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Antiplatelet vs. Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-Analysis of Randomized
Sihua Liu1,2,3, Xiao Zhang1,2, Xuesong Bai1,2
1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
Insights
Anticoagulation therapy for cervical artery dissection (CAD) appears superior to antiplatelet therapy, showing a reduced risk of ischemic stroke without increasing bleeding complications. Further research is needed to refine treatment protocols for CAD management.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Optimal management for cervical artery dissection (CAD) remains uncertain.
- Randomized controlled trials (RCTs) are crucial for comparing antiplatelet and anticoagulation therapies in CAD patients.
Approach:
- A systematic literature search was performed across major databases (MEDLINE, Embase, Cochrane Library).
- Two high-quality RCTs involving 444 patients (intention-to-treat) and 370 patients (per-protocol) were included for meta-analysis.
- Relative risk (RR) was calculated to compare antiplatelet versus anticoagulation therapies, with heterogeneity assessed using I-squared statistics.
Key Points:
- In the intention-to-treat population, antiplatelet therapy was associated with a significantly higher rate of ischemic stroke within 3 months (RR = 6.73) compared to anticoagulation.
- No significant differences were observed between the groups for transient ischemic attack, intracranial hemorrhage, or major extracranial bleeding.
- Per-protocol analysis yielded results consistent with the intention-to-treat findings.
Conclusions:
- Anticoagulation therapy demonstrates a lower risk of ischemic stroke compared to antiplatelet therapy for cervical artery dissection, without an increased risk of bleeding.
- Anticoagulation appears to be a more effective treatment for CAD, though further studies are recommended to address specific patient subgroups and treatment details.
Abstract:
Objective: The optimal management for cervical artery dissection (CAD) is uncertain. This study aimed to summarize the current randomized controlled trials (RCTs) to compare the efficacy and safety of antiplatelet and anticoagulation therapies for CAD. Methods: A literature search was conducted in the major databases, such as MEDLINE, Embase, and the Cochrane Library. Only the RCTs comparing the antiplatelet and anticoagulation therapies for the patients with CAD were included. Combined estimates of the relative risk (RR) of antiplatelet vs. anticoagulation were analyzed. Heterogeneity was measured using the I 2 statistical analysis. The analyses were performed in the intention-to-treat (ITT) and per-protocol (PP) population, respectively. Results: Two RCTs involving 444 patients in the ITT population and 370 patients in the PP population were included. The quality of studies was high overall. In the ITT population, compared with the patients in the anticoagulation group, the patients in the antiplatelet group showed a higher rate of ischemic stroke within 3 months (RR = 6.73 [95% CI, 1.22-37.15], I 2 = 0%, P = 0.029). No difference between these two treatment groups was found for the outcomes of transient ischemic attack (RR = 0.37 [95% CI, 0.09-1.58], I 2 = 0%, P = 0.181), intracranial hemorrhage (RR = 0.33 [95% CI, 0.01-7.98], I 2 = 0%, P = 0.494), major extracranial bleeding (RR = 0.31 [95% CI, 0.01-7.60], I 2 = 0%, P = 0.476), or the composite of these outcomes within 3 months. For the PP population, the results of the meta-analysis of outcomes between the antiplatelet and anticoagulation groups were consistent with the ITT population. Conclusions: Compared with the antiplatelet group, the anticoagulation group has a lower risk of ischemic stroke without increasing bleeding risk when treating CAD. Anticoagulation seems to be superior over the antiplatelet in treating CAD but needs to be further tested by specifying several issues, such as location, initial symptom types, and treatment protocols.
