汀类药物和新型降压药物（如血管紧张素受体阻滞剂）广泛应用之前开展；目前尚不清楚这对试验结果可能产生的影响。无论如何，对于有症状的重度狭窄患者，颈动脉内膜切除术明显优于药物治疗。相反，对于有症状的中度狭窄或无症状狭窄患者，内膜切除术的获益较小，手术干预的决策必须综合考虑外科医生的熟练程度和患者的合并症情况。目前，缺乏证据支持在常规颈动脉疾病管理中应用颈动脉血管成形术及支架置入术。对于不能安全进行内膜切除术的重度有症状狭窄的某些患者，血管内治疗仍可能获益。然而，对于无症状患者或有症状但内膜切除术风险较高的中度狭窄患者，任何干预可能都无益。
