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Ye SL, Wang C, Wang LL, Xu TZ, Li XQ, Tang T. Oral Anticoagulant and Antiplatelet Therapy for Cervical Artery Dissection: A Meta-Analysis of Clinical Trials. Clin Appl Thromb Hemost 2021; 27:10760296211051708. [PMID: 34846211 PMCID: PMC8647220 DOI: 10.1177/10760296211051708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Carotid and vertebral artery dissections are estimated to account for ∼20% of
strokes in patients under 45-years-old. This meta-analysis compared the efficacy
and safety of treatment with anticoagulants versus antiplatelet agents to
determine the optimal therapy. We searched 4 electronic databases for clinical
trials published from January 1, 1980 to August 25, 2021 that included patients
who received anticoagulant or antiplatelet therapy for carotid and/or vertebral
artery dissections. The curative effect was judged by recanalization evaluated
by imaging. The primary outcomes were all cause death and ischemic stroke;
secondary outcomes included hemorrhage and transient ischemic attack (TIA).
Patients who received only a single drug treatment were divided into
antiplatelet or anticoagulant groups; all received conservative treatment
without surgical intervention. For this investigation, we pooled the available
studies to conduct a meta-analysis, which included 7 articles with 1126
patients. The curative effect of vascular recanalization was not significantly
different between the 2 treatment groups (odds ratio [OR] = 0.913, 95%
confidence interval [CI]: 0.611-1.365, P = .657); similarly, no
significant differences were found regarding the primary outcomes all cause
death (OR = 1.747, 95%CI: 0.202-15.079, P = .612) and ischemic
stroke (OR = 2.289, 95%CI: 0.997-5.254, P = .051). Patients
treated with anticoagulants were more likely to experience TIA (OR = 0.517,
95%CI: 0.252-1.060, P = .072) and hemorrhage (OR = 0.468,
95%CI: 0.210-1.042, P = .063), but the differences were not
statistically significant. Overall, there were no statistically significant
differences between anticoagulant therapy and antiplatelet therapy for the
treatment of carotid and vertebral artery dissections.
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Affiliation(s)
- Sheng-Lin Ye
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Chuang Wang
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lu-Lu Wang
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tian-Ze Xu
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiao-Qiang Li
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tao Tang
- 665061Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Jenkins JM, Norton J, Hampton T, Weeks R. Rare case of bilateral traumatic internal carotid artery dissection. BMJ Case Rep 2016; 2016:bcr-2016-217262. [PMID: 27651410 DOI: 10.1136/bcr-2016-217262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A 55-year-old man was working in a trench when the wall collapsed in on him, pinning him to the wall. On arrival in the emergency department the patient began reporting of right-sided headache. Neurological examination revealed left-sided reduced sensation with weakness. Whole-body CT scan showed right-sided flail chest and bilateral haemothorax as well as loss of flow and thinning of the distal right internal carotid artery (ICA) and loss of grey white matter differentiation in keeping with traumatic ICA dissection with a right middle cerebral artery (MCA) infarct. He was started on aspirin 300 mg once daily. 3 days postadmission the patient experienced worsening of vision and expressive dysphasia. CT angiogram showed bilateral ICA dissections extending from C2 to the skull base. The patient was managed conservatively in the stroke unit for infarction and was discharged home for follow-up in stroke clinic.
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Affiliation(s)
| | | | - Timothy Hampton
- Department of Neuroradiology, King's College Hospital, London, UK
| | - Robert Weeks
- Department of Neuroradiology, King's College Hospital, London, UK
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Abstract
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.
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Affiliation(s)
- Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland; Neurorehabilitation Unit, Felix Platter Hospital, University Center for Medicine of Aging and Rehabilitation, Burgfelderstrasse 101, Basel CH - 4012, Switzerland.
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
| | - Alexander Von Hessling
- Department of Radiology, Neuroradiology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
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Abstract
Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.
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Caprio FZ, Bernstein RA, Alberts MJ, Curran Y, Bergman D, Korutz AW, Syed F, Ansari SA, Prabhakaran S. Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections. Cerebrovasc Dis 2014; 38:247-53. [DOI: 10.1159/000366265] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 07/29/2014] [Indexed: 11/19/2022] Open
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Ahlhelm F, Benz RM, Ulmer S, Lyrer P, Stippich C, Engelter S. Endovascular treatment of cervical artery dissection: ten case reports and review of the literature. INTERVENTIONAL NEUROLOGY 2013; 1:143-50. [PMID: 25187774 PMCID: PMC4138958 DOI: 10.1159/000351687] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE The role of endovascular treatment in cases of cervical artery dissection (CeAD) is debatable. With an increasing number of endovascular therapies such as endovascular recanalization and embolization the number of complications such as iatrogenic dissection is also rising. We report our experience with endovascular stenting in the treatment of patients presenting with CeAD. METHODS We included all consecutive patients with CeAD (n = 168) treated in our hospital between 2001 and 2010 for our retrospective study. Patients with CeAD were considered eligible for stenting: (1) in iatrogenic dissections and (2) in noniatrogenic dissections if they suffered from recurrent ischemic events despite antithrombotic treatment. RESULTS During our observation period 10 out of 168 patients presenting with CeAD were selected for stenting. Several types of stents were used. Stenting was technically successful in 8 but unsuccessful in 2 patients with complete arterial occlusion. Stent-related clinically apparent complications occurred in 3 of the 10 patients. All were transient. During a mean follow-up of 47 (±24.8) months none of the patients had new cerebrovascular ischemic events. CONCLUSION In our patient sample stenting due to dissection is a rare procedure performed in less than 10% of CAD patients. It should be considered as a feasible rescue treatment in cases of impending stroke despite optimal antithrombotic therapy.
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Affiliation(s)
- Frank Ahlhelm
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Robyn Melanie Benz
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Stephan Ulmer
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology, University of Basel Hospital, Basel, Switzerland
| | - Christoph Stippich
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology, University of Basel Hospital, Basel, Switzerland
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Lenz M, Bula-Sternberg J, Koch T, Bula P, Bonnaire F. [Traumatic dissection of the internal carotid artery following whiplash injury. Diagnostic workup and therapy of an often overlooked but potentially dangerous additional vascular lesion]. Unfallchirurg 2012; 115:369-76. [PMID: 22367514 DOI: 10.1007/s00113-011-2130-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report on the case of a 33-year-old male patient who was brought to the emergency room of our hospital after suffering a high-energy trauma due to an automobile accident. Besides a scaphoid fracture there were no signs of any neurological deficits. After several hours without clinical symptoms the patient developed dysarthria as the first manifestation of local cerebral ischemia based on a traumatic dissection of the internal carotid artery. Under systemic high-dose heparin therapy, fast and complete remission of all neurological disorders could be achieved. In the course of time a dissecting aneurysm developed. Temporary anticoagulation with phenprocoumon was started in the meantime and no further complications have appeared up to now. Besides presenting this absorbing case, this article highlights the diagnostic and therapeutic regime in cases of a traumatic dissection of supra-aortal arteries for rapid and adequate management of this rare but potentially dangerous complication.
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Affiliation(s)
- M Lenz
- Klinik für Allgemein- und Viszeralchirurgie, Akademisches Lehrkrankenhaus der Technischen Universität Dresden, Weißeritztal-Kliniken GmbH, Bürgerstraße 7, 01705, Freital, Deutschland.
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Abstract
Carotid artery dissection is a cause of stroke, especially in young and middle-aged patients. A dissection occurs when there is an intimal tear or rupture of the vasa vasorum, leading to an intramural hematoma, which is thought to result from trauma or can occur spontaneously, and is likely multifactorial, involving environmental and intrinsic factors. The clinical diagnosis of carotid artery dissection can be challenging, with common presentations including pain, partial Horner syndrome, cranial nerve palsies, or cerebral ischemia. With the use of noninvasive imaging, including magnetic resonance and computed tomography angiography, the diagnosis of carotid dissection has increased in frequency. Treatment options include thrombolysis, antiplatelet or anticoagulation therapy, endovascular or surgical interventions. The choice of appropriate therapy remains controversial as most carotid dissections heal on their own and there are no randomized trials to compare treatment options.
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10
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Stevic I, Chan HH, Chan AK. Carotid artery dissections: Thrombosis of the false lumen. Thromb Res 2011; 128:317-24. [DOI: 10.1016/j.thromres.2011.06.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 06/16/2011] [Accepted: 06/24/2011] [Indexed: 11/30/2022]
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Levy M, Levy E, Maimon S. Atypical postpartum stroke presenting as opalski syndrome: case report and review of the literature. Case Rep Neurol 2011; 3:191-8. [PMID: 21941497 PMCID: PMC3177790 DOI: 10.1159/000331441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose We present the first case of combined arterial (vertebral artery dissection) and venous [central sinus vein thrombosis (CSVT)] diseases presenting as Opalski syndrome in a female patient following induced delivery. Case Description A 32-year-old woman was admitted to our institute two weeks after induced delivery with intriguing neurological findings that were finally diagnosed as a combined venous-arterial disease. Although she was referred diagnosed with CSVT, her neurological findings indicated Wallenberg ‘plus’ syndrome with ipsilateral hemiparesis (Opalski syndrome), further confirmed by neuroimaging revealing arterial disease (vertebral artery dissection) combined with incidental acute CSVT. Coagulation, gynecological and cardiac problems were ruled out. Treatment consisted of continuous heparin with rigorous control of her blood pressure. Nine days later, the patient was discharged with prominent improvements. Most of the symptoms resolved following 3 months of rehabilitation. Conclusions Atypical strokes (such as Opalski syndrome) might present in postpartum patients. This rare diagnosis should be suspected in patients with Wallenberg ‘plus’ syndrome, and neuroimaging studies for determining the presence of arterial disease and brain stem lesions should be performed. Concomitant CSVT is rare and might mislead. Fine diagnosis followed by immediate conservative treatment can be of great benefit.
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Affiliation(s)
- Mikael Levy
- Interventional Neuroradiology Unit, Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Srivastava P. Optimization of antiplatelet/antithrombotic therapy for secondary stroke prevention. Ann Indian Acad Neurol 2011; 13:6-13. [PMID: 20436740 PMCID: PMC2859581 DOI: 10.4103/0972-2327.61270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 07/30/2009] [Accepted: 11/14/2009] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Padma Srivastava
- Department of Neurology, CN Center, AIIMS, Ansari Nagar, New Delhi, India
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13
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Abstract
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.
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Affiliation(s)
- Philippe Lyrer
- Department of Neurology, University Hospital Basel, Petersgraben 4, Basel, Switzerland, 4031
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Jeon P, Kim BM, Kim DI, Shin YS, Kim KH, Park SI, Kim DJ, Suh SH. Emergent self-expanding stent placement for acute intracranial or extracranial internal carotid artery dissection with significant hemodynamic insufficiency. AJNR Am J Neuroradiol 2010; 31:1529-32. [PMID: 20430849 DOI: 10.3174/ajnr.a2115] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE ICAD with hemodynamic insufficiency may present with either fulminant infarct or with progressive neurologic deterioration. The purpose of this study was to evaluate the safety and efficacy of emergent self-expanding stent placement for acute intracranial or extracranial ICAD with significant hemodynamic insufficiency. MATERIALS AND METHODS Eight patients (7 men and 1 woman; age range, 20-55 years; NIHSS score, 5-21) underwent emergent self-expanding stent placement for treatment of significant hemodynamic insufficiency due to acute ICAD. The safety and efficacy of emergent self-expanding stent placement were retrospectively evaluated. RESULTS All patients presented with progressive (n = 6) or fluctuating (n = 2) neurologic deficits and revealed markedly decreased perfusion on CT or MR perfusion studies. Conventional angiography revealed acute occlusion (n = 2) or critical stenosis (n = 6) in intracranial (n = 3) or extracranial (n = 5) carotid arteries with a lack of sufficient collaterals. Stent placement was successful in all patients without any procedure-related complications. In all patients, hemodynamic insufficiency was corrected immediately after stent placement, and neurologic symptoms were completely resolved during several days. Mean improvement of the NIHSS score between baseline and discharge was 11.6 (range, 5-21). All patients remained neurologically intact (mRS, 0) during clinical follow-up for a mean of 21 months (range, 8-50 months). Angiographic follow-up was available for 6 patients at 3-12 months. None of the 6 patients revealed residual or in-stent restenosis. CONCLUSIONS Self-expanding stent placement is a safe and effective option for selected patients with significant hemodynamic insufficiency due to acute intracranial or extracranial ICAD.
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Affiliation(s)
- P Jeon
- Department of Radiology, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
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.
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Affiliation(s)
- Alex Abou-Chebl
- Section of Stroke and Neurological Critical Care, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Kim YK, Schulman S. Cervical artery dissection: pathology, epidemiology and management. Thromb Res 2009; 123:810-21. [PMID: 19269682 DOI: 10.1016/j.thromres.2009.01.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 01/16/2009] [Accepted: 01/19/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cervical artery dissection is often treated with anticoagulants to prevent ischemic stroke. The risk-benefit ratio of anticoagulation versus antiplatelet therapy is unclear. OBJECTIVES To provide an educational review of current data on the disease to explain the rationale for the treatment options and to explore the results of management studies in order to determine if anticoagulation is justified. METHODS We searched the databases MEDLINE and EMBASE as well as bibliographies for information on anticoagulants and antiplatelet agents in cervical, i.e. carotid and/or vertebral artery, dissection. RESULTS There are no randomized controlled trials on the treatment. One systematic review from 2003 identified 20 case series or cohort studies. We identified 9 additional studies with a total of 1,033 patients. Of those, 731 received anticoagulation sometimes followed by platelet inhibition vs. 282 patients treated with antiplatelet agents alone. The rate of ischemic stroke was 2.3% vs. 6.9% and bleeding complications were reported in 0.7% vs. 0%. CONCLUSION It cannot be excluded that there is a net benefit from anticoagulant therapy in cervical dissection, but the studies are flawed by considerable bias. Very ill patients at a high risk of ischemic stroke may have been given aspirin due to fear of hemorrhagic complications. A randomized controlled trial is planned and will be crucial to resolve this issue.
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Affiliation(s)
- Yang-Ki Kim
- Department of Medicine, McMaster University, Hamilton ON, Canada
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Rosenwasser RH. Extracranial traumatic carotid artery dissections in children. J Neurosurg Pediatr 2008; 2:99-100; discussion 100. [PMID: 18671612 DOI: 10.3171/ped/2008/2/8/099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Dissection of the cervicocerebral arteries is an infrequent occurrence but is a leading cause of stroke in young and otherwise healthy patients. A brief review of the history, pathogenesis, and management is presented. The proper management for stroke prevention in dissection is unclear as there have been no randomized, controlled trials performed; small trials are under way.
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Dissecting aneurysms of the vertebrobasilar system. A comprehensive review on natural history and treatment options. Neurosurg Rev 2008; 31:131-40; discussion 140. [DOI: 10.1007/s10143-008-0124-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 12/05/2007] [Accepted: 01/01/2008] [Indexed: 11/27/2022]
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Engelter ST, Brandt T, Debette S, Caso V, Lichy C, Pezzini A, Abboud S, Bersano A, Dittrich R, Grond-Ginsbach C, Hausser I, Kloss M, Grau AJ, Tatlisumak T, Leys D, Lyrer PA. Antiplatelets Versus Anticoagulation in Cervical Artery Dissection. Stroke 2007; 38:2605-11. [PMID: 17656656 DOI: 10.1161/strokeaha.107.489666] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The widespread preference of anticoagulants over antiplatelets in patients with cervical artery dissection (CAD) is empirical rather than evidence-based.
Summary of Review—
This article summarizes pathophysiological considerations, clinical experiences, and the findings of a systematic metaanalysis about antithrombotic agents in CAD patients. As a result, there are several putative arguments in favor as well as against immediate anticoagulation in CAD patients.
Conclusions—
A randomized controlled trial comparing antiplatelets with anticoagulation is needed and ethically justified. However, attributable to the large sample size which is required to gather meaningful results, such a trial represents a huge venture. This comprehensive overview may be helpful for the design and the promotion of such a trial. In addition, it could be used to encourage both participation of centers and randomization of CAD patients. Alternatively, antithrombotic treatment decisions can be customized based on clinical and paraclinical characteristics of individual CAD patients. Stroke severity with National Institutes of Health Stroke Scale score ≥15, accompanying intracranial dissection, local compression syndromes without ischemic events, or concomitant diseases with increased bleeding risk are features in which antiplatelets seem preferable. In turn, in CAD patients with (pseudo)occlusion of the dissected artery, high intensity transient signals in transcranial ultrasound studies despite (dual) antiplatelets, multiple ischemic events in the same circulation, or with free-floating thrombus immediate anticoagulation is favored.
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Affiliation(s)
- Stefan T Engelter
- Neurological Clinic and Stroke Unit, University Hospital Basel, Petersgraben 4, Basel, Switzerland.
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Hardmeier M, Gobbi C, Buitrago C, Steck A, Lyrer P, Engelter S. Dissection of the internal carotid artery mimicking episodic cluster headache. J Neurol 2007; 254:253-4. [PMID: 17334959 DOI: 10.1007/s00415-006-0337-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2006] [Accepted: 04/03/2006] [Indexed: 12/26/2022]
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Imray CHE, Pattinson KTS. Potential role for TCD-directed antiplatelet agents in symptomatic carotid artery dissection. Stroke 2006; 37:767. [PMID: 16505347 DOI: 10.1161/01.str.0000204060.73207.c5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
BACKGROUND Extracranial internal carotid artery dissection can lead to occlusion of the artery and hence cause an ischaemic stroke. It is the underlying stroke mechanism in approximately 2.5% of all strokes. It is the second leading cause of stroke in patients younger than 45 years of age. Anticoagulants or antiplatelets may prevent arterial thrombosis in extracranial internal carotid artery dissection, but these benefits may be offset by increased bleeding. OBJECTIVES To determine whether antithrombotic drugs (antiplatelet drugs, anticoagulation) are effective and safe in the treatment of patients with extracranial internal carotid artery dissection, and which is the better treatment. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2002). In addition we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2002), MEDLINE (January 1966 to May 2002) and EMBASE (January 1980 to June 2002), and checked all relevant papers for additional eligible studies. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials assessing the efficacy of anticoagulants or antiplatelets for the treatment of extracranial internal carotid artery dissection, and non-randomised trials, e.g. case series (studies), that reported on any antithrombotic treatment with at least 4 patients, were eligible for inclusion. Data from all eligible studies were extracted independently by two reviewers. Disagreements were resolved by discussion. DATA COLLECTION AND ANALYSIS Data on the primary outcome measures were extracted systematically. These were: death (all causes) and death or disability. Secondary outcomes were: first stroke occurrence, stroke recurrence, any stroke during reported follow-up, extracranial haemorrhage, and intracranial haemorrhage. The first choice treatment was taken for analyses. MAIN RESULTS No randomised trials were identified. No reliable comparisons of antiplatelet drugs or anticoagulants with control were available. Twenty-six eligible studies including 327 patients (who either received antiplatelet drugs or anticoagulants) were to be included in the comparative analysis. There was no significant difference in odds of death comparing antiplatelet drugs with anticoagulants (Peto odds ratio (Peto OR) 1.59, 95% CI 0.22-11.59). There was also no significant difference in the odds of being dead or disabled (Peto OR 1.94, 95% CI 0.76-4.91). Few intracranial haemorrhages (0.5%) were reported for patients on anticoagulants, none for patients on antiplatelets. REVIEWER'S CONCLUSIONS There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control. There is, therefore, 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. We suggest that a randomised trial including at least 1400 patients in each treatment arm with this condition is clearly needed.
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Affiliation(s)
- P Lyrer
- Neurology, University Hospital Basel, Petersgraben 4, Basel, Switzerland
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