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Antiplatelets Versus Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-analysis of 2064
Abdulrahman Ibrahim Hagrass1, Bashar Khaled Almaghary2, Mohamed Abdelhady Mostafa3
1Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
Insights
This study compared antiplatelet (AP) versus anticoagulant (AC) therapies for cervical artery dissection (CeAD) in young adults. Results showed no significant differences in mortality or recurrent stroke, though AC favored in RCTs for primary ischemic stroke.
Area of Science:
- Neurology
- Vascular Medicine
- Clinical Trials
Background:
- Cervical artery dissection (CeAD) is a leading cause of stroke in individuals under 50.
- Optimal antithrombotic treatment for CeAD remains debated, lacking definitive consensus.
- This study aimed to compare the efficacy and safety of antiplatelet (AP) versus anticoagulant (AC) therapies.
Approach:
- A systematic meta-analysis was conducted on cohort studies and randomized controlled trials (RCTs) published up to September 2021.
- Included studies compared AP and AC treatments for CeAD.
- Statistical analysis used odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes.
Key Points:
- The meta-analysis included 15 studies with 2064 patients.
- No significant differences were observed between AP and AC for mortality, recurrent stroke, recurrent TIA, symptomatic intracranial hemorrhage, or complete recanalization.
- Anticoagulants showed a significant advantage over antiplatelets for primary ischemic stroke in RCTs.
Conclusions:
- While most outcomes showed no significant difference, anticoagulants may offer benefits for primary ischemic stroke in CeAD patients.
- Further high-quality research is recommended to refine treatment strategies and potentially avoid unnecessary anticoagulation.
- Confounding factors like dosage and compliance require careful consideration in future studies.
Background And Objectives:
In young people aged < 50 years, cervical artery dissection (CeAD) is among the most common causes of stroke. Currently, there is no consensus regarding the safest and most effective antithrombotic treatment for CeAD. We aimed to synthesize concrete evidence from studies that compared the efficacy and safety of antiplatelet (AP) versus anticoagulant (AC) therapies for CeAD.
Methods:
We searched major electronic databases/search engines from inception till September 2021. Cohort studies and randomized controlled trials (RCTs) comparing anticoagulants with antiplatelets for CeAD were included. A meta-analysis was conducted using articles that were obtained and found to be relevant. Mean difference (MD) with 95% confidence interval (CI) was used for continuous data and odds ratio (OR) with 95% CI for dichotomous data.
Results:
Our analysis included 15 studies involving 2064 patients, 909 (44%) of whom received antiplatelets and 1155 (56%) received anticoagulants. Our analysis showed a non-significant difference in terms of the 3-month mortality (OR 0.47, 95% CI 0.03-7.58), > 3-month mortality (OR 1.63, 95% CI 0.40-6.56), recurrent stroke (OR 0.97, 95% CI 0.46-2.02), recurrent transient ischaemic attack (TIA) (OR 0.93, 95% CI 0.44-1.98), symptomatic intracranial haemorrhage (sICH) (OR 0.38, 95% CI 0.12-1.19), and complete recanalization (OR 0.70, 95% CI 0.46-1.06). Regarding primary ischaemic stroke, the results favoured AC over AP among RCTs (OR 6.97, 95% CI 1.25-38.83).
Conclusion:
Our study did not show a considerable difference between the two groups, as all outcomes showed non-significant differences between them, except for primary ischaemic stroke (RCTs) and complete recanalization (observational studies), which showed a significant favour of AC over AP. Even though primary ischaemic stroke is an important outcome, several crucial points that could affect these results should be paid attention to. These include the incomplete adjustment for the confounding effect of AP-AC doses, frequencies, administration compliance, and others. We recommend more well-designed studies to assess if unnecessary anticoagulation can be avoided in CeAD.
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