Antithrombotic drugs for carotid artery dissection

Malignant ischemic stroke revealing a spontaneous carotid dissection in a young patient: Rare case report

Ischemic stroke remains today a major health problem that requires adequate management and etiological research. The prevalence in young people has increased. This article is a case report of a 37-year-old female diabetic patient who had an acute ischemic stroke due to spontaneous dissection of the right internal carotid artery. The article discusses the epidemiology, pathophysiology, diagnosis, and treatment of cervical artery dissection, which is a common cause of stroke in young patients. The use of antiplatelet and anticoagulant therapy, as well as endovascular and surgical interventions, is also discussed. Spontaneous carotid bulb dissection is an emergency in ischemic stroke in young people. The prognosis depends on the severity of the initial injury and the extent of collateral circulation, with successful recovery in 75% of cases.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Stroke is the third leading cause of early death worldwide. Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Patient outcomes might be improved if they are offered anticoagulants that reduce their risk of developing new blood clots and do not increase the risk of bleeding. This is an update of a Cochrane Review first published in 1995, with updates in 2004, 2008, and 2015.

OBJECTIVES

To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) for people with acute presumed or confirmed ischaemic stroke. Our hypotheses were that, compared with a policy of avoiding their use, early anticoagulation would be associated with: • reduced risk of death or dependence in activities of daily living a few months after stroke onset; • reduced risk of early recurrent ischaemic stroke; • increased risk of symptomatic intracranial and extracranial haemorrhage; and • reduced risk of deep vein thrombosis and pulmonary embolism.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (August 2021); the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), in the Cochrane Library (searched 5 August 2021); MEDLINE (2014 to 5 August 2021); and Embase (2014 to 5 August 2021). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We assessed the overall certainty of the evidence for each outcome using RoB1 and GRADE methods.

MAIN RESULTS

We included 28 trials involving 24,025 participants. Quality of the trials varied considerably. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition, or reporting bias. Anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence is related to effects of anticoagulant therapy initiated within the first 48 hours of onset. No evidence suggests that early anticoagulation reduced the odds of death or dependence at the end of follow-up (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.92 to 1.03; 12 RCTs, 22,428 participants; high-certainty evidence). Similarly, we found no evidence suggesting that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (OR 0.99, 95% CI 0.90 to 1.09; 22 RCTs, 22,602 participants; low-certainty evidence) during the treatment period. Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.75, 95% CI 0.65 to 0.88; 12 RCTs, 21,665 participants; moderate-certainty evidence), it was also associated with an increase in symptomatic intracranial haemorrhage (OR 2.47; 95% CI 1.90 to 3.21; 20 RCTs, 23,221 participants; moderate-certainty evidence). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60, 95% CI 0.44 to 0.81; 14 RCTs, 22,544 participants; high-certainty evidence), but this benefit was offset by an increase in extracranial haemorrhage (OR 2.99, 95% CI 2.24 to 3.99; 18 RCTs, 22,255 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, four new relevant studies have been published, and conclusions remain consistent. People who have early anticoagulant therapy after acute ischaemic stroke do not demonstrate any net short- or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism but increased bleeding risk. Data do not support the routine use of any of the currently available anticoagulants for acute ischaemic stroke.

Cervical and intracranial artery dissections

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection

BACKGROUND

Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people.

OBJECTIVES

To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection.

SEARCH METHODS

We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies.

MAIN RESULTS

We did not find any completed RCTs or CCTs undertaken in this area of research.

AUTHORS' CONCLUSIONS

No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.

Carotid Dissection and Isolated Paralysis of Ipsilateral Half Tongue: Clinical Cases

OBJECTIVE

We report two cases of carotid dissection revealed by isolated paralysis of the ipsilateral half tongue. Observations. First patient, 52 years old, with no particular medical or surgical history, presented with isolated paralysis of the left half tongue preceded by two weeks of moderate-intensity cervicalgia and having been the subject to cervical manipulation. MRI revealed dissection of the left internal carotid artery in its prepetrous portion. The evolution after 6 weeks of platelet aggregating inhibitors treatment was favorable. The second patient, 74 years old, with no particular medical or chirurgical history, presented with a sudden onset of paralysis of the left half tongue preceded by unusual headaches associated with neck pain. Brain MRI showed aneurysmal ectasia of the left internal carotid with parietal irregularity suggestive of carotid dissection. The evolution after four weeks of treatment with anticoagulant was favorable.

CONCLUSION

Carotid dissection revealed by isolated paralysis of the half tongue is rare. It is generally of good prognosis. However, in paralysis of half tongue, it must be urgently sought and treated to reduce the risk of a transient or constituted ischemic accident.

Spontaneous Bilateral Dissection of the Vertebral Artery: A Case Report

Spontaneous dissection of the vertebral artery refers to cases that do not involve significant blunt or penetrating trauma as a precipitating factor. However, cases of spontaneous dissection of the vertebral artery do have a history of trivial or minor injury involving some degree of cervical distortion such as chiropractic neck manipulation, as the extreme hyperextension and/or rotation of the neck may create areas of stretch and lead to intimal or adventitial tears in the vertebral artery causing dissection. It is a relatively rare, potentially disabling and sometimes an under-diagnosed cause of stroke. It accounts for 2% of all ischemic strokes and 7% of the cases are bilateral. Herein we present a case of bilateral vertebral artery dissection complicated by basilar artery stroke in a young male patient following chiropractic manipulation of the neck. Neuroimaging modalities upon presentation confirmed the diagnosis. Antiplatelets were administered, and a great clinical outcome after three months was achieved. This report demonstrates the potential hazards associated with neck trauma, including chiropractic manipulation, as it is under reported in Saudi Arabia.

Posttraumatic cerebrovascular injuries in children. A systematic review

INTRODUCTION

Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner.

METHODS

We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019.

RESULTS

After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking.

CONCLUSION

While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.

The endovascular emergency treatment of an acute carotid artery dissection after Krav Maga training—a case report

Carotid artery dissection accounts for 20%–30% of all ischemic strokes in young patients aged <50 years. Recent guidelines on carotid disease management do not differentiate between traumatic and spontaneous dissection. We present a case of a 36-year-old male patient with the right internal carotid artery dissection treated with two XACT Abbot 6–8 mm × 40 mm stents placement after he was strangled during Krav Maga training. It is the most effective way to prevent the imminent stroke in the penumbral region. The safety and outcome of stent placement in internal carotid artery dissection remains unclear and further randomized trials are needed.

Clinical Outcomes of Anticoagulation Therapy in Patients With Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery

The aim of this study was to determine the clinical outcomes of long-term anticoagulation therapy in patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and to evaluate whether conservative treatment with anticoagulation therapy is a safe and effective treatment modality for these patients.In this single center, observational cohort study, data from a prospectively recruiting symptomatic SIDSMA registry, including demographics, risk factors of interest, clinical characteristics and outcomes, and initial and follow-up computed tomography angiography (CTA) findings, were analyzed retrospectively. During an 8-year period, a total of 52 consecutive patients who underwent conservative treatment with the use of long-term anticoagulation were included in this study. Clinical symptoms resolved within 11 days in all except 4 patients (7.7%); 3 received endovascular treatment for persistent symptoms and 1 received surgical repair. The mean duration of anticoagulation therapy was 9 (range: 3-60) months. A follow-up CTA showed complete remodeling in 20 (41.7%) patients, and the mean diameter and the incidence of false lumen thrombosis were also decreased significantly. There was no anticoagulation therapy-related mortality or morbidity except 2 (4.2%) minor bleeding complications, and no symptomatic recurrence or aggravation of the dissection occurred during the mean follow-up period of 47.5 (range: 10-97) months. The present study showed that long-term anticoagulation therapy could result in a high rate of complete remodeling during the natural course of symptomatic SIDSMA. Conservative treatment with long-term anticoagulation therapy could be an optimal treatment strategy for symptomatic SIDSMA.

Diagnosis and treatment of cervical artery dissection

Cervical artery dissection (CAD) is a major cause of stroke in the young. A mural hematoma is detected in most CAD patients. The intramural blood accumulation should not be considered a reason to withhold intravenous thrombolysis in patients with CAD-related stroke. Because intravenous-thrombolyzed CAD patients might not recover as well as other stroke patients, acute endovascular treatment is an alternative. Regarding the choice of antithrombotic agents, this article discusses the findings of 4 meta-analyses across observational data, the current status of 3 randomized controlled trials, and arguments and counterarguments favoring anticoagulants over antiplatelets. Furthermore, the role of stenting and surgery is addressed.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Clot prevention with anticoagulants might improve outcomes if bleeding risks are low. This is an update of a Cochrane review first published in 1995, with recent updates in 2004 and 2008.

OBJECTIVES

To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) in people with acute presumed or confirmed ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA) (The Cochrane Library 2014 Issue 6), MEDLINE (2008 to June 2014) and EMBASE (2008 to June 2014). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data.

MAIN RESULTS

We included 24 trials involving 23,748 participants. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence relates to the effects of anticoagulant therapy initiated within the first 48 hours of onset. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow-up. Similarly, based on eight trials (22,125 participants), there was no evidence that early anticoagulation reduced the odds of being dead or dependent at the end of follow-up (OR 0.99; 95% CI 0.93 to 1.04). Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99).

AUTHORS' CONCLUSIONS

Since the last version of the review, no new relevant studies have been published and so there is no additional information to change the conclusions. Early anticoagulant therapy is not associated with net short- or long-term benefit in people with acute ischaemic stroke. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any of the currently available anticoagulants in acute ischaemic stroke.

Individualized endovascular treatment of high-grade traumatic vertebral artery injury

BACKGROUND

Traumatic vertebral artery injury (TVAI) is associated with craniocervical trauma that can lead to potentially fatal posterior circulation stroke. It presents a clinical challenge since it is hard to detect and there are no widely accepted guidelines on diagnosis and management. High-grade TVAI is more difficult to treat and no consensus has been reached yet.

METHODS

We performed a single-center, long-term, therapeutic study involving 272 patients with craniocervical injury, eleven of which were diagnosed with high-grade TVAI. Individualized endovascular treatments were performed on these patients based upon the hemodynamic and morphological characteristics of the injured vertebral artery. Postoperative angiography was conducted at 2 weeks, 3 months and 6 months, and then annually after intervention.

RESULTS

Ten vertebral pseudoaneurysms and one arteriovenous fistula (AVF) were confirmed by postoperative angiography. All the participants' neurological deficit symptoms disappeared or were significantly alleviated gradually, and no new symptoms were found after endovascular treatment. Follow-up angiography of the patients with pseudoaneurysms showed a normally shaped vertebral artery with no stenosis or aneurysms; the angiographic result of the patient with the AVF presented successful embolization in the proximal vertebral artery fistula with no progression or new stenosis. Their modified Rankin Scale (mRS) scores were also satisfactory.

CONCLUSIONS

Application of individualized endovascular therapy in high-grade TVAI is safe, technically feasible and clinically effective, but there is no comparison between endovascular management and other management approaches because randomized trials cannot be carried out currently.

Spontaneous Bilateral Vertebral Artery Dissection During a Basketball Game: A Case Report

Spontaneous vertebral artery dissection accounts for 2% of all ischemic strokes and can occur as a consequence of sports events. We present an unusual case of spontaneous bilateral vertebral artery dissection in a 30-year-old male patient during a basketball game. He developed severe dysphagia, right hemiparesis, and balance dysfunction. We also present a review of the pathology, diagnosis, symptomatology, treatment, prognosis, and occurrence of this entity in sports.

Antiplatelets versus anticoagulants for the treatment of cervical artery dissection: Bayesian meta-analysis

OBJECTIVE

To compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection.

DESIGN

Systematic review with Bayesian meta-analysis.

DATA SOURCES

The reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors.

STUDY SELECTION

Studies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection.

DATA EXTRACTION

Data were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups.

DATA SYNTHESIS

Thirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ(2) = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30).

CONCLUSION

In view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.

Optimization of antiplatelet/antithrombotic therapy for secondary stroke prevention

Role of antiplatelet therapy in secondary stroke prevention is of major significance. Antiplatelet agents predominantly in use are aspirin, clopidogrel, and combination regimes. The review focuses on the optimization of antiplatelet regimen based on evidence obtained from randomized-controlled trials, on different antiplatelet regimes and the risk assessment that may be unique to each patient.

Treatment of acute ischemic stroke: beyond thrombolysis and supportive care

The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease. There are scant data to support the use of acute anticoagulation therapy over anti-platelet therapy in cardioembolic stroke and large-vessel atherosclerosis, although it may be reasonable in a certain subset of patients. However, augmentation of blood flow with early surgery, stenting, or induced hypertension, may play a role in patients with large artery stenosis. The less commonly identified stroke mechanisms may warrant special consideration in treatment. Controversy remains regarding the optimal anti-thrombotic treatment of arterial dissection. Reversible cerebral vasoconstriction syndrome may benefit from therapy with calcium channel blockers, high-dose steroids, or magnesium, although spontaneous recovery may occur. Inflammatory vasculopathies, such as isolated angiitis of the central nervous system and temporal arteritis, require prompt diagnosis as the mainstay of therapy is immunosuppression. Cerebral venous thrombosis is a rare cause of stroke, but one that needs early identification and treatment with anticoagulation. Rapid determination of stroke mechanism is essential for making these critical early treatment decisions.

A reversible aptamer improves outcome and safety in murine models of stroke and hemorrhage

Treatment of acute ischemic stroke with intravenous tissue-type plasminogen activator is underutilized partly due to the risk of life-threatening hemorrhage. In response to the clinical need for safer stroke therapy, we explored using an aptamer-based therapeutic strategy to promote cerebral reperfusion in a murine model of ischemic stroke. Aptamers are nucleic acid ligands that bind to their targets with high affinity and specificity, and can be rapidly reversed with an antidote. Here we show that a Factor IXa aptamer administered intravenously after 60 minutes of cerebral ischemia and reperfusion improved neurological function and was associated with reduced thrombin generation and decreased inflammation. Moreover, when the aptamer was administered in the setting of intracranial hemorrhage, treatment with its specific antidote reduced hematoma volume and improved survival. The ability to rapidly reverse a pharmacologic agent that improves neurological function after ischemic stroke should intracranial hemorrhage arise indicates that aptamer-antidote pairs may represent a novel, safer approach to treatment of stroke.

Quadruple spontaneous cervical artery dissection following aneurysm embolization: a rare posttreatment complication

We present a unique case of multiple sCADs occurring after a ruptured intracranial aneurysm embolization. We discuss the impact of head extension during embolization as the prevailing factor in multiple artery dissections in this case and point out another cause of new-onset neurologic deficit in patients with aneurysmal SAH.

Antithrombotic drugs for carotid artery dissection

BACKGROUND

Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients.

OBJECTIVES

1. To determine whether, in patients with eICAD, treatment with anticoagulants, antiplatelet agents or control was associated with a better functional outcome. 2. To compare, among patients treated with either anticoagulants or antiplatelet agents, the risk of ischaemic strokes and major bleeding episodes.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2009). In addition, we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to November 2009) and EMBASE (January 1980 to November 2009), checked all relevant papers for additional eligible studies and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and non-randomised studies (if they reported on outcome stratified by antithrombotic treatment and included at least four patients) of anticoagulants or antiplatelet agents for the treatment of extracranial internal carotid artery dissection. Two review authors independently extracted data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were death (all causes) and death or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period. The first choice treatment was taken for analyses.

MAIN RESULTS

We did not find any completed randomised trials. Comparing antiplatelets with anticoagulants across 36 observational studies (1285 patients), there were no significant differences in the odds of death (Peto odds ratio (Peto OR) 2.02, 95% CI 0.62 to 6.60), or the occurrence of ischaemic stroke (OR 0.63, 95% CI 0.21 to 1.86) (34 studies, 1262 patients). For the outcome of death or disability, there was a non-significant trend in favour of anticoagulants (OR 1.77, 95% CI 0.98 to 3.22; P = 0.06) (26 studies, 463 patients). Symptomatic intracranial haemorrhages (5/627; 0.8%) and major extracranial haemorrhages (7/425; 1.6%) occurred only in the anticoagulation group; however, for both these outcomes, the estimates were imprecise and indicated no significant difference between the two treatment modalities.

AUTHORS' CONCLUSIONS

There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control, thus there is no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs and the reported non-randomised studies did not show any evidence of a significant difference between the two.

Fell off of a horse--journey from Emergency Department to Stroke clinic

The authors present a case of a young woman who presented with transient episodes of left-sided weakness after she fell off a horse. She attended Emergency Department twice before being referred to the Stroke clinic, where she was diagnosed with carotid artery dissection.

Cervical artery dissection

Spontaneous and traumatic cervical artery dissection is a common cause of stroke in the young. It generally carries an excellent prognosis if treatment is initiated early. Antiplatelet therapy may be as effective as or safer than warfarin, although no randomized prospective studies have addressed the issue of optimal medical therapy. Rarely, endovascular therapy may be indicated for the treatment of ruptured aneurysms or to prevent recurrent ischemia.

Dissection of the epiaortic and intracranial arteries

Dissection of epiaortic vessels is a rare event but can have serious clinical consequences such as ischaemic injury to the brain, cerebellum or, more rarely to the retina and is an important cause of stroke in young adults. The main clinical presentation is headache or neck pain, usually but not always associated with Horner syndrome or other local symptoms, followed by an ischemic event in the carotid or vertebral district. Very rarely, the dissection can extend to the intracranial vessels leading to subarachnoid hemorrhage. The time between the headache and the stroke is variable, ranging from a few seconds to weeks. Suspecting an arterial dissection in cases of unexplained head or neck pain in young patients is than crucial to avoid cerebrovascular events; the clinical suspect must be confirmed by ultrasound examination of the epiaortic vessels as a first screening exam, followed by an appropriate neuroimaging study. Treatment with anticoagulants, although not supported by randomized trials, is generally employed to prevent embolic events. The prognosis of stroke caused by arterial dissection does not differ from that of ischaemic events of other origin; the rate of recurrence is low and most patients have only one event in their live. Clinical research with multicenter recruitment is ongoing to provide more solid evidence on the management and prognosis of arterial dissections.

Comparison of conservative and operative treatment for blunt carotid injuries: analysis of the National Trauma Data Bank

OBJECTIVES

Blunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions.

METHODS

BCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank(1) using data gathered from 2002 to 2006. Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared.

RESULTS

A total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit (-3.1 +/- 6.8 vs -7.6 +/- 8.3; P = .01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P = .003), and total Injury Severity Score (29.8 +/- 13.3 vs 26.1 +/- 14.1; P = .02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay (13.4 +/- 15.3 days vs 13.7 +/- 13.6 days; P = .86), total Functional Independence Measure (8.8 +/- 3.3 vs 9.3 +/- 3.1; P = .38), progression of original neurologic insult (7.5% vs 4.6%; P = .61) or mortality (28.1% vs 19%; P = .08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score (22.4 +/- 12.2 vs 31.4 +/- 15.4; P = .01) and length of intensive care unit (ICU) and hospital stay (5.0 +/- 6.0 days vs 10.7 +/- 10.4 days; P = .01, and 10.3 +/- 9.2 days vs 19.3 +/- 17.7 days; P = .01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment.

CONCLUSION

BCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery.

Extracranial-intracranial arterial bypass surgery for occlusive carotid artery disease

BACKGROUND

The EC/IC Bypass Study Group found no benefit of extracranial to intracranial (EC/IC) bypass surgery over medical therapy in patients with symptomatic carotid artery occlusion (sCAO). However, the study was criticised for many reasons and the real effect of this treatment is still not known conclusively.

OBJECTIVES

To determine whether bypass surgery plus medical care is superior to medical care alone in patients with sCAO.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched June 2009). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). We also searched ongoing trials and research registers, checked reference lists of relevant articles, and contacted colleagues, trial authors and researchers.

SELECTION CRITERIA

Randomised controlled trials (RCT) and non-random studies of EC/IC bypass surgery plus best medical treatment compared with best medical treatment alone to prevent subsequent stroke, improve cerebral haemodynamics and reduce dependency after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, and extracted data items on the number of outcome events onto a data extraction form. We only analysed secondary outcomes if the study provided information on at least one primary outcome. We also used intention-to-treat analysis where possible.

MAIN RESULTS

We included 21 trials, including two RCTs, involving 2591 patients. For all endpoints, no benefit of EC/IC bypass surgery was shown either in the RCTs (any death: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.62 to 1.05, P = 0.11; stroke: OR 0.99, 95% CI 0.79 to 1.23, P = 0.91; death and dependency: OR 0.94, 95% CI 0.74 to 1.21, P = 0.64), or in the non-RCTs (any death: OR 1.00, 95% CI 0.62 to 1.62, P = 0.99; stroke: OR 0.80, 95% CI 0.54 to 1.18, P = 0.25; death and dependency: OR 0.80, 95% CI 0.50 to 1.29, P = 0.37).

AUTHORS' CONCLUSIONS

EC/IC bypass surgery in patients with sCAO disease was neither superior nor inferior to medical care alone. However, most studies included patients irrespective of their cerebral haemodynamics. Participation in an ongoing RCT, which is restricted to patients with impaired haemodynamics, is recommended as these patients might benefit from bypass surgery.

Clinical and radiographic natural history of cervical artery dissections

BACKGROUND

Cervical artery dissection (CADsx) is a common cause of stroke in young patients, but long-term clinical and radiographic follow-up from a large population is lacking.

METHODS

Epidemiologic data, treatment, recurrence, and other features were extracted from the records of all patients seen at our stroke center with confirmed CAD during a 15-year period. A subset of cases was examined to provide detailed information about vessel status.

RESULTS

In all, 177 patients (mean age 44.0 +/- 11.1 years) were identified, with the male patients being older than the female patients. Almost 60% of dissections were spontaneous, whereas the remainder involved some degree of head and/or neck trauma. More than 70% of patients were treated with anticoagulation. During follow-up (mean 18.2 months; 0-220 months) there were 15 cases (8.5%) of recurrent ischemic events, and two cases (1.1%) of a recurrent dissection. About half of recurrent stroke/transient ischemic attack events occurred within 2 weeks of presentation. There was no clear association between the choice of antithrombotic agent and recurrent ischemic events. Detailed analysis of imaging findings was performed in 51 cases. Some degree of recanalization was seen in 58.8% of patients overall, and was more frequent in women. The average time to total or near-total recanalization was 4.7 +/- 2.5 months. Patients with complete occlusions at presentation tended not to recanalize.

CONCLUSIONS

This large series from a single institution highlights many of the features of CAD. A relatively benign course with low recurrence rate is supported, independent of the type and duration of antithrombotic therapy.

Vertebral artery dissection presenting as a Brown-Séquard syndrome: a case report

INTRODUCTION

Vertebral artery dissection has become increasingly recognized as an important cause of stroke. It usually presents with posterior headache or neck pain followed within hours or days by signs of posterior circulation stroke. To the best of our knowledge, the clinical presentation of a Brown-Séquard syndrome with a vertebral artery dissection has been reported only once before.

CASE PRESENTATION

An otherwise healthy 35-year-old man presented with acute left-sided weakness. He had experienced left-sided posterior neck pain after a 4-hour flight 4 weeks previously. Physical examination was consistent with a left Brown-Séquard syndrome. Magnetic resonance angiography showed evidence of left vertebral artery dissection. He improved after therapy with anticoagulants.

CONCLUSION

We report a case of an unusual presentation of a relatively uncommon condition. This diagnosis should be considered early in relatively young patients with stroke-like symptoms or unexplained neck pain, because missing a dissection can result in adverse outcomes.

Cervical-artery dissections: predisposing factors, diagnosis, and outcome

Cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults and can lead to various clinical symptoms, some of which are benign (eg, headache, neck pain, Horner's syndrome, and cranial-nerve palsy), but most patients have a stroke or transient ischaemic attack. In addition to trauma to the neck, other risk factors have been suggested, such as infection, migraine, hyperhomocysteinaemia, and the 677TT genotype of the 5,10-methylenetetrahydrofolate reductase gene (MTHFR 677TT), although evidence is sparse. An underlying arteriopathy, which could in part be genetically determined, is believed to have a role in the development of CAD. Importantly, both research on and optimum management of CAD strongly rely on diagnostic accuracy. Although the functional outcome of CAD is good in most patients, socioprofessional effects can be important. Incidence of the disorder in the general population is underestimated. Mortality and short-term recurrence rates are low but possibly also underestimated. Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

Evaluation and management of stroke

In contrast to myocardial infarction, stroke is a heterogeneous disease with multiple different causes. Determination of stroke mechanism is critical to choosing optimal therapy to prevent recurrence. This article reviews the diagnostic approach to stroke and prognostic and treatment implications of specific stroke mechanisms. Data on the role of antiplatelet and anticoagulant therapy in secondary stroke prevention, as well as the role of these agents and thrombolytic therapy in acute stroke treatment are reviewed. Situations of particular relevance to the practicing hematologist—stroke in the young, patients with multiple recurrent strokes, patients with abnormal hypercoagulable laboratory testing, and treatment of intracerebral hemorrhage following thrombolytic therapy—are discussed.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by blood clots blocking an artery in the brain. Clot prevention with anticoagulants might improve outcome if bleeding risks were low. This is an update of a Cochrane review first published in 1995, and previously updated in 2004.

OBJECTIVES

To assess the effect of anticoagulant therapy versus control in the early treatment (less than 14 days) of patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 2 October 2007), and two Internet clinical trials registries for relevant ongoing studies (last searched October 2007).

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in patients with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data.

MAIN RESULTS

Twenty-four trials involving 23,748 participants were included. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow up. Similarly, based on eight trials (22,125 participants), there was no evidence that anticoagulants reduced the odds of being dead or dependent at the end of follow up (OR 0.99; 95% CI 0.93 to 1.04). Although anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, anticoagulants reduced the frequency of pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99).

AUTHORS' CONCLUSIONS

Since the last version of the review, neither of the two new relevant studies have provided additional information to change the conclusions. In patients with acute ischaemic stroke, immediate anticoagulant therapy is not associated with net short or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any the currently available anticoagulants in acute ischaemic stroke.

Transient ischemic attack: risk stratification and treatment

A major challenge facing the physician evaluating patients with transient ischemic attack is determining which patients are at highest short-term risk of stroke. A number of stratification schemes have been recently developed incorporating easily obtainable clinical information about the individual patient. Further, emerging data suggest a role for brain and vascular imaging in risk stratification. Many aspects of acute management of transient ischemic attack, such as which patients should be hospitalized and choice of acute antithrombotic therapy, remain controversial because of a lack of evidence from controlled trials. For longer-term prevention, there is much firmer evidence from multiple large randomized trials, and these data are reviewed in this article.

Cervicocranial arterial dissection

Cervicocranial arterial dissection (CCAD) occurs when there is a tear in the intimal layer of the carotid or vertebral arteries with subsequent extravasation of blood into the subintimal layers. The dissection may be extradural, intradural, or extend over both segments. The contents of the subintimal layers are highly thrombogenic, and thus, embolism, vessel stenosis, or occlusion may follow. Symptoms of dissection may be caused by local injury to the blood vessel or by ischemia to the retina or brain. Thus, dissection should always be considered in patients who present with Horner syndrome associated with ipsilateral headache, carotidynia, ocular pain, or amaurosis fugax. Rare neuro-ophthalmologic presentations of dissection include anterior and posterior ischemic optic neuropathy; central retinal artery occlusion; ophthalmic artery occlusion; transient ophthalmoparesis; and third, fourth, or sixth cranial nerve palsy. The most common serious complication of dissection is ischemic stroke. No randomized controlled trials have evaluated therapies for patients presenting with CCAD. Thus, treatment is essentially empiric and often varies by region. Medical management is first line in most patients. Given the propensity for thrombus formation and early embolization or occlusion, acute anticoagulation using intravenous heparin or low-molecular-weight heparinoids followed by short-term, dose-adjusted warfarin is the treatment of choice for most patients with extradural CCAD who present early after symptom onset. The risk of cerebral ischemia is greatest in the first few weeks after dissection; thus, it is reasonable to recommend antiplatelet agents for patients who present late and have not had evidence of ischemia. Intradural dissection is rare but is associated with a meaningful risk of subarachnoid hemorrhage (SAH). As a result, anticoagulants and antiplatelet agents should not be used if SAH is suspected or confirmed. Endovascular intervention may be necessary in a small minority of cases with recurrent events despite anticoagulation or SAH due to intradural dissection. Of special note, CCAD is not considered a contraindication for tissue plasminogen activator use in acute stroke patients who are otherwise eligible for treatment.

[Clinical treatment and therapy for dissected cervicocerebral artery]

Dissection of a cervicocerebral artery (CAD) is the second leading cause of stroke at younger ages. The pathogenesis of spontaneous CAD is not fully clarified. Defective connective tissue components may cause an arteriopathy predisposing to CAD in combination with certain trigger and risk factors. The clinical spectrum includes local pain in the neck, headaches, Horner's syndrome, isolated cranial nerve deficits, and hemispheric or brainstem infarction. Noninvasively, CAD is confirmed by Duplex sonography, MRI, and MRA. There is no controlled study for best treatment or management. Rational initial empiric treatment in acute CAD to prevent secondary embolism is partial thromboplastin time-guided anticoagulation by intravenous heparin followed by anticoagulation with warfarin. Carotid surgery for treating CAD is not recommended. The duration of anticoagulation is best guided by Doppler sonography follow-up and should extend until normalization of blood flow or at least 6 months after the vessel was occluded. Caution should be recommended for exercises that involve excessive head movements. The recurrence rate for CAD is low at <1%/year except for patients with known hereditary connective tissue disorders or in cases with familial dissections.

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

Antithrombotic Therapy for Stroke in Young Adults

Stroke in young adults is a markedly heterogeneous disease, and remains an understudied phenomenon. While advances are being made in our understanding of the pathophysiology of its underlying conditions, treatment concerns are controversial, and clinical trials are sorely lacking. This review presents an overview of some of the relevant management issues in hypercoagulable states, migraine, patent foramen ovale, vascular dissection and venous sinus thrombosis.