Ictus isquémico e infección por SARS-CoV-2, ¿asociación casual o causal?

espanolIntroduccion Se ha comunicado la asociacion de ictus isquemico y COVID-19, con mayor frecuencia en aquellos pacientes mas graves. Sin embargo, se desconoce en que medida podria estar en relacion con la inflamacion sistemica y la hipercoagulabilidad producidas en el contexto de la infeccion. Metodos Descripcion de 4 pacientes atendidos en nuestro centro por ictus isquemico y diagnostico de COVID-19, clasificandolos segun el grado de probabilidad causal entre el estado de hipercoagulabilidad y el ictus isquemico. Revision de la literatura sobre los posibles mecanismos implicados en la etiopatogenia del ictus isquemico en este contexto. Resultados Dos pacientes se consideraron con alta probabilidad causal: presentaban infartos corticales, sin enfermedad cardioembolica ni arterial significativa, con parametros de inflamacion sistemica e hipercoagulabilidad; las otras 2 pacientes eran de edad avanzada y el ictus isquemico se considero cardioembolico, con una probable asociacion casual de COVID-19. Conclusiones La inflamacion sistemica, junto con la posible accion directa del virus, provocaria disfuncion endotelial, generando un estado de hipercoagulabilidad que podria considerarse una causa potencial de ictus isquemico. Sin embargo, puesto que los mecanismos del ictus pueden ser multiples, se precisan estudios mas amplios que evaluen esta hipotesis. Mientras tanto, el estudio etiologico del ictus en pacientes con COVID-19 debe ser sistematico atendiendo a los protocolos vigentes, con las adaptaciones necesarias en relacion con las circunstancias clinicas y epidemiologicas de la actual pandemia. EnglishIntroduction Ischaemic stroke has been reported in patients with COVID-19, particularly in more severe cases. However, it is unclear to what extent this is linked to systemic inflammation and hypercoagulability secondary to the infection. Methods We describe the cases of 4 patients with ischaemic stroke and COVID-19 who were attended at our hospital. Patients are classified according to the likelihood of a causal relationship between the hypercoagulable state and ischaemic stroke. We also conducted a review of studies addressing the possible mechanisms involved in the aetiopathogenesis of ischaemic stroke in these patients. Results The association between COVID-19 and stroke was probably causal in 2 patients, who presented cortical infarcts and had no relevant arterial or cardioembolic disease, but did show signs of hypercoagulability and systemic inflammation in laboratory analyses. The other 2 patients were of advanced age and presented cardioembolic ischaemic stroke; the association in these patients was probably incidental. Conclusions Systemic inflammation and the potential direct action of the virus may cause endothelial dysfunction, resulting in a hypercoagulable state that could be considered a potential cause of ischaemic stroke. However, stroke involves multiple pathophysiological mechanisms; studies with larger samples are therefore needed to confirm our hypothesis. The management protocol for patients with stroke and COVID-19 should include a complete aetiological study, with the appropriate safety precautions always being observed.