Dippel D W, Vermeulen M, Braakman R, Habbema J D
Center for Clinical Decision Sciences, Erasmus University, Rotterdam, The Netherlands.
Neurosurgery. 1994 Mar;34(3):449-57; discussion 457-8. doi: 10.1227/00006123-199403000-00010.
Three patients with transient ischemic attacks (TIAs), a stenotic or ulcerating carotid lesion, and an unruptured aneurysm are discussed. Decision analysis is used in comparing treatment strategies for each patient: clipping of the aneurysm, endarterectomy, or both, with or without platelet aggregation inhibitors. Bayesian sensitivity analysis with Monte Carlo simulation is used to estimate 95% confidence limits for the difference in discounted quality-adjusted life expectancy between the treatment strategies. Platelet-inhibiting therapy is indicated for all three patients, despite the increased risk of complications from subarachnoid hemorrhage. Carotid endarterectomy cannot be recommended for any of the three patients. With regard to aneurysm surgery, a toss-up exists in one patient; in another, the aneurysm should be clipped; and in one, the decision depends on the probability that the TIAs originate from the aneurysm. Guidelines for the management of similar patients are given. For patients with TIAs, a moderate carotid stenosis, and an intracranial aneurysm that does not seem to be related to the symptoms, neither clipping of the aneurysm nor endarterectomy can be recommended with confidence; however, when the intracranial aneurysm is just as likely to be the source of the TIAs as not, clipping is recommended up to the age of 70, when the surgical risks are moderately high.
讨论了3例患有短暂性脑缺血发作（TIA）、颈动脉病变狭窄或溃疡以及未破裂动脉瘤的患者。采用决策分析比较每位患者的治疗策略：动脉瘤夹闭术、动脉内膜切除术或两者同时进行，使用或不使用血小板聚集抑制剂。采用贝叶斯敏感性分析和蒙特卡罗模拟来估计治疗策略之间贴现质量调整预期寿命差异的95%置信区间。尽管蛛网膜下腔出血并发症风险增加，但所有3例患者均需进行血小板抑制治疗。这3例患者均不建议进行颈动脉内膜切除术。关于动脉瘤手术，1例患者情况难定；另1例患者应进行动脉瘤夹闭术；还有1例患者的决策取决于TIA是否起源于动脉瘤的概率。给出了类似患者的管理指南。对于患有TIA、中度颈动脉狭窄且颅内动脉瘤似乎与症状无关的患者，不建议贸然进行动脉瘤夹闭术或动脉内膜切除术；然而，当颅内动脉瘤同样可能是TIA的来源时，对于70岁以下且手术风险适度较高的患者，建议进行动脉瘤夹闭术。
