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Kaufmann JE, Gensicke H, Schaedelin S, Luft AR, Goeggel-Simonetti B, Fischer U, Michel P, Strambo D, Kägi G, Vehoff J, Nedeltchev K, Kahles T, Kellert L, Rosenbaum S, von Rennenberg R, Riegler C, Seiffge D, Sarikaya H, Zietz A, Wischmann J, Polymeris AA, Hänsel M, Globas C, Bonati LH, Brehm A, De Marchis GM, Peters N, Nolte CH, Christensen H, Wegener S, Psychogios MN, Arnold M, Lyrer P, Traenka C, Engelter ST. Toward Individual Treatment in Cervical Artery Dissection: Subgroup Analysis of the TREAT-CAD Randomized Trial. Ann Neurol 2024; 95:886-897. [PMID: 38362818 DOI: 10.1002/ana.26886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Uncertainty remains regarding antithrombotic treatment in cervical artery dissection. This analysis aimed to explore whether certain patient profiles influence the effects of different types of antithrombotic treatment. METHODS This was a post hoc exploratory analysis based on the per-protocol dataset from TREAT-CAD (NCT02046460), a randomized controlled trial comparing aspirin to anticoagulation in patients with cervical artery dissection. We explored the potential effects of distinct patient profiles on outcomes in participants treated with either aspirin or anticoagulation. Profiles included (1) presenting with ischemia (no/yes), (2) occlusion of the dissected artery (no/yes), (3) early versus delayed treatment start (median), and (4) intracranial extension of the dissection (no/yes). Outcomes included clinical (stroke, major hemorrhage, death) and magnetic resonance imaging outcomes (new ischemic or hemorrhagic brain lesions) and were assessed for each subgroup in separate logistic models without adjustment for multiple testing. RESULTS All 173 (100%) per-protocol participants were eligible for the analyses. Participants without occlusion had decreased odds of events when treated with anticoagulation (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.07-0.86). This effect was more pronounced in participants presenting with cerebral ischemia (n = 118; OR = 0.16, 95% CI = 0.04-0.55). In the latter, those with early treatment (OR = 0.26, 95% CI = 0.07-0.85) or without intracranial extension of the dissection (OR = 0.34, 95% CI = 0.11-0.97) had decreased odds of events when treated with anticoagulation. INTERPRETATION Anticoagulation might be preferable in patients with cervical artery dissection presenting with ischemia and no occlusion or no intracranial extension of the dissection. These findings need confirmation. ANN NEUROL 2024;95:886-897.
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Affiliation(s)
- Josefin E Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
- Center for Neurology and Rehabilitation, Cereneo, Vitznau, Switzerland
| | - Barbara Goeggel-Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neuropediatrics, Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Regina von Rennenberg
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - David Seiffge
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | | | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Hänsel
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Christoph Globas
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Healths at Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Engelter ST, Lyrer P, Traenka C. Cervical and intracranial artery dissections. Ther Adv Neurol Disord 2021; 14:17562864211037238. [PMID: 34408787 PMCID: PMC8366117 DOI: 10.1177/17562864211037238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Stefan T Engelter
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Petersgraben 4, Basel 4031, Switzerland
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