van Elk Theodora, Maes Louise, van der Meij Anne, Lemmens Robin, Uyttenboogaart Maarten, de Borst Gert J, Zeebregts Clark J, Nederkoorn Paul J
Department of Neurology, University Medical Centre Groningen, Groningen, the Netherlands.
Department of Neurology, University Hospital Leuven, Leuven, Belgium.
EJVES Vasc Forum. 2023 Dec 19;61:31-35. doi: 10.1016/j.ejvsvf.2023.12.002. eCollection 2024.
Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions.
15%至20%的急性缺血性卒中患者存在串联病变，其定义为颅内大血管血栓栓塞性闭塞与同侧颈内动脉高度狭窄或闭塞同时存在。与单纯颅内闭塞的患者相比，这些患者的预后往往更差，残疾和死亡率更高。与单纯静脉溶栓治疗相比，采用血管内血栓切除术治疗颅内病变明显改善了预后。然而，对于串联病变患者的颅外颈动脉病变，最佳治疗策略仍不明确。目前的指南建议，对于短暂性脑缺血发作或非致残性卒中且颈内动脉中度或重度狭窄的患者，在首次发病后两周内进行颈动脉内膜切除术，以预防重大卒中复发和死亡。或者，在血管内血栓切除术（EVT）期间，可通过血管内放置支架来治疗有症状的颈动脉。这将无需进行第二次手术，立即降低卒中复发风险，提高患者满意度，并且可能具有成本效益。然而，双联抗血小板治疗可能会增加急性缺血性卒中患者发生有症状颅内出血的风险。目前正在进行随机对照试验，以评估在急性串联病变卒中患者的EVT期间立即进行颈动脉支架置入术的疗效和安全性，这将影响当前关于此类串联病变所致急性缺血性卒中患者治疗的指南。
