Matalanis G, Lusby R J
University of Sydney Department of Surgery, Repatriation General Hospital, Concord, NSW.
Clin Exp Neurol. 1988;25:17-26.
Carotid endarterectomy is a controversial procedure. Despite the increasing incidence of its performance, there have been as yet no prospective randomised trials which have conclusively shown its benefits for patients with carotid artery atherosclerosis. Until the results of such studies become available, a rational approach to the estimation of stroke risk in these patients can be based on an understanding of their carotid plaque morphology. Over the past 4 years we have examined plaque morphology with a B-mode duplex scanner and have been able to categorise the degree of heterogeneity of plaques into 4 types depending on the degree of plaque echolucency. We have shown good correlation between the preoperative plaque type and the operation specimen. Furthermore, we have found that the risk of symptom development correlates with the development of a more echolucent plaque. Finally, while plaque heterogeneity may be a good predictor of the risk of embolism from the plaque, other deleterious factors such as hypertension may determine the severity of the ensuing neurological event. The approach in our unit has been to operate on symptomatic patients with demonstrated high grade or heterogeneous carotid artery atherosclerosis appropriate to the patient's symptoms. We have found that most asymptomatic patients have subcritical stenoses and dense homogeneous plaques, and we treat these conservatively. On the other hand, surgery is recommended for asymptomatic patients with high grade stenoses and heterogeneous plaques. We have been able to follow this policy with a morbidity and mortality of 2.6% and 1.0% respectively.
颈动脉内膜切除术是一种存在争议的手术。尽管其实施率不断上升，但尚无前瞻性随机试验能够确凿地证明其对颈动脉粥样硬化患者的益处。在获得此类研究结果之前，评估这些患者中风风险的合理方法可基于对其颈动脉斑块形态的了解。在过去4年中，我们使用B型双功扫描仪检查了斑块形态，并能够根据斑块回声强度将斑块的异质性程度分为4种类型。我们已经证明术前斑块类型与手术标本之间具有良好的相关性。此外，我们发现症状发展的风险与更具回声性的斑块的形成相关。最后，虽然斑块异质性可能是斑块栓塞风险的良好预测指标，但其他有害因素，如高血压，可能决定随后神经事件的严重程度。我们科室的方法是对有症状且经证实患有与患者症状相符的高度或异质性颈动脉粥样硬化的患者进行手术。我们发现大多数无症状患者有亚临界狭窄和致密均匀的斑块，我们对这些患者进行保守治疗。另一方面，对于有高度狭窄和异质性斑块的无症状患者，建议进行手术。我们能够遵循这一政策，发病率和死亡率分别为2.6%和1.0%。
