Acidente vascular cerebral (AVC) isquêmico

Em 2019, houve 3.29 milhões de mortes no mundo como resultado de AVC´s isquêmicos. O AVC é uma das principais causas de incapacidade grave em longo prazo nos Estados Unidos e no mundo.[9]GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021 Oct;20(10):795-820. https://www.doi.org/10.1016/S1474-4422(21)00252-0 http://www.ncbi.nlm.nih.gov/pubmed/34487721?tool=bestpractice.com [11]Tsao CW, Aday AW, Almarzooq ZI, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2023 update: a report from the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-621. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001123 http://www.ncbi.nlm.nih.gov/pubmed/36695182?tool=bestpractice.com ​​ O prognóstico do desfecho funcional pode ser avaliado de forma confiável utilizando-se escores prognósticos bem validados, como o escore ASTRAL ou o iScore.[249]Cooray C, Mazya M, Bottai M, et al. External validation of the ASTRAL and DRAGON scores for prediction of functional outcome in stroke. Stroke. 2016 Jun;47(6):1493-9. https://www.ahajournals.org/doi/full/10.1161/strokeaha.116.012802 http://www.ncbi.nlm.nih.gov/pubmed/27174528?tool=bestpractice.com

A trombólise intravenosa e a trombectomia mecânica, juntas e separadas, podem comprovadamente melhorar o desfecho do AVC. Tratar os pacientes em unidades especializadas em AVC é eficaz.[119]Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-418. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000211 http://www.ncbi.nlm.nih.gov/pubmed/31662037?tool=bestpractice.com [222]Langhorne P, Ramachandra S, Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev. 2020 Apr 23;(4):CD000197. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000197.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/32324916?tool=bestpractice.com [223]Adeoye O, Nyström KV, Yavagal DR, et al. Recommendations for the establishment of stroke systems of care: a 2019 update. Stroke. 2019 Jul;50(7):e187-210. https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000173 http://www.ncbi.nlm.nih.gov/pubmed/31104615?tool=bestpractice.com ​ [ ] How does organized inpatient care compare with care on a general medical ward for people with stroke/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.3108/fullMostre-me a resposta

Em geral, os pacientes com trombose venosa cerebral têm um desfecho favorável.[8]Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e77-90. https://www.doi.org/10.1161/STR.0000000000000456 http://www.ncbi.nlm.nih.gov/pubmed/38284265?tool=bestpractice.com ​ A maioria dos pacientes com TVC alcança independência funcional e sobrevive sem incapacidade física.[8]Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e77-90. https://www.doi.org/10.1161/STR.0000000000000456 http://www.ncbi.nlm.nih.gov/pubmed/38284265?tool=bestpractice.com ​ No entanto, não são incomuns sintomas residuais relacionados a cognição, humor, fadiga e cefaleia, que afetam a qualidade de vida de maneira negativa.[8]Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e77-90. https://www.doi.org/10.1161/STR.0000000000000456 http://www.ncbi.nlm.nih.gov/pubmed/38284265?tool=bestpractice.com [202]Field TS, Dizonno V, Almekhlafi MA, et al. Study of rivaroxaban for cerebral venous thrombosis: a randomized controlled feasibility trial comparing anticoagulation with rivaroxaban to standard-of-care in symptomatic cerebral venous thrombosis. Stroke. 2023 Nov;54(11):2724-36. https://www.doi.org/10.1161/STROKEAHA.123.044113 http://www.ncbi.nlm.nih.gov/pubmed/37675613?tool=bestpractice.com ​[250]Hiltunen S, Putaala J, Haapaniemi E, et al. Long-term outcome after cerebral venous thrombosis: analysis of functional and vocational outcome, residual symptoms, and adverse events in 161 patients. J Neurol. 2016 Mar;263(3):477-84. https://www.doi.org/10.1007/s00415-015-7996-9 http://www.ncbi.nlm.nih.gov/pubmed/26725090?tool=bestpractice.com [251]Koopman K, Uyttenboogaart M, Vroomen PC, et al. Long-term sequelae after cerebral venous thrombosis in functionally independent patients. J Stroke Cerebrovasc Dis. 2009 May-Jun;18(3):198-202. https://www.doi.org/10.1016/j.jstrokecerebrovasdis.2008.10.004 http://www.ncbi.nlm.nih.gov/pubmed/19426890?tool=bestpractice.com [252]Preter M, Tzourio C, Ameri A, et al. Long-term prognosis in cerebral venous thrombosis. Follow-up of 77 patients. Stroke. 1996 Feb;27(2):243-6. https://www.doi.org/10.1161/01.str.27.2.243 http://www.ncbi.nlm.nih.gov/pubmed/8571417?tool=bestpractice.com ​​​ Os fatores associados a prognóstico desfavorável incluem idade avançada, câncer ativo, redução do nível de consciência e hemorragia intracerebral.[7]Ferro JM, Canhão P, Stam J, et al. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke. 2004 Mar;35(3):664-70. https://www.doi.org/10.1161/01.STR.0000117571.76197.26 http://www.ncbi.nlm.nih.gov/pubmed/14976332?tool=bestpractice.com ​​​​​[8]Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e77-90. https://www.doi.org/10.1161/STR.0000000000000456 http://www.ncbi.nlm.nih.gov/pubmed/38284265?tool=bestpractice.com ​[253]Klein P, Shu L, Nguyen TN, et al. Outcome prediction in cerebral venous thrombosis: the IN-REvASC score. J Stroke. 2022 Sep;24(3):404-16. https://www.doi.org/10.5853/jos.2022.01606 http://www.ncbi.nlm.nih.gov/pubmed/36221944?tool=bestpractice.com

Complicações clínicas comumente associadas ao AVC incluem pneumonia por aspiração, infecção do trato urinário, depressão, desnutrição e trombose venosa profunda (TVP).

Uma metanálise sobre a eficácia da fisioterapia após o AVC constatou que várias intervenções melhoraram os desfechos funcionais, mesmo quando foram instituídas tardiamente após o AVC.[254]Ferrarello F, Baccini M, Rinaldi LA, et al. Efficacy of physiotherapy interventions late after stroke: a meta-analysis. J Neurol Neurosurg Psychiatry. 2011 Feb;82(2):136-43. http://www.ncbi.nlm.nih.gov/pubmed/20826872?tool=bestpractice.com

Pacientes tratados com ativador do plasminogênio tecidual recombinante (r-tPA) intravenoso

Esses pacientes são mais propensos a ter um desfecho melhor que pacientes não tratados com r-tPA, apesar do risco de 6% de hemorragia intracraniana sintomática.[153]National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7. https://www.nejm.org/doi/full/10.1056/NEJM199512143332401 http://www.ncbi.nlm.nih.gov/pubmed/7477192?tool=bestpractice.com

O número estimado necessário para tratar para prevenir um caso adicional de incapacidade relacionada ao AVC até 4.5 horas após o início dos sintomas é:[152]Saver JL. Number needed to treat estimates incorporating effects over the entire range of clinical outcomes: novel derivation method and application to thrombolytic therapy for acute stroke. Arch Neurol. 2004 Jul;61(7):1066-70. https://jamanetwork.com/journals/jamaneurology/fullarticle/786159 http://www.ncbi.nlm.nih.gov/pubmed/15262737?tool=bestpractice.com

• 3 (após a administração de r-tPA)

• 2-4 (após a administração de r-tPA associado a trombectomia)

O número estimado necessário para tratar para prevenir um caso adicional de incapacidade relacionada ao AVC até 4.5 a 9.0 horas após o início dos sintomas é:

• 25 (após a administração de r-tPA).