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Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Directions
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摘要: 颅内动脉粥样硬化性狭窄(intracranial atherosclerotic stenosis，ICAS)是导致缺血性卒中最主要的病因之一，在亚洲人群中高发。自2011年美国主导的高质量随机对照研究结果发布以来，ICAS的治疗一直备受关注和争议。近期，首个基于中国人群的ICAS血管内治疗与药物治疗随机对照研究结果正式发布，证实血管内治疗不劣于药物治疗效果，对于药物难治性血流动力学障碍的ICAS患者, 血管内治疗获益可能更大，从而使ICAS的治疗再次引起全球关注。基于此，本文针对ICAS的疾病特点、治疗现状和未来发展进行系统阐述，以期为临床提供借鉴和指导。期待未来通过更严格的管理，提高患者的依从性，进而减少卒中的复发率和死亡率。
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关键词:
- 颅内动脉粥样硬化性狭窄 /
- 药物治疗 /
- 血管内治疗 /
- 卒中
Abstract: Intracranial atherosclerotic stenosis (ICAS) is a leading cause of ischemic stroke, especially in Asia. Since the publication of high-quality randomized controlled trials conducted by the United States in 2011, ICAS has been a subject of controversy and concerns. Recently, the results of a randomized controlled trial published in the leading international medical journal compare the effectiveness of endovascular treatment and medical treatment for ICAS in the Chinese population, which has reattracted public attention to this issue. Endovascular therapy is not inferior to medical treatment, and the benefits of endovascular therapy may be greater in drug-refractory patients with hemodynamic disorders.Therefore, this paper systematically discusses ICAS disease characteristics, treatment status, and future directions, suggesting that endovascular therapy may be of further benefit to drug-refractory patients with hemodynamic disorders, and stricter medical management and improved patient compliance will further reduce stroke recurrences and mortality.作者贡献：罗继昌负责论文初稿撰写; 焦力群、王韬负责论文修订和审校。利益冲突：所有作者均声明不存在利益冲突 -
[1] Weisberg LA. Clinical characteristics of transient ischemic attacks in black patients[J]. Neurology, 1991, 41: 1410-1414. doi: 10.1212/WNL.41.9.1410 [2] Qureshi AI, Safdar K, Patel M, et al. Stroke in young black patients. Risk factors, subtypes, and prognosis[J]. Stroke, 1995, 26: 1995-1998. doi: 10.1161/01.STR.26.11.1995 [3] Sacco RL, Kargman DE, Gu Q, et al. Race-ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study[J]. Stroke, 1995, 26: 14-20. doi: 10.1161/01.STR.26.1.14 [4] Wityk RJ, Lehman D, Klag M, et al. Race and sex differences in the distribution of cerebral atherosclerosis[J]. Stroke, 1996, 27: 1974-1980. doi: 10.1161/01.STR.27.11.1974 [5] Wong LK. Global burden of intracranial atherosclerosis[J]. Int J Stroke, 2006, 1: 158-159. doi: 10.1111/j.1747-4949.2006.00045.x [6] Gorelick PB, Wong KS, Bae HJ, et al. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier[J]. Stroke, 2008, 39: 2396-2399. doi: 10.1161/STROKEAHA.107.505776 [7] Wang Y, Zhao X, Liu L, et al. Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China: the Chinese Intracranial Atherosclerosis (CICAS) Study[J]. Stroke, 2014, 45: 663-669. doi: 10.1161/STROKEAHA.113.003508 [8] Lange MC, Ribas G, Scavasine V, et al. Stroke recurrence in the different subtypes of ischemic stroke. The importance of the intracranial disease[J]. Arq Neuropsiquiatr, 2018, 76: 649-653. doi: 10.1590/0004-282x20180095 [9] Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis[J]. N Engl J Med, 2011, 365: 993-1003. doi: 10.1056/NEJMoa1105335 [10] Zaidat OO, Fitzsimmons BF, Woodward BK, et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial[J]. JAMA, 2015, 313: 1240-1248. doi: 10.1001/jama.2015.1693 [11] Gao P, Wang T, Wang D, et al. Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial[J]. JAMA, 2022, 328: 534-542. doi: 10.1001/jama.2022.12000 [12] Brinjikji W, Huston J, 3rd, Rabinstein AA, et al. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability[J]. J Neurosurg, 2016, 124: 27-42. doi: 10.3171/2015.1.JNS142452 [13] Yang B, Ma Y, Wang T, et al. Carotid Endarterectomy and Stenting in a Chinese Population: Safety Outcome of the Revascularization of Extracranial Carotid Artery Stenosis Trial[J]. Transl Stroke Res, 2021, 12: 239-247. doi: 10.1007/s12975-020-00835-8 [14] Moossy J. Morphology, sites and epidemiology of cerebral atherosclerosis[J]. Res Publ Assoc Res Nerv Ment Dis, 1966, 41: 1-22. [15] Velican C. Studies on the age-related changes occurring in human cerebral arteries[J]. Atherosclerosis, 1970, 11: 509-529. doi: 10.1016/0021-9150(70)90029-8 [16] Masuoka T, Hayashi N, Hori E, et al. Distribution of internal elastic lamina and external elastic lamina in the internal carotid artery: possible relationship with atherosclerosis[J]. Neurol Med Chir (Tokyo), 2010, 50: 179-182. doi: 10.2176/nmc.50.179 [17] Portanova A, Hakakian N, Mikulis DJ, et al. Intracranial vasa vasorum: insights and implications for imaging[J]. Radiology, 2013, 267: 667-679. doi: 10.1148/radiol.13112310 [18] Galili O, Herrmann J, Woodrum J, et al. Adventitial vasa vasorum heterogeneity among different vascular beds[J]. J Vasc Surg, 2004, 40: 529-535. doi: 10.1016/j.jvs.2004.06.032 [19] Kim YD, Choi HY, Cho HJ, et al. Increasing frequency and burden of cerebral artery atherosclerosis in Korean stroke patients[J]. Yonsei Med J, 2010, 51: 318-325. doi: 10.3349/ymj.2010.51.3.318 [20] Sylaja P, Pandian JD, Kaul S, et al. Ischemic stroke profile, risk factors, and outcomes in India: the Indo-US Collaborative Stroke Project[J]. Stroke, 2018, 49: 219-222. doi: 10.1161/STROKEAHA.117.018700 [21] Bang OY, Saver JL, Liebeskind DS, et al. Impact of metabolic syndrome on distribution of cervicocephalic atherosclerosis: data from a diverse race-ethnic group[J]. J Neurol Sci, 2009, 284: 40-45. doi: 10.1016/j.jns.2009.03.033 [22] Dearborn JL, Zhang Y, Qiao Y, et al. Intracranial atherosclerosis and dementia: the Atherosclerosis Risk in Communities (ARIC) study[J]. Neurology, 2017, 88: 1556-1563. doi: 10.1212/WNL.0000000000003837 [23] Hurford R, Wolters FJ, Li L, et al. Prognosis of asymptomatic intracranial stenosis in patients with transient ischemic attack and minor stroke[J]. JAMA neurology, 2020, 77: 947-954. doi: 10.1001/jamaneurol.2020.1326 [24] Leng X, Hurford R, Feng X, et al. Intracranial arterial stenosis in Caucasian versus Chinese patients with TIA and minor stroke: two contemporaneous cohorts and a systematic review[J]. J Neurol Neurosurg Psychiatry, 2021, 92: 590-597. doi: 10.1136/jnnp-2020-325630 [25] Liu M, Sariya S, Khasiyev F, et al. Genetic determinants of intracranial large artery stenosis in the northern Manhattan study[J]. J Neurol Sci, 2022, 436: 120218. doi: 10.1016/j.jns.2022.120218 [26] Wu S, Wu B, Liu M, et al. Stroke in China: advances and challenges in epidemiology, prevention, and manage-ment[J]. Lancet Neurol, 2019, 18: 394-405. doi: 10.1016/S1474-4422(18)30500-3 [27] Gutierrez J, Turan TN, Hoh BL, et al. Intracranial atherosclerotic stenosis: risk factors, diagnosis, and treatment[J]. Lancet Neurol, 2022, 21: 355-368. doi: 10.1016/S1474-4422(21)00376-8 [28] Pasterkamp G, Schoneveld AH, van Wolferen W, et al. The impact of atherosclerotic arterial remodeling on percent-age of luminal stenosis varies widely within the arterial system. a postmortem study[J]. Arterioscler Thromb Vasc Biol, 1997, 17: 3057-3063. doi: 10.1161/01.ATV.17.11.3057 [29] Gutierrez J, Goldman J, Honig LS, et al. Determinants of cerebrovascular remodeling: do large brain arteries accommodate stenosis?[J]. Atherosclerosis, 2014, 235: 371-379. doi: 10.1016/j.atherosclerosis.2014.05.925 [30] Wabnitz AM, Derdeyn CP, Fiorella DJ, et al. Hemody-namic markers in the anterior circulation as predictors of recurrent stroke in patients with intracranial stenosis[J]. Stroke, 2019, 50: 143-147. doi: 10.1161/STROKEAHA.118.020840 [31] Yu W, Jiang WJ. Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke[J]. Stroke Vasc Neurol, 2018, 3: 140-146. doi: 10.1136/svn-2018-000158 [32] Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association[J]. Stroke, 2021, 52: e364-e467. [33] Kern R, Steinke W, Daffertshofer M, et al. Stroke recurrences in patients with symptomatic vs asymptomatic middle cerebral artery disease[J]. Neurology, 2005, 65: 859-864. doi: 10.1212/01.wnl.0000175983.76110.59 [34] Jung JM, Kang DW, Yu KH, et al. Predictors of recurrent stroke in patients with symptomatic intracranial arterial stenosis[J]. Stroke, 2012, 43: 2785-2787. doi: 10.1161/STROKEAHA.112.659185 [35] Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial[J]. Circulation, 2004, 110: 1202-1208. doi: 10.1161/01.CIR.0000140675.85342.1B [36] Steinhubl SR, Berger PB, Mann JT, et al. Early and sustained dual oral antiplatelet therapy following percutane-ous coronary intervention: a randomized controlled trial[J]. JAMA, 2002, 288: 2411-2420. doi: 10.1001/jama.288.19.2411 [37] Markus HS, Droste DW, Kaps M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial[J]. Circulation, 2005, 111: 2233-2240. doi: 10.1161/01.CIR.0000163561.90680.1C [38] Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack[J]. N Engl J Med, 2013, 369: 11-19. doi: 10.1056/NEJMoa1215340 [39] Turan TN, Cotsonis G, Lynn MJ, et al. Relationship between blood pressure and stroke recurrence in patients with intracranial arterial stenosis[J]. Circulation, 2007, 115: 2969-2975. doi: 10.1161/CIRCULATIONAHA.106.622464 [40] Turan TN, Makki AA, Tsappidi S, et al. Risk factors associated with severity and location of intracranial arterial stenosis[J]. Stroke, 2010, 41: 1636-1640. doi: 10.1161/STROKEAHA.110.584672 [41] Bose A, Hartmann M, Henkes H, et al. A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study[J]. Stroke, 2007, 38: 1531-1537. doi: 10.1161/STROKEAHA.106.477711 [42] Fiorella D, Levy EI, Turk AS, et al. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results[J]. Stroke, 2007, 38: 881-887. doi: 10.1161/01.STR.0000257963.65728.e8 [43] Miao Z, Jiang L, Wu H, et al. Randomized controlled trial of symptomatic middle cerebral artery stenosis: endovascular versus medical therapy in a Chinese population[J]. Stroke, 2012, 43: 3284-3290. doi: 10.1161/STROKEAHA.112.662270 [44] Gao P, Zhao Z, Wang D, et al. China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS): A new, prospective, multicenter, randomized controlled trial in China[J]. Interv Neuroradiol, 2015, 21: 196-204. doi: 10.1177/1591019915581778 [45] Miao Z, Zhang Y, Shuai J, et al. Thirty-Day Outcome of a Multicenter Registry Study of Stenting for Symptomatic Intracranial Artery Stenosis in China[J]. Stroke, 2015, 46: 2822-2829. doi: 10.1161/STROKEAHA.115.010549 [46] Miao Z, Song L, Liebeskind DS, et al. Outcomes of tailored angioplasty and/or stenting for symptomatic intracranial atherosclerosis: a prospective cohort study after SAMMPRIS[J]. J Neurointerv Surg, 2015, 7: 331-335. doi: 10.1136/neurintsurg-2014-011109 [47] Zhang L, Huang Q, Zhang Y, et al. Wingspan stents for the treatment of symptomatic atherosclerotic stenosis in small intracranial vessels: safety and efficacy evaluation[J]. AJNR Am J Neuroradiol, 2012, 33: 343-347. doi: 10.3174/ajnr.A2772 [48] Li J, Zhao ZW, Gao GD, et al. Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis[J]. Cardiovasc Intervent Radiol, 2012, 35: 268-278. doi: 10.1007/s00270-011-0163-5 [49] Yu J, Wang L, Deng J, et al. Treatment of symptomatic intracranial atherosclerotic stenosis with a normal-sized Gateway balloon and Wingspan stent[J]. J Int Med Res, 2010, 38: 1968-1974. doi: 10.1177/147323001003800610 [50] Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis[J]. N Engl J Med, 2011, 365: 993-1003. doi: 10.1056/NEJMoa1105335 [51] Derdeyn CP, Chimowitz MI, Lynn MJ, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial[J]. Lancet, 2014, 383: 333-341. doi: 10.1016/S0140-6736(13)62038-3 [52] Luo J, Wang T, Gao P, et al. Endovascular treatment of intracranial atherosclerotic stenosis: current debates and future prospects[J]. Front Neurol, 2018, 9: 666. doi: 10.3389/fneur.2018.00666 [53] Wang Y, Wang T, Dmytriw AA, et al. Safety of endovascular therapy for symptomatic intracranial artery stenosis: a national prospective registry[J]. Stroke Vasc Neurol, 2022, 7: 166-171. doi: 10.1136/svn-2021-000979 [54] Gao P, Wang D, Zhao Z, et al. Multicenter Prospective Trial of Stent Placement in Patients with Symptomatic High-Grade Intracranial Stenosis[J]. AJNR Am J Neuroradiol, 2016, 37: 1275-1280. doi: 10.3174/ajnr.A4698 [55] Qureshi AI, Caplan LR. Intracranial atherosclerosis[J]. Lancet, 2014, 383: 984-998. doi: 10.1016/S0140-6736(13)61088-0 [56] Romano JG, Prabhakaran S, Nizam A, et al. Infarct Recurrence in Intracranial Atherosclerosis: Results from the MyRIAD Study[J]. J Stroke Cerebrovasc Dis, 2021, 30: 105504. doi: 10.1016/j.jstrokecerebrovasdis.2020.105504 [57] Del Brutto VJ, Liebeskind DS, Romano JG, et al. Risk Factors Control and Early Recurrent Cerebral Infarction in Patients with Symptomatic Intracranial Atherosclerotic Disease[J]. J Stroke Cerebrovasc Dis, 2021, 30: 105914. doi: 10.1016/j.jstrokecerebrovasdis.2021.105914 [58] März W, Dippel FW, Theobald K, et al. Utilization of lipid-modifying therapy and low-density lipoprotein cholesterol goal attainment in patients at high and very-high cardiovascular risk: Real-world evidence from Germany[J]. Atherosclerosis, 2018, 268: 99-107. doi: 10.1016/j.atherosclerosis.2017.11.020 [59] Assmann G, Benecke H, Neiss A, et al. Gap between guidelines and practice: attainment of treatment targets in patients with primary hypercholesterolemia starting statin therapy. Results of the 4E-Registry (Efficacy Calculation and Measurement of Cardiovascular and Cerebrovascular Events including Physicians' Experience and Evaluation)[J]. Eur J Cardiovasc Prev Rehabil, 2006, 13: 776-783. doi: 10.1097/01.hjr.0000189805.76482.6e [60] Wang AY, Chang CH, Chen CC, et al. Leave Nothing Behind: Treatment of Intracranial Atherosclerotic Disease with Drug-Coated Balloon Angioplasty[J]. Clin Neuroradiol, 2021, 31: 35-44. doi: 10.1007/s00062-020-00935-w [61] Jiang WJ, Cheng-Ching E, Abou-Chebl A, et al. Multicenter analysis of stenting in symptomatic intracranial atherosclerosis[J]. Neurosurgery, 2012, 70: 25-30; discussion 31. doi: 10.1227/NEU.0b013e31822d274d [62] Wang ZL, Gao BL, Li TX, et al. Severe symptomatic intracranial internal carotid artery stenosis treated with intracranial stenting: a single center study with 58 patients[J]. Diagn Interv Radiol, 2016, 22: 178-183. doi: 10.5152/dir.2015.15191 [63] SSYLVIA Study Investigators. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results[J]. Stroke, 2004, 35: 1388-1392. doi: 10.1161/01.STR.0000128708.86762.d6 [64] Inoue T, Node K. Molecular basis of restenosis and novel issues of drug-eluting stents[J]. Circ J, 2009, 73: 615-621. doi: 10.1253/circj.CJ-09-0059 [65] Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization[J]. Eur Heart J, 2019, 40: 87-165. doi: 10.1093/eurheartj/ehy394 [66] Jia B, Zhang X, Ma N, et al. Comparison of Drug-Eluting Stent With Bare-Metal Stent in Patients With Symptomatic High-grade Intracranial Atherosclerotic Stenosis: A Randomized Clinical Trial[J]. JAMA Neurol, 2022, 79: 176-184. doi: 10.1001/jamaneurol.2021.4804 [67] Pfisterer M, Brunner-La Rocca HP, Buser PT, et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents[J]. J Am Coll Cardiol, 2006, 48: 2584-2591. doi: 10.1016/j.jacc.2006.10.026 [68] Wang Y, Ma Y, Gao P, et al. First Report of Drug-Coated Balloon Angioplasty for Vertebral Artery Origin Stenosis[J]. JACC Cardiovasc Interv, 2018, 11: 500-502. doi: 10.1016/j.jcin.2017.09.040 [69] Wang Y, Feng Y, Wang T, et al. Drug-coated balloon for vertebral artery origin stenosis: a pilot study[J]. J Neurointerv Surg, 2021, 13: 827-830. doi: 10.1136/neurintsurg-2020-016723 -
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