Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
Neurology, University of California Irvine, Irvine, California, USA.
J Neurointerv Surg. 2024 Apr 23;16(5):522-528. doi: 10.1136/jnis-2022-019628.
The management of intracranial atherosclerotic disease (ICAD) has been evolving with advanced imaging, refinements of best medical treatment, and the development of endovascular options. There has been a significant increase in the use of endovascular therapy for symptomatic ICAD in the USA over the past 6 years. The rationale for this review is to update neurointerventionalists in these areas so that evidence-based decisions can be considered when counseling potential patients regarding their risks, benefits, and potential complications. The landmark SAMMPRIS trial demonstrated superiority of aggressive medical management (AMM) over intracranial stenting as an initial treatment. However, the risk of disabling or fatal stroke remains high in patients presenting with stroke treated with AMM. Recent studies showed a significantly lower rate of periprocedural complications from intracranial stenting. Patients who have failed medical treatment may therefore benefit from intracranial stenting, particularly in those with hemodynamic compromise and large vessel embolic stroke. Drug coated angioplasty balloons and drug eluting stents may potentially reduce the risk of in-stent re-stenosis. Large vessel occlusion (LVO) due to underlying ICAD is seen in a subset of thrombectomy-eligible patients. The use of stenting as a rescue therapy in LVO thrombectomy has also shown promising early results.
颅内动脉粥样硬化性疾病（ICAD）的管理随着先进的影像学技术、最佳药物治疗的改进以及血管内治疗方法的发展而不断演变。在过去的 6 年中，美国症状性 ICAD 的血管内治疗使用率显著增加。进行本次综述的基本原理是为神经介入医师提供这些领域的最新信息，以便在为可能的患者提供咨询时，能够考虑基于证据的决策，了解其风险、获益和潜在并发症。具有里程碑意义的 SAMMPRIS 试验表明，强化药物治疗（AMM）优于颅内支架置入，作为初始治疗方法。然而，接受 AMM 治疗的卒中患者仍存在较高的致残性或致死性卒中风险。最近的研究显示，颅内支架置入的围手术期并发症发生率显著降低。因此，对于药物治疗失败的患者，颅内支架置入可能会获益，尤其是那些存在血流动力学障碍和大血管栓塞性卒中的患者。药物涂层球囊和药物洗脱支架可能会降低支架内再狭窄的风险。在适合取栓治疗的患者中，会出现因基础 ICAD 导致的大血管闭塞（LVO）。支架取栓术治疗 LVO 中支架作为挽救性治疗的应用也取得了令人鼓舞的早期结果。
