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Ictus isquémico

Ante cuadros de pérdidas de conciencia, caídas, dificultad para hablar, torpeza en la movilidad de las extremidades o parálisis, hemos de pensar en la posibilidad de un ictus de naturaleza isquémica. La aterosclerosis de los troncos supraaórticos, especialmente de la bifurcación carotídea, es una causa frecuente de ictus isquémico, justificando aproximadamente el 20% de todos los accidentes isquémicos cerebrovasculares. No obstante, es fundamental el estudio cardiológico (electrocardiograma, ecocardiografía y monitorización del ritmo) para descartar fuentes embolígenas o arritmias que pudieran justificar la clínica de déficit neurológico.

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Diagnóstico:

 

El eco-doppler es hoy día la técnica no invasiva de elección para el examen de pacientes con sospecha de lesión carotídea o su seguimiento. Dependiendo del grado de fiabilidad de la exploración, puede ser necesario la realización de otras pruebas de imagen para la confirmación de las lesiones, habitualmente Angio-RMN o Angio-TAC. La angiografía, a pesar de ser más precisa, no está exenta de complicaciones debido a su carácter invasivo.

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Tratamiento:

 

Aunque el principal criterio usado para decidir si un paciente debe ser considerado para cirugía es el grado de estenosis, la historia natural de las lesiones ateroscleróticas  es completamente diferente en pacientes sintomáticos que en asintomáticos. El riesgo de recurrencia clínica es superior al 13% en los primeros y tan sólo del 1-2% en los segundos. Esto hace que el beneficio preventivo de la cirugía sea más reducido y, por consiguiente, que se deba seleccionar adecuadamente los pacientes. Sin embargo, el modelo de progresión de la estenosis carotídea es impredecible. Placas moderadamente estenóticas evolucionan rápidamente y causan alteraciones cerebrovasculares graves, mientras que estenosis importantes pueden permanecer asintomáticas. Esto sugiere que las características morfológicas de la placa (estables o vulnerables) y la biología celular implicada sea diferente en cada caso.

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Tratamientos:

Tratamiento médico:

En pacientes con una estenosis carotídea moderada (<50% en sintomáticos y <70% en asintomáticos) se recomienda tratamiento médico. El tratamiento médico óptimo debe tender a estabilizar la placa de ateroma, disminuyendo su progresión, con el uso de estatinas y a reducir la incidencia de nuevos ictus mediante el empleo de antiagregación plaquetaria (aspirina sola o en combinación con clopidogrel durante la fase aguda).

 

Además, la mejor terapia médica debe incluir un control riguroso de los factores de riesgo cardiovascular: tensión arterial no superior a 130/ 80 mmHg (IECA o ARA); hemoglobina glicosidada A1C ≤7% en diabéticos, niveles de LDL-colesterol <100mg/dL; no fumar; hacer ejercicio y reducción del peso.

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Tratamiento quirúrgico:

La evidencia médica establece que la cirugía carotídea está absolutamente indicada en:

 

1.Pacientes sintomáticos neurológicos con una estenosis ≥50%, siempre que la tasa de complicaciones operatorias sea <6% (ictus/ muerte). La cirugía debería hacerse en las dos primeras semanas del inicio de los síntomas (AIT o ictus).

2.Pacientes asintomáticos con un estenosis >70%, siempre que el riesgo asociado con la cirugía sea menor del 3%. El beneficio de la cirugía es menor en mujeres.

 

Técnicas quirúrgicas:

Endarterectomía Carotídea.

La endarterectomía carotídea es la técnica quirúrgica de elección en el tratamiento de la enfermedad esteno-oclusiva de la carótida extra-craneal, con una eficacia y seguridad sustentada en numerosos estudios. La extracción de la placa de ateroma puede realizarse con anestesia general o loco-regional, bien mediante una arteriotomía longitudinal convencional o mediante una técnica de eversión. A pesar de que esta cirugía presupone la interrupción del flujo sanguíneo cerebral, no existe en la actualidad ninguna evidencia que soporte el uso rutinario de shunt. En la práctica clínica su uso es selectivo.

En caso de arteriotomía, se recomienda el cierre con un parche de angioplastia (venosa o sintética), ya que reduce significativamente el riesgo de restenosis y de complicaciones perioperatorias (ictus y muerte) en relación con el cierre mediante sutura directa. Este beneficio es mayor en mujeres.

 

Con independencia de ello, todos los pacientes deberían se tratados antes, durante y después del procedimiento quirúrgico con aspirina y estatinas.

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Angioplastia/ Stent Carotídeo.

La angioplastia-stent carotídeo (CAS) puede estar indicada en casos de cuellos hostiles (operados de laringe y radiados), restenosis carotídeas y bifurcaciones carotídeas altas. La CAS no es aconsejable en pacientes con severa ateromatosis del arco aórtico y arterias calcificadas o tortuosas. Estudios recientes muestran una mayor tasa de complicaciones neurológicas perioperatorias y riesgo de restenosis con estas técnicas. La CAS sólo debería ser ofrecida a pacientes sintomáticos con un riesgo quirúrgico muy elevado y en centros con gran experiencia endovascular

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