Department of Neurology, University of Alabama at Birmingham, 1720 7th Ave S-SC 650, Birmingham, AL, 35294, USA.
Department of Neurology, Columbia University Medical Center, New York, NY, USA.
Curr Cardiol Rep. 2019 Jan 19;21(1):4. doi: 10.1007/s11886-019-1089-9.
To review the current literature that supports the notion that cerebral hemodynamic compromise from internal carotid artery stenosis may be a cause of vascular cognitive impairment that is amenable to treatment by revascularization.
Converging evidence suggests that successful carotid endarterectomy and carotid artery stenting are associated with reversal of cognitive decline in many patients with severe but asymptomatic carotid artery stenosis. Most of these findings have been derived from cohort studies and comparisons with either normal or surgical controls. Failure to find treatment benefit in a number of studies appears to have been the result of patient heterogeneity or confounding from concomitant conditions independently associated with cognitive decline, such as heart failure and other cardiovascular risk factors, or failure to establish pre-procedure hemodynamic failure. Patients with severe carotid artery stenosis causing cerebral hemodynamic impairment may have a reversible cause of cognitive decline. None of the prior studies, however, were done in the context of a randomized clinical trial with large numbers of participants. The ongoing CREST-2 trial comparing revascularization with medical therapy versus medical therapy alone, and its associated CREST-H study determining whether cognitive decline is reversible among those with hemodynamic compromise may address this question.
回顾目前支持这样一种观点的文献，即颈动脉狭窄导致的脑血流动力学受损可能是血管性认知障碍的一个原因，这种障碍可以通过血运重建来治疗。
越来越多的证据表明，成功的颈动脉内膜切除术和颈动脉支架置入术与许多严重但无症状的颈动脉狭窄患者认知能力下降的逆转有关。这些发现大多来自队列研究，并与正常人群或手术对照组进行比较。一些研究未能发现治疗益处，似乎是由于患者异质性或同时存在与认知能力下降独立相关的合并症（如心力衰竭和其他心血管危险因素）或未能确定术前血流动力学衰竭所致。严重颈动脉狭窄导致脑血流动力学受损的患者，其认知能力下降可能有一个可逆的原因。然而，之前的研究都没有在随机临床试验的背景下进行，而且参与者人数也不够多。正在进行的 CREST-2 试验比较了血运重建与药物治疗与单纯药物治疗的效果，以及其相关的 CREST-H 研究确定血流动力学受损患者的认知能力下降是否可逆，这可能会回答这个问题。
