Letter by Kvernland et al Regarding Article, "Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Disease: Classification and Clinical Implications".
Letter by Kvernland et al Regarding Article, "Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Disease: Classification and Clinical Implications".
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DOI：
10.1161/strokeaha.119.027673
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发表时间：
2019-11
期刊：
影响因子：
8.3
通讯作者：
Alexandra Kvernland;S. Yaghi;A. D. de Havenon
中科院分区：
文献类型：
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作者：
Alexandra Kvernland;S. Yaghi;A. D. de Havenon
Feng 等人最近发表的文章 1“症状性颅内动脉粥样硬化疾病的卒中机制：分类和临床意义”对症状性颅内动脉粥样硬化 (ICAS) 的卒中机制进行了有趣的分析，这对于确定最有效的二级预防疗法至关重要。作者报告了对索引中风事件的可能机制进行分类的良好到优秀的评估者内和评估者间一致性。对患者进行为期一年的随访，以确定中风母动脉血管分布中复发性中风或短暂性脑缺血发作的发生率。作者发现，同时患有动脉间栓塞和灌注不足的患者复发风险较高。这项研究有几个主要局限性。首先，一年内只有 17 名患者复发中风。由于结果事件数量较少，无法进行多项关键分析，其中最重要的是分析哪种梗塞模式与高复发风险相关。此外，由于结果数量较少，作者无法调整重要的潜在混杂因素，例如合格症状 ICAS 的狭窄严重程度、侧支状况或医疗管理差异。其次，至少 91 名患者存在低灌注（59.4%；46 名患者存在孤立性低灌注，45 名患者存在动脉-动脉栓塞和低灌注）。相反，50%（122 名中的 61 名）患者受影响动脉狭窄< 70%。因此，一些管腔狭窄<70%的患者被编码为边界区梗死，这与先前的研究相矛盾，即当管腔狭窄<75%时脑血流不太可能受损。 2第三，这项研究没有区分皮质和内部边界区梗塞，这可能并不预示着类似的复发风险。 3 事实上，一项研究表明，虽然内部边界区梗塞可能与远端灌注受损有关，但皮质边界区梗塞更有可能与皮质边界区栓塞清除率降低有关，而与严重狭窄、闭塞或远端灌注受损相关的可能性较小。 4
The recent article by Feng et al, 1 “Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Disease: Classification and Clinical Implications,” is an interesting analysis of stroke mechanisms in symptomatic intracranial atherosclerosis (ICAS), which is crucial for identifying the most effective secondary prevention therapies. The authors report good-to-excellent intrarater and interrater agreement classifying the probable mechanism of the index stroke event. Patients were followed for 1 year to determine the rate of recurrent stroke or transient ischemic attack in the index stroke parent artery’s vascular distribution. The authors found a higher risk of recurrence in patients with a mix of arteryto-artery embolism and hypoperfusion. This study has several major limitations. First, only 17 patients had recurrent stroke in 1 year. The low number of outcome events prevented several crucial analyses, the most important of which is analyzing which of the infarct patterns is associated with the high risk of recurrence. In addition, due to the small number of outcomes, the authors could not adjust for important potential confounders, such as stenosis severity of the qualifying symptomatic ICAS, collateral status, or differences in medical management. Second, hypoperfusion was present in at least 91 patients (59.4%; 46 with isolated hypoperfusion and 45 with artery-toartery embolism and hypoperfusion). On the contrary, 50%(61 of 122) of patients had< 70% stenosis of the affected artery. Therefore, some patients with luminal stenosis< 70% were coded as border-zone infarcts, which contradicts prior studies showing that impaired cerebral blood flow is unlikely when the luminal stenosis is< 75%. 2Third, this study does not differentiate between cortical and internal border-zone infarcts, which may not portend a similar risk of recurrence. 3 In fact, one study suggests that while internal border-zone infarcts are likely related to impaired distal perfusion, cortical border-zone infarcts are more likely related to reduced clearance of emboli in the cortical border-zone territory and less likely related to severe stenosis, occlusion, or impaired distal perfusion. 4