Serkin Zakhar, Le Scott, Sila Cathy
Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue/HAN 5040, Cleveland, OH, 44106, USA.
Curr Treat Options Neurol. 2019 Sep 26;21(10):48. doi: 10.1007/s11940-019-0589-7.
Cervicocephalic arterial dissection (CeAD) is the most commonly identified cause of stroke in young healthy individuals. The management of acute ischemic stroke due to the diagnosed or suspected CeAD is well established and is appropriate for thrombolysis. There is a substantial risk of stroke recurrence in the early post-stroke period. The optimum method of stroke prevention in the subacute period remains debatable. In our review, we focused on the management of recurrent stroke in CeAD, the choice of various antithrombotic agents for stroke risk reduction with regard to specific pathogenetic mechanisms of dissections, and the utility of endovascular therapy.
Recent studies suggest that various pathogenetic types of CeAD based on radiologic characteristics may be associated with greater risk of thrombogenicity, especially in the early post-stroke period. The use of anticoagulants has been shown to be effective in the eliminating microembolic signals (MES) detected by transcranial Doppler (TCD). The only randomized trial that compared combinations of antiplatelet agents and vitamin K-agonist anticoagulation did not find significant difference in risk of stroke, major bleeding, or mortality. The benefit of dual antiplatelet therapy cannot be excluded. Limited data on the use of direct oral anticoagulant agents (DOAC) is currently available. Endovascular therapy with stenting, while potentially effective, may pose significant risk of complications. Therefore, it needs to be carefully considered on a case-to-case basis. The recurrence of ischemic stroke in patients with CeAD is overall rare. No significant difference in treatment with various antiplatelet and anticoagulant agents has been shown in randomized trials. Only a few studies were based on radiological characteristics of dissections. An ongoing randomized trial is investigating the role of MES and the efficacy of antiplatelet versus anticoagulation agents. The role of DOAC agents has yet to be determined in clinical trials. Stenting in CeAD is an effective revascularization technique and may be considered in selected patients. However, current data is only based on low evidence level findings from small studies, lacking longitudinal outcomes and prognosis.
颈脑动脉夹层（CeAD）是年轻健康个体中最常见的卒中病因。已确诊或疑似CeAD所致急性缺血性卒中的管理方法已确立，且适合溶栓治疗。卒中后早期存在卒中复发的重大风险。亚急性期预防卒中的最佳方法仍存在争议。在我们的综述中，我们重点关注CeAD复发性卒中的管理、针对夹层特定发病机制选择各种抗血栓药物以降低卒中风险，以及血管内治疗的效用。
近期研究表明，基于放射学特征的各种发病类型的CeAD可能与更高的血栓形成风险相关，尤其是在卒中后早期。已证明使用抗凝剂可有效消除经颅多普勒（TCD）检测到的微栓子信号（MES）。唯一一项比较抗血小板药物与维生素K拮抗剂抗凝联合使用的随机试验未发现卒中风险、大出血或死亡率有显著差异。不能排除双重抗血小板治疗的益处。目前关于直接口服抗凝剂（DOAC）使用的数据有限。支架置入的血管内治疗虽然可能有效，但可能带来重大并发症风险。因此，需要根据具体情况仔细考虑。CeAD患者缺血性卒中的复发总体罕见。随机试验未显示各种抗血小板和抗凝药物治疗有显著差异。仅有少数研究基于夹层的放射学特征。一项正在进行的随机试验正在研究MES的作用以及抗血小板药物与抗凝药物的疗效。DOAC药物在临床试验中的作用尚未确定。CeAD中的支架置入是一种有效的血管重建技术，可在选定患者中考虑。然而，目前的数据仅基于小型研究的低证据水平结果，缺乏纵向结局和预后。
