Trivedi Rikin A, Weerakkody Ruwan A, Turner Carole, Kirkpatrick Peter J
Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
Br J Neurosurg. 2009 Aug;23(4):387-92. doi: 10.1080/02688690902814741.
Carotid artery disease underlies a significant proportion of ischaemic strokes. Whilst secondary prevention by drug treatment is the first step in managing patients with known carotid stenoses, evidence from a number of large randomised controlled trials have clearly demonstrated a benefit for surgical treatment in symptomatic patients with moderate-to-severe stenosis. In asymptomatic patients with severe stenosis a benefit is conferred by surgery in selected patients. Carotid endarterectomy has formed the mainstay of surgical treatment. Endovascular angioplasty (with/without stenting) for carotid stenoses has been proposed as a viable or even superior alternative to carotid endarterectomy. The results from four large randomised controlled trials comparing the two modalities, considered together suggest a marginally better outcome for carotid endarterectomy compared with angioplasty in terms of perioperative mortality and stroke, though the results of further studies are awaited. For carotid surgery, a multi-centre randomised controlled trial evaluating the use of local anaesthesia versus general anaesthesia demonstrated no significant difference in outcome. Refinements in surgical technique such as patch angioplasty and intraluminal shunting provide equivocal benefit, with wide variation in their usage and in the results of studies evaluating them. More robust evidence supporting or refuting a benefit for these techniques is required.
相当一部分缺血性中风的病因是颈动脉疾病。虽然药物治疗二级预防是已知颈动脉狭窄患者管理的第一步，但多项大型随机对照试验的证据清楚地表明，对于有症状的中重度狭窄患者，手术治疗有益。对于无症状的重度狭窄患者，在部分患者中手术治疗也有益处。颈动脉内膜切除术一直是手术治疗的主要方式。对于颈动脉狭窄，血管内血管成形术（带/不带支架）已被提议作为颈动脉内膜切除术的一种可行甚至更优的替代方案。四项比较这两种方式的大型随机对照试验结果综合来看表明，在围手术期死亡率和中风方面，颈动脉内膜切除术的结果略优于血管成形术，不过仍有待进一步研究结果。对于颈动脉手术，一项评估局部麻醉与全身麻醉使用情况的多中心随机对照试验表明，结果无显著差异。诸如补片血管成形术和腔内分流术等手术技术的改进带来的益处并不明确，其使用情况以及评估它们的研究结果差异很大。需要更有力的证据来支持或反驳这些技术的益处。
