Bogiatzi Chrysi, Cocker Myra S, Beanlands Robert, Spence J David
University of Western Ontario, Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute , London , Canada.
Expert Opin Med Diagn. 2012 Mar;6(2):139-51. doi: 10.1517/17530059.2012.662954. Epub 2012 Feb 17.
With more intensive medical therapy, the risk of stroke in patients with asymptomatic carotid stenosis (ACS) is now below the risk of carotid endarterectomy or stenting (intervention); ∼ 90% of patients would be better with only medical therapy. It is important, therefore, to have methods to identify the ∼ 10% of patients who stand to benefit from intervention.
We review the evidence that the risk of asymptomatic stenosis is now below the risk of intervention, and evidence for several approaches to identifying high-risk ACS: transcranial Doppler embolus detection, echolucency and neovascularity on ultrasound, ulceration on three-dimensional ultrasound, plaque composition on magnetic resonance imaging (MRI), plaque inflammation on positron emission tomography and assessment of cerebral blood flow reserve.
Carotid endarterectomy or stenting should be performed only in patients with ACS if they have microemboli on transcranial Doppler, three or more ulcers detected on three-dimensional ultrasound or other features of unstable plaque such as plaque echolucency on ultrasound, intraplaque hemorrhage detected on MRI, inflamed plaques detected on PET/CT or reduced cerebral blood flow reserve. Most patients with ACS (∼ 90%) would be better off with intensive medical therapy than with intervention.
随着医学治疗手段的不断强化，无症状性颈动脉狭窄（ACS）患者发生中风的风险现已低于颈动脉内膜切除术或支架置入术（干预）的风险；约90%的患者仅接受药物治疗效果更佳。因此，拥有识别出约10%能从干预中获益的患者的方法很重要。
我们回顾了无症状性狭窄风险现已低于干预风险的证据，以及几种识别高危ACS的方法的证据：经颅多普勒栓子检测、超声检查中的回声性和新生血管形成、三维超声检查中的溃疡形成、磁共振成像（MRI）上的斑块成分、正电子发射断层扫描中的斑块炎症以及脑血流储备评估。
对于ACS患者，只有在经颅多普勒检测到微栓子、三维超声检测到三个或更多溃疡或存在不稳定斑块的其他特征（如超声检查中的斑块回声性、MRI检测到的斑块内出血、PET/CT检测到的炎症斑块或脑血流储备降低）时，才应进行颈动脉内膜切除术或支架置入术。大多数ACS患者（约90%）接受强化药物治疗比接受干预效果更好。
