无症状性颈内动脉狭窄和颅内动脉狭窄诊治进展

doi:10.3969/j.issn.1673-5765.2023.10.003

摘要/Abstract

摘要： 本文探讨无症状性颈内动脉狭窄（asymptomatic carotid artery stenosis，aCAS）或无症状性颅内动脉狭窄（asymptomatic intracranial artery stenosis，aICAS）的优化筛查策略，以及基于分子标志物和影像学的精准预防策略。aCAS的患病率为1.5%，其风险评分有助于aCAS的筛查。aICAS患病率为6.9%～12.8%，与研究人群和筛查方法的不同有关。对于aCAS或aICAS患者，动脉管腔的狭窄程度和管壁的稳定性与卒中风险相关。新近的研究显示，动脉粥样硬化斑块内出血可增加卒中和冠心病的发病风险。aCAS或aICAS降低脑血流、脑灌注，增加1～3倍的痴呆或认知障碍风险。对于aCAS患者，随着药物治疗的优化和进展，颈动脉内膜剥脱术或颈动脉支架置入术治疗的相对获益需要再评价，选择合适的患者和减少手术并发症非常关键。对于aICAS患者，特别是严重狭窄或多发狭窄、进展性颅内动脉粥样硬化疾病、aICAS远端供血区域存在静止性脑梗死的患者，抗血小板和他汀类药物治疗可能获益，但需权衡出血和其他风险。

文章导读： aCAS和aICAS是心脑血管疾病的一种危险因素，在中国人群中发生率较高，但目前其流行病学数据及其在心脑血管疾病风险中的机制尚不清晰，兼顾经济、适用的筛查方法亟待开发、完善和验证。

关键词: 无症状性颈内动脉狭窄; 无症状性颅内动脉狭窄; 筛查; 预防

Abstract: To discuss the optimizing strategy in screening for the asymptomatic carotid artery stenosis (aCAS) or asymptomatic intracranial artery stenosis (aICAS) and the precise strategy in prevention for stroke based on the biomarkers and the imaging manifestations. The prevalence of aCAS was about 1.5% and the risk scores of aCAS were helpfull in the screening. The prevalence of aICAS was 6.9%～12.8%, according to the different study population and the screening tools. In patients with aCAS or aICAS, the severity of the vascular stenosis and the stability of the tube wall will affect the risk for stroke. Intraplaque hemorrhage was proved to increase the risk of incidence in stroke or coronary heart disease in the recent study. The cerebral blood flow and the cerebral perfusion decreased in the patients with aCAS or aICAS, which increased the risk of dementia or cognitive impairment with one to three times. Whether the patients with aCAS will benefit from carotid endarterectomy (CEA) or carotid artery stenting (CAS) need reevaluation as the drug therapy has made great progress. It play an important role to select a suitable patient and to reduce the complication of operation when making decisions. For the patients with aICAS, especially those with severe stenosis or multiple stenosis, progressive intracranial atherosclerosis disease, silent brain infarction within the brain territory distal to the aICAS, antiplatelet therapy and statins could be beneficial, with the consideration of cerebral hemorraghe or other adverse effects.

Key words: Asymptomatic carotid artery stenosis; Asymptomatic intracranial artery stenosis; Screening; Prevention

李雯博, 刘洁, 刘阳, 张龙友, 李世平, 郑华光. 无症状性颈内动脉狭窄和颅内动脉狭窄诊治进展[J]. 中国卒中杂志, 2023, 18(10): 1115-1120.

LI Wenbo, LIU Jie, LIU Yang, ZHANG Longyou, LI Shiping, ZHENG Huaguang. Advances in Study of Asymptomatic Carotid Artery Stenosis and Asymptomatic Intracranial Artery Stenosis[J]. Chinese Journal of Stroke, 2023, 18(10): 1115-1120.

参考文献

[1] WANG Y J，LI Z X，GU H Q，et al. China stroke statistics：an update on the 2019 report from the National Center for Healthcare Quality Management in Neurological Diseases，China National Clinical Research Center for Neurological Diseases，the Chinese Stroke Association，National Center for Chronic and Non-communicable Disease Control and Prevention，Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations[J]. Stroke Vasc Neurol，2022，7（5）：415-450.
[2] CHENG S F，BROWN M M，SIMISTER R J，et al. Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke[J]. Br J Surg，2019，106（7）：872–878.
[3] GUTIERREZ J，TURAN T N，HOH B L，et al. Intracranial atherosclerotic stenosis：risk factors，diagnosis，and treatment[J]. Lancet Neurol，2022，21（4）：355-368.
[4] WANG Y J，ZHAO X Q，LIU L P，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（3）：663-669.
[5] US Preventive Services Task Force，KRIST A H，DAVIDSON K W，et al. Screening for asymptomatic carotid artery stenosis：US preventive services task force recommendation statement[J]. JAMA，2021，325（5）：476-481.
[6] GUIRGUIS-BLAKE J M，WEBBER E M，COPPOLA E L，et al. Screening for asymptomatic carotid artery stenosis in the general population：updated evidence report and systematic review for the US preventive services task force[J]. JAMA，2021，325（5）：487-489.
[7] PSYCHOGIOS M，BREHM A，LÓPEZ-CANCIO E，et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease[J]. Eur Stroke J，2022，7（3）：Ⅲ-Ⅳ.
[8] SONG P G，FANG Z，WANG H Y，et al. Global and regional prevalence，burden，and risk factors for carotid atherosclerosis：a systematic review，meta-analysis，and modelling study[J/OL]. Lancet Glob Health，2020，8（5）：e721-e729[2023-03-09]. https://doi.org/10.1016/s2214-109x（20）30117-0.
[9] MESCHIA J F，BUSHNELL C，BODEN-ALBALA B，et al. Guidelines for the primary prevention of stroke：a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke，2014，45（12）：3754-832.
[10] POORTHUIS M H F，HALLIDAY A，MASSA M S，et al. Validation of risk prediction models to detect asymptomatic carotid stenosis[J/OL]. J Am Heart Assoc，2020，9（8）：e014766[2023-03-09]. https://doi.org/10.1161/jaha.119.014766.
[11] POORTHUIS M H F，SHERLIKER P，MORRIS D R，et al. Development and internal validation of a risk score to detect asymptomatic carotid stenosis[J]. Eur J Vasc Endovasc Surg，2021，61（3）：365-373.
[12] WONG K O，HUANG Y H，YANG H B，et al. A door-to-door survey of intracranial atherosclerosis in Liangbei County，China[J]. Neurology，2007，68（23）：2031-2034.
[13] SUN Q，WANG Q，WANG X，et al. Prevalence and cardiovascular risk factors of asymptomatic intracranial arterial stenosis：the Kongcun Town Study in Shandong，China[J]. Eur J Neurol，2020，27（4）：729-735.
[14] LI S Y，FANG F，CUI M，et al. Incidental findings on brain MRI among Chinese at the age of 55-65 years：the Taizhou imaging study[J]. Sci Rep，2019，9（1）：464.
[15] GUTIERREZ J，KHASIYEV F，LIU M H，et al. Determinants and outcomes of asymptomatic intracranial atherosclerotic stenosis[J]. J Am Coll Cardiol，2021，78（6）：562-571.
[16] YANG D，LIU M H，WILLEY Z J，et al. Physical activity is inversely associated with severe intracranial stenosis in stroke-free participants of NOMAS[J]. Stroke，2023，54（1）：159-166.
[17] MEHTA A，KHASIYEV F，WRIGHT C B，et al. Intracranial large artery stenosis and past infectious exposures：results from the NOMAS cohort[J]. Stroke，2022，53（5）：1589-1596.
[18] HOWARD D P J，GAZIANO L，ROTHWELL P M，et al. Risk of stroke in relation to degree of asymptomatic carotid stenosis：a population-based cohort study，systematic review，and meta-analysis[J]. Lancet Neurol，2021，20（3）：193-202.
[19] KWEE R M，VAN OOSTENBRUGGE R J，HOFSTRA L，et al. Identifying vulnerable carotid plaques by noninvasive imaging[J]. Neurology，2008，70（24 ）：2401-2409.
[20] U-KING-IM J M，YOUNG V，GILLARD J H，et al. Carotid-artery imaging in the diagnosis and management of patients at risk of stroke[J]. Lancet Neurol，2009，8（6）：569-580.
[21] BRINJIKJI W，HUSTON J，RABINSTEIN A A，et al. Contemporary carotid imaging：from degree of stenosis to plaque vulnerability[J]. J Neurosurg，2016，124（1）：27-42.
[22] SABA L，SAAM T，JÄGER H R，et al. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications[J]. Lancet Neurol，2019，18（6）：559-572.
[23] BOS D，VAN DAM-NOLEN D H K，GUPTA A，et al. Advances in multimodality carotid plaque imaging：AJR expert panel narrative review[J]. Am J Roentgenol，2021，217（1）：16-26.
[24] SABA P S，PARODI G，GANAU A，et al. From risk factors to clinical disease：new opportunities and challenges for cardiovascular risk prediction[J]. J Am Coll Cardiol，2021，77（11）：1436-1438.
[25] BRUNNER G，VIRANI S S，SUN W S，et al. Associations between carotid artery plaque burden，plaque characteristics，and cardiovascular events：the ARIC carotid magnetic resonance imaging study[J]. JAMA Cardiol，2021，6（1）：79-86.
[26] BOS D，ARSHI B，VAN DEN BOUWHUIJSEN Q J A，et al. Atherosclerotic carotid plaque composition and incident stroke and coronary events[J]. J Am Coll Cardiol，2021，77（11）：1426-1435.
[27] Van der TOORN J E，BOS D，IKRAM M K，et al. Carotid plaque composition and prediction of incident atherosclerotic cardiovascular disease[J/OL]. Circ Cardiovasc Imaging，2022，15（3）：e013602[2023-03-09]. https://doi.org/10.1161/circimaging.121.013602.
[28] XU W H，LI M L，GAO S，et al. Middle cerebral artery intraplaque hemorrhage：prevalence and clinical relevance[J]. Ann Neurol，2012，71（2）：195-198.
[29] YU J H，KWAK H S，CHUNG G H，et al. Association of intraplaque hemorrhage and acute infarction in patients with basilar artery plaque[J]. Stroke，2015，46（10）：2768-2772.
[30] XU W H. High-resolution MRI of intracranial large artery diseases：how to use it in clinical practice?[J]. Stroke Vasc Neurol，2019，4（2）：102-104.
[31] SILVESTRINI M，PAOLINO I，VERNIERI F，et al. Cerebral hemodynamics and cognitive performance in patients with asymptomatic carotid stenosis[J]. Neurology，2009，72（12）：1062-1068.
[32] LAZAR R M，WADLEY V G，MYERS T，et al. Baseline cognitive impairment in patients with asymptomatic carotid stenosis in the CREST-2 Trial[J]. Stroke，2021，52（12）：3855-3863.
[33] SURI M F K，ZHOU J C，QIAO Y，et al. Cognitive impairment and intracranial atherosclerotic stenosis in general population.[J/OL]. Neurology，2018，90（14）：e1240-e1247[2023-03-09]. https://doi.org/10.1212/wnl.0000000000005250.
[34] DEARBORN J L，ZHANG Y Y，QIAO Y，et al. Intracranial atherosclerosis and dementia：the atherosclerosis risk in communities（ARIC）study[J]. Neurology，2017，88（16）：1556-1563.
[35] KANG K M，BYUN M S，LEE J H，et al. Association of carotid and intracranial stenosis with Alzheimer's disease biomarkers[J/OL]. Alzheimers Res Ther，2020，12（1）：106[2023-03-09]. https://doi.org/10.1186/s13195-020-00675-6.
[36] GOTTESMAN R F，MOSLEY T H，KNOPMAN D S，et al. Association of intracranial atherosclerotic disease with brain β-amyloid deposition：secondary analysis of the ARIC study[J]. JAMA Neurol，2020，77（3）：350-357.
[37] PARASKEVAS K I，FAGGIOLI G，ANCETTI S，et al. Editor's choice - asymptomatic carotid stenosis and cognitive impairment：a systematic review[J]. Eur J Vasc Endovasc Surg，2021，61（6）：888-899.
[38] GREENBERG S M. Vascular contributions to brain health：cross-cutting themes[J]. Stroke，2022，53（2）：391-393.
[39] BONATI L H，JANSEN O，DE BORST G J，et al. Management of atherosclerotic extracranial carotid artery stenosis[J]. Lancet Neurol，2022，21（3）：273-283.
[40] CHANG R W，TUCKER L Y，ROTHENBERG K A，et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention[J]. JAMA，2022，327（20）：1974-1982.
[41] REIFF T，ECKSTEIN H H，MANSMANN U，et al. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis：5-year results of a multicentre，randomised controlled trial[J]. Lancet Neurol，2022，21（10）：877-888.
[42] WHITE C J，BROTT T G，GRAY W A，et al. Carotid artery stenting：JACC state-of-the-art review[J]. J Am Coll Cardiol，2022，80（2）：155-170.
[43] WAKSMAN R，TORGUSON R. The vulnerable plaque detected：time to consider treatment[J]. Lancet，2021，397（10278）：943-945.
[44] KAMTCHUM-TATUENE J，SABA L，HELDNER M R，et al. Interleukin-6 predicts carotid plaque severity，vulnerability，and progression[J/OL]. Circ Res，2022，131（2）：e22-e33[2023-03-09]. https://doi.org/10.1161/circresaha.122.320877.
[45] PSYCHOGIOS M，BREHM A，LÓPEZ-CANCIO E，et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease[J/OL]. Eur Stroke J，2022，7（3）：Ⅲ-Ⅳ[2023-03-09]. https://doi.org/10.1177/23969873221099715.