目的:无症状颈动脉狭窄(AsxCS)患者的最佳治疗一直存在争议。我们更新了2021年专家评论和立场声明,重点介绍AsxCS患者诊断和管理的最新进展。
方法:截至2023年8月1日,使用PubMed/PubMedCentral对文献进行了系统回顾,EMBASE和Scopus。以下关键词用于各种组合:“无症状颈动脉狭窄”,“颈动脉内膜切除术”(CEA),“颈动脉支架置入术”(CAS)和“经颈动脉血管重建术”(TCAR)。涵盖的领域包括:i)改善AsxCS患者的最佳医疗(BMT)和降低中风风险,ii)手术/血管内技能/技术和结果的技术进步,iii)风险因素,用于识别高风险AsxCS患者亚组的临床/影像学特征和风险预测模型,and,iv)认知功能障碍与AsxCS之间的关联。
结果:BMT对所有AsxCS患者都是必需的,无论他们最终是否会提供CEA/CAS/TCAR。尽管进行了BMT,但仍存在中风高风险的特定患者亚组应考虑进行颈动脉血运重建手术。这些包括严重(≥80%)AsxCS的患者,经颅多普勒检测到的微栓子,双重超声检查的斑块回声,脑CTA/MRA扫描上的无症状梗塞,减少脑血管储备,腔旁低回声区的大小增加,AsxCS进展,颈动脉斑块溃疡和斑块内出血。AsxCS患者的治疗应个体化,考虑到患者的个人偏好/需求,临床/影像学特征,文化/民族/社会因素。缺乏支持/驳斥AsxCS与认知功能障碍之间关联的确凿证据。
结论:AsxCS患者的最佳管理应包括所有个体的BMT和一些无症状患者亚组的预防性颈动脉血运重建手术(CEA/CAS/TCAR)。此外,考虑到个人患者的需求/偏好,临床/影像学特征,社会/文化因素和可用的卒中风险预测模型。未来的研究应该研究AsxCS与认知功能之间的关系以及颈动脉血运重建程序在认知功能障碍进展/逆转中的作用。
OBJECTIVE: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS.
METHODS: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: \"asymptomatic carotid stenosis,\" \"carotid endarterectomy\" (CEA), \"carotid artery stenting\" (CAS), and \"transcarotid artery revascularization\" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS.
RESULTS: BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking.
CONCLUSIONS: The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction.