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Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in
Hugh S Markus1, Christopher Levi2, Alice King3
1Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, England.
Insights
Antiplatelet agents (APs) and anticoagulants (ACs) showed similar effectiveness in preventing recurrent stroke after extracranial artery dissection. This randomized trial found no significant difference in stroke or death rates between AP and AC therapies over 12 months.
Area of Science:
- Neurology
- Vascular Medicine
- Clinical Trials
Background:
- Extracranial carotid and vertebral artery dissection is a significant cause of stroke, especially in younger populations.
- Observational studies suggest a high risk of recurrent stroke, but optimal medical management remains unclear.
- Both antiplatelet agents (APs) and anticoagulants (ACs) are utilized, yet comparative efficacy is unknown.
Purpose of the Study:
- To compare the effectiveness of antiplatelet (AP) versus anticoagulant (AC) therapy in preventing stroke in patients with cervical artery dissection.
- To assess the risk of recurrent stroke within a randomized clinical trial framework.
- To evaluate the impact of AP and AC therapies on arterial imaging outcomes, such as recanalization.
Main Methods:
- A randomized, prospective, open-label, international multicenter study.
- 250 participants with recent-onset extracranial carotid or vertebral artery dissection were randomized to either AP or AC therapy.
- Follow-up data at 1 year were collected, with central blinded review of clinical and imaging endpoints.
Main Results:
- The 1-year recurrent stroke rate was low and not significantly different between the AP and AC groups (2.4% overall).
- No significant differences were observed between treatment groups for primary outcomes (stroke and death) or secondary outcomes (angiographic recanalization).
- Imaging analysis showed no difference in residual arterial narrowing or occlusion between patients treated with APs versus ACs.
Conclusions:
- In patients with extracranial artery dissection, antiplatelet therapy and anticoagulant therapy demonstrate comparable efficacy in preventing recurrent stroke.
- The low rate of recurrent stroke observed suggests that both treatment strategies are effective in this patient population.
- Further research may explore long-term outcomes and specific patient subgroups, but current evidence supports either AP or AC as a valid treatment option.
Importance:
Extracranial carotid and vertebral artery dissection is an important cause of stroke, particularly in younger individuals. In some but not all observational studies, it has been associated with a high risk of recurrent stroke. Both antiplatelet agents (APs) and anticoagulants (ACs) are used to reduce stroke risk, but whether 1 treatment strategy is more effective is unknown.
Objective:
To determine whether AP or AC therapy is more effective in preventing stroke in cervical dissection and the risk of recurrent stroke in a randomized clinical trial setting. A secondary outcome was to determine the effect on arterial imaging outcomes.
Design, Setting, And Participants:
Randomized, prospective, open-label international multicenter parallel design study with central blinded review of both clinical and imaging end points. Recruitment was conducted in 39 stroke and neurology secondary care centers in the United Kingdom and 7 centers in Australia between February 24, 2006, and June 17, 2013. One-year follow-up and analysis was conducted in 2018. Two hundred fifty participants with extracranial carotid and vertebral dissection with symptom onset within the last 7 days were recruited. Follow-up data at 1 year were available for all participants.
Interventions:
Randomization to AP or AC (heparin followed by warfarin) for 3 months, after which the choice of AP and AC agents was decided by the local clinician.
Main Outcomes And Measures:
The primary end point was ipsilateral stroke and death. A planned per protocol (PP) analysis was performed in patients meeting the inclusion criteria following central review of imaging to confirm the diagnosis of dissection. A secondary end point was angiographic recanalization in those with imaging confirmed dissection.
Results:
Two hundred fifty patients were randomized (118 carotid and 132 vertebral), 126 to AP and 124 to AC. Mean (SD) age was 49 (12) years. Mean (SD) time to randomization was 3.65 (1.91) days. The recurrent stroke rate at 1 year was 6 of 250 (2.4%) on ITT analysis and 5 of 197 (2.5%) on PP analysis. There were no significant differences between treatment groups for any outcome. Of the 181 patients with confirmed dissection and complete imaging at baseline and 3 months, there was no difference in the presence of residual narrowing or occlusion between those receiving AP (n = 56 of 92) vs those receiving AC (n = 53 of 89) (P = .97).
Conclusions And Relevance:
During 12 months of follow-up, the number of recurrent strokes was low. There was no difference between treatment groups in outcome events or the rate of recanalization.
Trial Registration:
ISRCTN.com Identifier: CTN44555237.
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