症状性大动脉颅内动脉粥样硬化卒中预防实践指南：美国神经病学学会指南小组委员会的报告。
Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory: Report of the AAN Guideline Subcommittee.
机构信息
From the Department of Neurology (T.N.T., M.I.C.), Medical University of South Carolina, Charleston; Department of Neurology (O.O.Z.), Mercy Health, Toledo, OH; Department of Neurology (G.S.G.), University of Kansas, Kansas City, MO; Department of Neurology (A.C., J.G.L.), SUNY Upstate Medical University, Syracuse, NY; Department of Neurology (A.J.F.), Cleveland Medical Center, OH; Department of Neurology (L.B.G.), University of Kentucky, Lexington; Department of Neurosurgery (N.R.G.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Neurology (S.R.M., L.R.W.), University of Pennsylvania, Philadelphia; Departments of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (R.S.S.), University of Alabama, Birmingham; Department of Neurosurgery (M.J.S.), Loyola University Chicago, Maywood, IL; Department of Neurology (A.B.S.), Massachusetts General Hospital, Boston; Department of Neurology (A.A.R.), Mayo Clinic, Rochester; American Academy of Neurology (M.D.O., H.S.), Minneapolis, MN; and Department of Neurosurgery (J.J.F.), University of Michigan Health-West, Grand Rapids.
出版信息
Neurology. 2022 Mar 22;98(12):486-498. doi: 10.1212/WNL.0000000000200030.
BACKGROUND AND OBJECTIVES
To review treatments for reducing the risk of recurrent stroke or death in patients with symptomatic intracranial atherosclerotic arterial stenosis (sICAS).
METHODS
The development of this practice advisory followed the process outlined in the American Academy of Neurology as amended. The systematic review included studies through November 2020. Recommendations were based on evidence, related evidence, principles of care, and inferences.
MAJOR RECOMMENDATIONS
Clinicians should recommend aspirin 325 mg/d for long-term prevention of stroke and death and should recommend adding clopidogrel 75 mg/d to aspirin for up to 90 days to further reduce stroke risk in patients with severe (70%-99%) sICAS who have low risk of hemorrhagic transformation. Clinicians should recommend high-intensity statin therapy to achieve a goal low-density lipoprotein cholesterol level <70 mg/dL, a long-term blood pressure target of <140/90 mm Hg, at least moderate physical activity, and treatment of other modifiable vascular risk factors for patients with sICAS. Clinicians should not recommend percutaneous transluminal angioplasty and stenting for stroke prevention in patients with moderate (50%-69%) sICAS or as the initial treatment for stroke prevention in patients with severe sICAS. Clinicians should not routinely recommend angioplasty alone or indirect bypass for stroke prevention in patients with sICAS outside clinical trials. Clinicians should not recommend direct bypass for stroke prevention in patients with sICAS. Clinicians should counsel patients about the risks of percutaneous transluminal angioplasty and stenting and alternative treatments if one of these procedures is being contemplated.
背景与目的
回顾治疗方案，以降低症状性颅内动脉粥样硬化性狭窄（sICAS）患者再次发生卒中或死亡的风险。
方法
本实践指南的制定遵循美国神经病学学会（American Academy of Neurology）概述的流程，并进行了修订。系统评价纳入截至 2020 年 11 月的研究。推荐建议基于证据、相关证据、护理原则和推论。
主要推荐意见
临床医生应建议患者每天服用 325mg 阿司匹林以长期预防卒中及死亡，且应建议对严重（70%-99%）sICAS 患者（出血转化风险低）加用氯吡格雷 75mg/d 与阿司匹林联用，以进一步降低卒中风险，持续时间不超过 90 天。临床医生应建议高强度他汀类药物治疗，以实现低密度脂蛋白胆固醇水平<70mg/dL、长期血压目标<140/90mmHg、至少适度体力活动和治疗 sICAS 患者其他可改变的血管危险因素。对于中度（50%-69%）sICAS 患者，或对于严重 sICAS 患者，不推荐经皮腔内血管成形术和支架置入术用于预防卒中。在临床试验之外，不推荐对 sICAS 患者常规采用血管成形术单独或间接旁路治疗预防卒中。不推荐对 sICAS 患者采用直接旁路治疗预防卒中。如果考虑进行其中一种操作，临床医生应向患者说明经皮腔内血管成形术和支架置入术的风险以及替代治疗方案。
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