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Updated: Jun 9, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Antithrombotic drugs for carotid artery dissection: Updated systematic review
Nikolaos S Avramiotis1,2, Fabian Schaub3, Sebastian Thilemann1,2
1Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
Insights
Anticoagulants may reduce death and disability in patients with extracranial internal carotid artery dissection (eICAD) compared to antiplatelets. This Cochrane Review update suggests individualized treatment decisions are advisable due to weak evidence for antiplatelets.
Area of Science:
- Neurology
- Vascular Medicine
- Evidence-Based Medicine
Background:
- Extracranial internal carotid artery dissection (eICAD) is a significant cause of stroke, particularly in younger individuals.
- Current treatment strategies for eICAD primarily involve antiplatelet or anticoagulant medications.
- A comprehensive review of the comparative benefits and harms of these treatments is crucial for optimizing patient outcomes.
Purpose of the Study:
- To compare the benefits and harms of antiplatelet versus anticoagulant therapy in patients diagnosed with eICAD.
- To update existing Cochrane Review evidence on eICAD treatment efficacy and safety.
- To inform clinical decision-making by synthesizing data from randomized controlled trials (RCTs) and non-randomized studies.
Main Methods:
- A systematic literature search was conducted across multiple databases (Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, EMBASE) and personal searches up to December 2023.
- Included studies were randomized-controlled trials (RCTs) and non-randomized studies comparing anticoagulants with antiplatelets in eICAD patients.
- Meta-analysis was performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for co-primary outcomes (death; death or disability) and secondary outcomes (ischemic stroke, intracranial hemorrhage, extracranial hemorrhage).
Main Results:
- Meta-analysis of 42 studies (2624 patients) indicated higher odds of death and death or disability in patients treated with antiplatelets compared to anticoagulants.
- Antiplatelet therapy was associated with a statistically significant increased odds of ischemic stroke in RCTs (OR 4.60).
- Antiplatelet-treated patients experienced significantly less symptomatic intracranial hemorrhage (OR 0.25) and a trend towards less major extracranial hemorrhage.
Conclusions:
- The current evidence supporting antiplatelets as the standard of care for eICAD is considered weak.
- Anticoagulant therapy appears to be associated with better outcomes regarding death and disability in eICAD patients.
- Individualized treatment decisions, carefully balancing the risks and harms of each therapeutic approach, are recommended for eICAD management.
Introduction:
Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients. In this Cochrane Review update we compared benefits and harms of eICAD-patients treated with either antiplatelets or anticoagulants.
Patients And Methods:
Eligible studies were identified through Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, and EMBASE and personal search until December 2023. We included randomized-controlled trials (RCTs) and non-randomized studies comparing anticoagulants with antiplatelets in eICAD-patients. Co-primary outcomes were (i) death (all causes) and (ii) death or disability. Secondary outcomes were ischemic stroke, symptomatic intracranial hemorrhage, and major extracranial hemorrhage. Odds ratios (OR) with 95% CIs were calculated for (i) all studies and (ii) separately for RCTs and non-randomized studies.
Results:
We meta-analyzed a total of 42 studies (2624 patients) including 2 RCTs (213 patients) for the primary outcome of death and 31 studies (1953 patients) including 1 RCT (115 patients) for the primary outcome of death or disability. Antiplatelet-treated patients had higher odds for death (ORall-studies 2.70, 95% CI 1.27-5.72; ORRTCs 6.80, 95% CI 0.14-345; ORnon-randomized studies 2.60, 95% CI 1.20-5.60) and death or disability (ORall-studies 2.1, 95% CI 1.58-2.66; ORRTCs 2.2, 95% CI 0.29-16.05; ORnon-randomized studies 2.1, 95% CI 1.58-2.66) than anticoagulated patients. Antiplatelet-treated patients had also higher odds for ischemic stroke, though this reached statistical significance only in the subgroup of RCTs (ORRTC 4.60, 95% CI 1.36-15.51). In turn, antiplatelet-treated patients had less symptomatic intracranial hemorrhage (ORall-studies 0.25, 95% CI 0.07-0.86) and a tendency toward less major extracranial hemorrhage (ORall-studies 0.17, 95% CI 0.03-1.03).
Discussion And Conclusion:
The evidence considering antiplatelets as standard of care in eICAD is weak. Individualized treatment decisions balancing risks versus harms seem recommendable.
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