Past, Present, and Future of Intracranial Atherosclerosis Treatment.
Past, Present, and Future of Intracranial Atherosclerosis Treatment.
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颅内动脉粥样硬化治疗的过去、现在和未来。
DOI：
10.1161/strokeaha.123.044270
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发表时间：
2024
期刊：
影响因子：
8.3
通讯作者：
Turan,TanyaN
中科院分区：
文献类型：
--
作者：
deHavenon,Adam;Turan,TanyaN
症状性颅内动脉粥样硬化性狭窄(SICAS)是一种典型的缺血性卒中或短暂性脑缺血发作，与相关的颅内动脉近端50%至99%的狭窄相关，是世界上最常见的缺血性卒中原因之一。1非ICAS卒中患者1年复发率为5%，2与无症状重症ICAS患者1年复发率相近。3在SICAS的临床试验中，1年复发率为≈15%4，5，并根据患者的特征，如狭窄程度或既往中风病史而有所不同。6、7在现实世界或富裕的队列中，第一年的比例甚至更高，达到20%至30%。8由于复发风险很高，ICAS人群中的随机临床试验(RCT)侧重于二级预防。在本文中，我们将回顾SICAS患者的主要RCT(图)。第一个纳入SICAS患者的随机对照试验是EC/IC Bypass研究([颅外/颅内吻合术国际合作研究]；n=1377)，该研究测试了因颅外颈动脉闭塞或ICAS导致的中风患者从颞浅动脉到大脑中动脉的外科吻合。9有四分之一的队列有资格登记患有大脑中动脉近端狭窄或闭塞，在患有ICAS的患者中，特殊分析显示，与整体试验类似，搭桥组的围术期中风和死亡风险高于内科组。十多年后，WASID(华法林阿司匹林症状性颅内疾病；n=569)和随后的SAMMPRIS(支架和积极医疗管理预防颅内狭窄复发中风；n=451)RCT研究了实践中使用的治疗方法(WASID的华法林抗凝和SAMMPRIS的血管成形术和支架)。这两项研究都改变了这一做法，确定了这些治疗方法导致的过度不良事件-WASID的出血事件和SAMMPRIS的围术期中风。此外，在SAMMPRIS中，即使超过了围手术期，在平均随访近3年后，支架植入术也没有比药物治疗更好的效果。10例SAMMPRIS后，又进行了2次血管成形术和支架置入术，Vavast(椎动脉支架试验；n=115)11和VISSIT([Vitesse Intra Stent Study for缺血性卒中治疗]；n=112)。12尽管支架技术不同，但它们也没有显示出任何益处，而且围手术期的风险是相同的。近十年后，另一项随机对照试验CASSIS([中国血管成形术和支架植入治疗症状性颅内严重狭窄]；n=358)的结果再次显示，在被选为手术风险较低的SICA人群中，支架植入没有任何好处。13这些随机对照试验的结果是，仅推荐将颅内支架置入术用于预防SICA卒中，作为治疗难治性患者的最后选择。14-16单纯血管成形术治疗SICA仍是一个活跃的研究领域。然而，SAMMPRIS确实为SICAS医疗管理建立了一个新的范式。SAMMPRIS的前90天需要阿司匹林和氯吡格雷的双重抗血小板治疗(DAPT)。虽然这种DAPT组合在SPS3(皮质下小卒中的二级预防)和Match(管理)中显示了出血并发症，但没有明显的益处
Symptomatic intracranial atherosclerotic stenosis (sICAS), typically defined as an ischemic stroke or transient ischemic attack associated with a proximal 50% to 99% stenosis of a relevant intracranial artery, is one of the most common causes of ischemic stroke in the world. 1 Non-ICAS strokes have a first-year recurrence rate of 5%, 2 which is similar to the 1-year stroke rate in patients with asymptomatic severe ICAS. 3 In clinical trials of sICAS, the 1-year recurrence rate has been≈ 15% 4, 5 and varies based on patient features such as degree of stenosis or history of prior stroke. 6, 7 In realworld or enriched cohorts, it is even higher at 20% to 30% in the first year. 8 Due to the high risk of recurrence, the randomized clinical trials (RCTs) in ICAS populations have focused on secondary prevention. In this article, we will review major RCTs in sICAS patients (Figure). The first RCT to include sICAS patients was the EC/IC Bypass Study ([International Cooperative Study of Extracranial/Intracranial Anastomosis]; n= 1377), which tested surgical anastomosis from the superficial temporal artery to the middle cerebral artery among patients with stroke due to extracranial carotid occlusion or ICAS. 9 One-quarter of the cohort qualified for enrollment with proximal middle cerebral artery stenosis or occlusion and, among those with ICAS, post hoc analyses showed an excessive periprocedural risk of stroke and death in the bypass group compared with the medical group, similar to the trial as a whole. Over a decade later, the WASID (Warfarin Aspirin Symptomatic Intracranial Disease; n= 569) and subsequent SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; n= 451)RCTs studied therapeutic approaches used in practice (warfarin anticoagulation in WASID and angioplasty plus stenting in SAMMPRIS). Both studies changed the practice by identifying excessive adverse events due to these therapeutic approaches—hemorrhagic events in WASID and periprocedural stroke in SAMMPRIS. 4, 5 Furthermore, in SAMMPRIS, even beyond the periprocedural period, there was no benefit of stenting over medical therapy after a mean follow-up of almost 3 years. 10 SAMMPRIS was followed by 2 more angioplasty and stenting RCTs, VAST (Vertebral Artery Stenting Trial; n= 115) 11 and VISSIT ([Vitesse Intracranial Stent Study for Ischemic Stroke Therapy]; n= 112). 12 They also showed no benefit and, despite different stenting technology, the same harmful periprocedural risk. Almost a decade later, the results of another RCT, CASSIS ([China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis]; n= 358), again showed no benefit from stenting in a sICAS population selected to be at lower procedural risk. 13 The result of these RCTs is that intracranial stenting for stroke prevention in sICAS is recommended only as an option of last resort in treatment-refractory patients. 14–16 The treatment of sICAS with angioplasty alone is still an active area of investigation. Yet, SAMMPRIS did establish a new paradigm for sICAS medical management. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was required for the first 90 days in SAMMPRIS. While this DAPT combination had demonstrated bleeding complications without clear benefit in the SPS3 (Secondary Prevention of Small Subcortical Strokes) and MATCH (Management