Klarin Derek, Cambria Richard P, Ergul Emel A, Silverman Scott B, Patel Virendra I, LaMuraglia Glenn M, Conrad Mark F, Clouse W Darrin
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, Mass.
J Vasc Surg. 2018 Nov;68(5):1390-1395. doi: 10.1016/j.jvs.2018.01.064. Epub 2018 May 24.
Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology.
We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed.
A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006).
Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.
尽管颈动脉粥样硬化介导的中风仍然是发病和死亡的主要原因，但鉴于医学治疗的进展，一些人认为对颈动脉狭窄的干预应仅限于有症状的患者。本研究旨在评估因颈动脉病因导致中风而入院的既往无症状患者的动脉粥样硬化危险因素概况、解剖特征和临床结局。
我们回顾了2005年至2015年期间入住三级转诊中心的3382例缺血性中风患者的数据。我们重点关注那些经影像学证实梗死灶位于同侧且记录有颈动脉狭窄≥50%的患者，由入院神经科团队判定中风病因与颈动脉相关。如果患者既往有短暂性脑缺血发作、同侧任何颈动脉病变相关的既往梗死、既往颈动脉血运重建、颅内出血或恶性肿瘤，则将其排除。评估患者的人口统计学数据、中风前的医学治疗、中风入院时的颈动脉影像学检查以及中风治疗和结局。
共识别出219例颈动脉中风患者（占所有中风患者的7%），其中61%为白人，66%为男性，平均年龄为68±12岁。高血压（79%）和吸烟（目前吸烟者占33%；既往吸烟者占29%）是主要危险因素。入院时，50%的患者正在接受抗血小板治疗（阿司匹林，n = 92 [41%]；氯吡格雷，n = 9 [4%]；双联治疗，n = 11 [5%]），55%的患者正在接受降脂药物治疗（他汀类药物，n = 115 [53%]；其他，n = 6 [2%]）；77例患者（35%）同时接受抗血小板和降脂治疗。在这219例患者中，156例（71%）表现为中度或重度中风（入院时美国国立卫生研究院中风量表≥5分），54例（25%）接受了溶栓治疗，96例（43%）表现为同侧颈内动脉闭塞，117例（53%）最终在中位时间4天接受了颈动脉血运重建。同时接受抗血小板和降脂治疗的患者发生中度或重度中风的可能性显著降低（44%对78%；P = 0.006）。
在既往无症状的患者中，43%的颈动脉相关中风的罪魁祸首病变是颈内动脉闭塞。既往无症状且未接受抗血小板和降脂联合药物治疗而发生颈动脉相关中风的患者，发生严重、致残性中风的可能性显著更高。然而，那些接受适当风险降低医学治疗的患者仍有发生颈动脉介导中风的风险。这些结果表明，对于有显著颈动脉狭窄的患者，仅靠药物治疗不太可能充分预防中风。
