TP12 - Estenose Carotídea e AVC Flashcards
Why to screen for carotid stenosis?
- Routine population screening is not recommended
- Selective screening for asymptomatic carotid stenosis may be considered in patients with multiple vascular risk factors to optimize risk factor control and medical therapy to reduce late cardiovascular morbidity and mortality
Porquê procurar a estenose carotídea?
- AVC – 1a causa de morte e incapacidade
- Enfarte Cerebral – 1a causa de AVC
- Aterosclerose – 1a causa de enfarte cerebral
- Carótida Interna – local mais comum de aterosclerose
Como pode evoluir a placa carotídea?
- placa fibrosa
- angiogénese
- hemorragia (placa instável)
- hemorragia + disrupção da placa
- úlcera + trombo
Quando procurar a estenose carotídea?
- AIT ou AVC; isquemia cerebral silenciosa
- Risco vascular importante (Dx coronária, DAP, FRCV)
- Sopro cervical, zumbido pulsátil
- Pré cirurgia cardiovascular major
Como procurar a estenose carotídea?
- Arteriografia
- AngioTAC
- EcoDoppler
- Angio RM
How to assess the carotid stenosis?
- Duplex ultrasound (as first-line), computed tomographic angiography, and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis
- Intra-arterial subtraction angiography should not be performed in patients being considered for revascularization, unless significant discrepancies on non-invasive imaging exist
Ecodoppler carotídeo e vertebral?
- não invasivo
- sem contraste
- sem radiação
- em tempo real
- morfológico e funcional
- operador dependente
Como caraterizar a placa carotídea?
Placa “vulnerável”
- placa com hemorragia
- placa com úlcera
- placa com trombo fresco
Como quantificar o grau de estenose?
NASCET - americano compara com calibre a jusante
ECST - compara com calibre local
Best Medical Treatment?
- Low-dose aspirin (75-325 mg) is recommended in patients with asymptomatic carotid stenosis for the prevention of late myocardial infarction
- Statin therapy is recommended for long-term prevention of stroke, EAM, and other CV events in patients with asymptomatic carotid disease
- Antihypertensive treatment is recommended for patients with hypertension and asymptomatic extracranial internal carotid artery stenosis to maintain long-term blood pressure < 140/90 mmHg
- Antiplatelet therapy is recommended in symptomatic patients with 50-99% stenosis not undergoing carotid endarterectomy or carotid stenting
Asymptomatic plaque and carotid endarterectomy?
In ‘average surgical risk’ patients with an asymptomatic 60-99% stenosis , carotid endarterectomy should be considered in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke
Symptomatic plaque and carotid endarterectomy?
- Carotid endarterectomy is recommended in patients reporting carotid territory symptoms within the preceding 6 months and who have a 70-90% carotid stenosis
- Carotid endarterectomy should be considered in patients reporting carotid territory symptoms within the preceding 6 months and who have a 50-69% carotid stenosis
When to operate the symptomatic patients?
- When revascularization is considered appropriate in symptomatic patients with 50-99% stenosis, as soon as possible, preferably within 14 days of symptom onset
- Patients who are to undergo revascularization within the first 14 days after onset of symptoms should undergo carotid endarterectomy, rather than carotid stenting
How to decide for urgent CEA?
- Revascularisation should be deferred in patients with 50-99% stenosis who suffer a disabling stroke whose area of infarction exceeds one-third of the ipsilateral middle cerebral artery territory
- Patients with 50-99% stenosis who present with stroke-in-evolution or crescendo transient ischaemic attacks should be considered for urgent CEA, preferably <24h
CEA vs CAStenting?
It is recommended that most patients who have suffered carotid territory symptoms within the preceding 6 months and who are aged >70 years and who have 50-99% stenosis should be treated by CEA, rather than CAS
