Nordmeyer Hannes, Chapot René, Haage Patrick
Department of Interventional Radiology and Neuroradiology, Neurocenter Solingen, radprax St. Lukas Hospital, Solingen, Germany.
School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany.
Rofo. 2019 Jul;191(7):643-652. doi: 10.1055/a-0855-4298. Epub 2019 Apr 4.
Intracranial atherosclerotic stenosis (ICAS) causes 5 - 10 % of all ischemic strokes in the European population. Indication for endovascular treatment is a special challenge and the selection of material as well as interventional techniques essentially differs from the treatment of extracranial stenoses. According to recent studies patient selection became evidence based; however the method should not be abandoned. New technical approaches can contribute to avoid complications.
We performed a review of the literature with regard to conservative as well as endovascular treatment of ICAS. Different technical approaches are discussed and strategies to avoid complications are stressed. Based on the treatment indication, the positions of the authorities and the professional societies are taken into account.
A single self-expanding stent is approved for the treatment of ICAS. Balloon mounted and other self-expanding Stents are available for off-label use. Anatomical conditions and features of the stenosis determine the choice of material. Distal wire perforations causing intracranial bleedings may occur during exchange manoeuvres and constitute one of the technical complications in the treatment of ICAS. In contrast, there is hardly any efficient way to eliminate the risk of ischemia in the territory of perforating arteries arising from the intracranial posterior circulation and the middle cerebral artery. The results of the randomized prospective trials strengthen the conservative treatment of ICAS. Endovascular treatment should not be withheld from patients with either hemodynamic stenosis, recurrent ischemic events under best medical treatment in the territory of the stenosed vessel or acute occlusions of a stenosis.
· Medical therapy and risk reduction constitute the primary treatment of intracranial stenosis.. · Recurrence under best medical treatment and acute occlusions of intracranial stenosis are indications for endovascular treatment.. · Acute occlusions due to intracranial stenosis often are treated by stenting and angioplasty after mechanical thrombectomy.. · Exchange manoeuvres with distal wire perforation can cause intracranial hemorrhage.. · Basal ganglia and brain stem ischemia constitute a specific risk in treatment of vessel segments bearing perforators..
· Nordmeyer H, Chapot R, Haage P. Endovascular Treatment of Intracranial Atherosclerotic Stenosis. Fortschr Röntgenstr 2019; 191: 643 - 652.
在欧洲人群中，颅内动脉粥样硬化性狭窄（ICAS）导致的缺血性卒中占所有缺血性卒中的5%-10%。血管内治疗的适应证是一项特殊挑战，材料的选择以及介入技术与颅外狭窄的治疗有本质区别。根据最近的研究，患者选择已基于证据；然而，该方法不应被摒弃。新的技术方法有助于避免并发症。
我们对有关ICAS保守治疗和血管内治疗的文献进行了综述。讨论了不同的技术方法，并强调了避免并发症的策略。基于治疗适应证，考虑了权威机构和专业学会的立场。
一种单一的自膨式支架被批准用于治疗ICAS。球囊扩张式和其他自膨式支架可用于非适应证使用。狭窄的解剖条件和特征决定了材料的选择。在交换操作过程中可能会发生导致颅内出血的远端导丝穿孔，这是ICAS治疗中的技术并发症之一。相比之下，几乎没有任何有效方法可以消除颅内后循环和大脑中动脉穿支动脉区域缺血的风险。随机前瞻性试验的结果强化了ICAS的保守治疗。对于有血流动力学狭窄、在狭窄血管区域接受最佳药物治疗时仍有复发性缺血事件或狭窄急性闭塞的患者，不应拒绝血管内治疗。
·药物治疗和风险降低是颅内狭窄的主要治疗方法。·在最佳药物治疗下复发以及颅内狭窄急性闭塞是血管内治疗的适应证。·颅内狭窄导致的急性闭塞通常在机械取栓后通过支架置入和血管成形术进行治疗。·带有远端导丝穿孔的交换操作可导致颅内出血。·基底节和脑干缺血是治疗有穿支的血管节段时的特定风险。
·诺德迈尔H，沙波特R，哈格P。颅内动脉粥样硬化性狭窄的血管内治疗。《Fortschr Röntgenstr》2019年；191:643-652。
