Hoak David A, Lutsep Helmi L
OHSU Stroke Center and Department of Neurology, Oregon Health & Science University, Portland, OR, USA.
OHSU Stroke Center and Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, CR 131, Portland, OR, 97239, USA.
Curr Cardiol Rep. 2016 Sep;18(9):83. doi: 10.1007/s11886-016-0762-5.
Intracranial atherosclerotic disease is a common cause of stroke worldwide, causing approximately 10 % of strokes in the USA and up to 50 % in Asian populations. Recurrent stroke risks are particularly high in those with a stenosis of 70 % or more and a recent transient ischemic attack or stroke. Warfarin has been associated with higher major hemorrhage rates and no reduction of recurrent stroke compared to aspirin in patients with symptomatic intracranial stenosis. After early trials showed the feasibility of stenting, two randomized trials compared stenting plus medical management to medical management alone in symptomatic intracranial stenosis. Stenting was linked with increased risk and showed no benefit in any subpopulation of patients. Aggressive medical management in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial was associated with half the risk of stroke compared to that in similar patients in a previous symptomatic intracranial stenosis trial after adjustment of confounding characteristics. Aggressive medical management comprises risk factor control, including a target systolic blood pressure <140 mmHg, a low density lipoprotein <70 mg/dL, hemoglobin A1C <7.0 %, and lifestyle management that incorporates exercise, smoking cessation and weight management, and the use of antithrombotics.
颅内动脉粥样硬化疾病是全球范围内中风的常见病因，在美国约占中风病例的10%，在亚洲人群中占比高达50%。对于颅内血管狭窄达70%及以上且近期有短暂性脑缺血发作或中风的患者，复发性中风风险尤其高。在有症状性颅内狭窄的患者中，与阿司匹林相比，华法林与更高的严重出血率相关，且不能降低复发性中风的风险。早期试验证明了支架置入术的可行性后，两项随机试验将支架置入术联合药物治疗与单纯药物治疗用于有症状性颅内狭窄的患者进行了比较。支架置入术与风险增加相关，且在任何亚组患者中均未显示出益处。在颅内狭窄支架置入与积极药物治疗预防复发性中风（SAMMPRIS）试验中，与之前有症状性颅内狭窄试验中类似患者相比，经过混杂因素调整后，积极药物治疗使中风风险降低了一半。积极药物治疗包括危险因素控制（目标收缩压<140 mmHg、低密度脂蛋白<70 mg/dL、糖化血红蛋白<7.0%）、包括运动、戒烟和体重管理的生活方式管理以及使用抗栓药物。
