微动脉粥样硬化是缺血性卒中常见但常被忽视的病因。
完整摘要 · 中文译文
背景：Fisher描述了腔隙性梗死的几种不同血管病理机制。然而，随后的文献和临床实践常常将症状性腔隙性卒中主要错误归因于脂质透明样变性和颅内分支开口处动脉粥样硬化。经典神经病理学研究提示，许多腔隙性卒中实际上由微动脉粥样硬化所致——即穿支动脉内的小动脉粥样硬化斑块。本研究旨在量化临床实践中症状性腔隙性梗死归因于微动脉粥样硬化的比例。 方法：按照PRISMA指南进行了三项系统荟萃分析，纳入大型临床系列研究，以明确：（1）缺血性卒中中由腔隙性梗死所致的比例；（2）在腔隙性事件中，纯运动性偏瘫（PMH）、纯感觉性卒中（PSS）、构音障碍-笨拙手综合征（DCH）、共济失调性偏瘫（AH）的相对频率；以及（3）微动脉粥样硬化、脂质透明样变性、颅内分支起始部动脉粥样硬化和栓塞对症状性腔隙性卒中的相对贡献比例。 结果：神经病理学系统评价显示：PMH由微动脉粥样硬化所致者占64%，脂质透明样变性占14%，栓塞占14%，颅内分支动脉粥样硬化占7%；PSS由脂质透明样变性所致者占100%；DCH和AH各由微动脉粥样硬化所致者占33%，颅内分支动脉粥样硬化占33%，栓塞占33%。第一项临床系列荟萃分析显示，在纳入32,169例患者的24项大型缺血性卒中系列研究中，腔隙性梗死频率为17.8%。第二项显示，在7项 一项纳入1，646例腔隙性梗死患者的大型系列研究中，亚型频率为：PMH-47%、PSS-10.6%、DCH-7.7%和AH-11.2%（其余为感觉运动性卒中及较少见的腔隙综合征）。定量合成表明：微动脉粥样硬化估计是腔隙性卒中 most common 的原因，占43%，其次为脂质透明样变性-20%、栓塞-20%和颅内分支起源动脉粥样硬化-17%；微动脉粥样硬化估计是所有缺血性卒中的7.7%的原因。 结论：穿通动脉内的微动脉粥样硬化斑块是脑缺血的常见原因，估计占所有缺血性卒中的1/13。这种微动脉粥样硬化的巨大负担可能是溶栓和他汀类药物治疗在特定腔隙性缺血性卒中患者中获益的重要病理生理学基础。
完整摘要 · 英文原文
BACKGROUND: Fisher described several distinct vascular pathologies underlying lacunar infarction. However, subsequent literature and clinical practice have often misattributed symptomatic lacunar stroke primarily to lipohyalinosis and intracranial branch ostial atherosclerosis. Classic neuropathologic studies indicate that many lacunar strokes are instead caused by microatherosclerosis - small atheromatous plaque within penetrating arteries. This study aims to quantify the proportion of symptomatic lacunar infarcts in clinical practice attributable to microatherosclerosis. METHODS: Three systematic meta-analyses, per PRISMA guidelines were performed of large clinical series to delineate: (1) the proportion of ischemic strokes due to lacunar infarcts; (2) among lacunar events, the relative frequencies of pure motor hemiparesis (PMH), pure sensory stroke (PSS), dysarthria-clumsy hand (DCH), ataxic hemiparesis (AH); and (3) proportional contribution of microatherosclerosis, lipohyalinosis, intracranial branch-origin atherosclerosis and embolism to symptomatic lacunar stroke. RESULTS: The neuropathology systematic review showed: PMH caused by microatherosclerosis-64%, lipohyalinosis-14%, embolism-14% and intracranial branch-artery atherosclerosis-7%; PSS caused by lipohyalinosis-100%: and DCH and AH each caused by microatherosclerosis-33%, intracranial branch-artery atherosclerosis-33%, and embolism-33%. The first clinical series meta-analysis showed, among 24 large ischemic stroke series enrolling 32,169 patients, lacunar infarct frequency was 17.8%. The second showed, among 7 large series enrolling 1,646 lacunar infarct patients, subtype frequencies were: PMH-47%, PSS-10.6%, DCH-7.7% and AH-11.2% (with the remainder sensorimotor stroke and less common lacunar syndromes). Quantitative synthesis indicated that: microatherosclerosis is estimated to be the most common cause of lacunar strokes, accounting for 43%, followed by lipohyalinosis-20%, embolism-20%, and intracranial branch-origin atherosclerosis-17%; and that microatherosclerosis is the estimated cause of 7.7% of all ischemic strokes. CONCLUSION: Microatherosclerotic plaque within a penetrating artery is a common cause of cerebral ischemia, accounting for an estimated 1 in 13 of all ischemic strokes. This substantial burden of microatherosclerosis may be an important pathophysiologic basis for the benefits of thrombolytic and statin therapy in select patients with lacunar ischemic strokes.