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Yaghi S, Shu L, Mandel DM, Leon Guerrero CR, Henninger N, Muppa J, Affan M, Ul Haq Lodhi O, Heldner MR, Antonenko K, Seiffge DJ, Arnold M, Salehi Omran S, Crandall RC, Lester E, Lopez Mena D, Arauz A, Nehme A, Boulanger M, Touzé E, Sousa JA, Sargento-Freitas J, Barata V, Castro-Chaves P, Brito MTÁP, Khan M, Mallick D, Rothstein A, Khazaal O, Kaufmann J, Engelter ST, Traenka C, Aguiar de Sousa D, Soares M, Rosa SD, Zhou LW, Gandhi P, Field TS, Mancini S, Metanis I, Leker RR, Pan K, Dantu V, Baumgartner KV, Burton TM, Freiin von Rennenberg R, Nolte CH, Choi RK, MacDonald JA, Bavarsad Shahripour R, Guo X, Ghannam M, AlMajali M, Samaniego EA, Sanchez S, Rioux B, Zine-Eddine F, Poppe AY, Fonseca AC, Baptista M, Cruz D, Romoli M, De Marco G, Longoni M, Keser Z, Griffin KJ, Kuohn L, Frontera JA, Amar J, Giles JA, Zedde M, Pascarella R, Grisendi I, Nzwalo H, Liebeskind DS, Molaie AM, Cavalier A, Kam W, Mac Grory B, Al Kasab S, Anadani M, Kicielinski KP, Eltatawy AR, Chervak LM, Chulluncuy-Rivas R, Aziz YN, Bakradze E, Tran TL, Rodrigo-Gisbert M, Requena M, Saleh Velez FG, Ortiz Garcia JG, Muddasani V, de Havenon A, Vishnu VY, Yaddanapudi SS, Adams L, Browngoehl A, Ranasinghe T, Dunston R, Lynch Z, Penckofer M, Siegler JE, Mayer SV, Willey JZ, Zubair AS, Cheng YK, Sharma R, Marto JP, Mendes Ferreira V, Klein P, Nguyen TN, Asad SD, Sarwat Z, Balabhadra A, Patel S, Secchi TL, Martins SC, Mantovani GP, Kim YD, Krishnaiah B, Elangovan C, Lingam S, Qureshi AY, Fridman S, Alvarado-Bolaños A, Khasiyev F, Linares G, Mannino M, Terruso V, Vassilopoulou S, Tentolouris-Piperas V, Martínez-Marino M, Carrasco Wall VA, Indraswari F, El Jamal S, Liu S, Alvi M, Ali F, Sarvath MM, Morsi RZ, Kass-Hout T, Shi F, Zhang J, Sokhi D, Said J, Simpkins AN, Gomez R, Sen S, Ghani MR, Elnazeir M, Xiao H, Kala NS, Khan F, Stretz C, Mohammadzadeh N, Goldstein ED, Furie KL. Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study. Stroke 2024. [PMID: 38335240 DOI: 10.1161/strokeaha.123.045731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Background: Small, randomized trials of cervical artery dissection (CAD) patients showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with CAD treated with antiplatelets versus anticoagulation. Methods: This is a multi-center observational retrospective international study (16 countries, 63 sites) that included CAD patients without major trauma. The exposure was antithrombotic treatment type (anticoagulation vs. antiplatelets) and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with Inverse Probability of Treatment Weighting (IPTW) to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an "as treated" cross-over approach and only included outcomes occurring on the above treatments. Results: The study included 3,636 patients [402 (11.1%) received exclusively anticoagulation and 2,453 (67.5%) received exclusively antiplatelets]. By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with IPTW, compared to antiplatelet therapy, anticoagulation was associated with a non-significantly lower risk of subsequent ischemic stroke by day 30 (adjusted HR 0.71 95% CI 0.45-1.12, p=0.145) and by day 180 (adjusted HR 0.80 95% CI 0.28-2.24, p=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR 1.39 95% CI 0.35-5.45, p=0.637) but was by day 180 (adjusted HR 5.56 95% CI 1.53-20.13, p=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR 0.40 95% CI 0.18-0.88) (Pinteraction=0.009). Conclusions: Our study does not rule out a benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.
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Affiliation(s)
- Shadi Yaghi
- Neurology, Alpert Medical School at Brown University, UNITED STATES
| | - Liqi Shu
- Neurology, Alpert Medical School of Brown University, UNITED STATES
| | - Daniel M Mandel
- Neurology, University of Miami Miller School of Medicine, UNITED STATES
| | | | - Nils Henninger
- Departments of Neurology and Psychiatry, University of Massachusetts Medical School, UNITED STATES
| | | | | | | | - Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, SWITZERLAND
| | - Kateryna Antonenko
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland, SWITZERLAND
| | - David J Seiffge
- Neurology, Inselspital, Bern University Hospital, University of Bern, SWITZERLAND
| | - Marcel Arnold
- Department of Neurology, University hospital of Bern, SWITZERLAND
| | | | | | | | - Diego Lopez Mena
- National Institute of Neurology and Neurosurgery of Mexico, MEXICO
| | - Antonio Arauz
- stroke clinic, Instituto Nacional de Neurologia, MEXICO
| | | | - Marion Boulanger
- Service de neurologie,, Universite Caen Normandie, CHU Caen Normandie, INSERM U1237, CYCERON, boulevard Henri Becquerel, Caen, France, Blood and Brain @ Caen-Normandie Institute (BB@C), Caen, France, FRANCE
| | | | | | | | | | | | | | - Muhib Khan
- Department of Neurology, Mayo Clinic, UNITED STATES
| | | | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania, UNITED STATES
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, UNITED STATES
| | | | | | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel, SWITZERLAND
| | | | - Mafalda Soares
- Lisbon Central University Hospital, University of Lisbon, PORTUGAL
| | - Sara Db Rosa
- Neuroradiology, Lisbon Central University Hospital, PORTUGAL
| | - Lily W Zhou
- Neurology, The University of British Columbia, CANADA
| | | | - Thalia S Field
- Centre for Brain Health, Division of Neurology, Vancouver Stroke Program, University of British Columbia, CANADA
| | | | - Issa Metanis
- Hebrew University-Hadassah Medical Center, ISRAEL
| | - Ronen R Leker
- Neurology, Hadassah-Hebrew University Medical Center, ISRAEL
| | - Kelly Pan
- Rhode Island Hospital, UNITED STATES
| | - Vishnu Dantu
- Barrow Neurological Institute - St. Joseph's Hospital and Medical Center, UNITED STATES
| | | | - Tina M Burton
- Neurology, The Warren Alpert Medical School of Brown University, UNITED STATES
| | - Regina Freiin von Rennenberg
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | | | | | - Reza Bavarsad Shahripour
- University of California San Diego Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, USA., UNITED STATES
| | - Xiaofan Guo
- Neurology, Department of Neurology, Loma Linda University Health, UNITED STATES
| | - Malik Ghannam
- Neurology, University of Iowa Hospitals and Clinics, UNITED STATES
| | | | - Edgar A Samaniego
- Neurology, Neurosurgery & Radiology, University of Iowa, UNITED STATES
| | | | | | | | | | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), University of Lisbon, PORTUGAL
| | - Maria Baptista
- Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto
| | - Diana Cruz
- Neurology, Hospital Santa Maria - CHULN, PORTUGAL
| | | | - Giovanna De Marco
- Neurology and Stroke Unit, Department of Neuroscience,, Bufalini Hospital, ITALY
| | | | | | | | - Lindsey Kuohn
- Department of Neurology, NYU Langone Health, UNITED STATES
| | | | - Jordan Amar
- Keck School of Medicine of the University of Southern California, UNITED STATES
| | - James A Giles
- Neurology, Yale University School of Medicine, UNITED STATES
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia
| | | | - Ilaria Grisendi
- Neuromotor physiology, Azienda USL-IRCCS di Reggio Emilia, ITALY
| | - Hipólito Nzwalo
- Ageing and Cerebrovascular Research Group, Algarve Biomedical Research Institute, PORTUGAL
| | - David S Liebeskind
- Neurovascular Imaging Research Core & Neurology, University of California, Los Angeles, UNITED STATES
| | - Amir M Molaie
- Neurology, University of California at Los Angeles Medical Center, UNITED STATES
| | - Annie Cavalier
- Neurology, Duke University School of Medicine, UNITED STATES
| | - Wayneho Kam
- Duke University Hospital; UNC Health Rex Comprehensive Stroke Center, UNITED STATES
| | - Brian Mac Grory
- Neurology, Duke University School of Medicine, UNITED STATES
| | - Sami Al Kasab
- Neurosurgery and Neurology, Medical University of south Carolina, UNITED STATES
| | - Mohammad Anadani
- Neurology, Medical University of South Carolina, College of Medicine, UNITED STATES
| | | | | | - Lina M Chervak
- Department of Neurology, University of Cincinnati Medical Center, UNITED STATES
| | | | - Yasmin Ninette Aziz
- Neurology and Rehabilitation Medicine, University of Cincinnati, UNITED STATES
| | | | | | - Marc Rodrigo-Gisbert
- Hospital Universitari Vall d'Hebron. Departament de Medicina, Universitat Autònoma de Barcelona. Barcelona. Spain
| | - Manuel Requena
- Neurology. Universitat Autònoma de Barcelona, Univ Hosp Vall d'Hebron, SPAIN
| | - Faddi Ghassan Saleh Velez
- Department of Neurology, Vascular Division, The University of Oklahoma Health Sciences Center, UNITED STATES
| | - Jorge G Ortiz Garcia
- Department of Neurology, Division of Critical Care Neurology, Division of Stroke and Cerebrovascular Disorders, The University of Oklahoma Health Sciences Center, UNITED STATES
| | | | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, UNITED STATES
| | | | | | | | | | | | - Randy Dunston
- Wake Forest University Baptist Medical Center, UNITED STATES
| | | | - Mary Penckofer
- Cooper Medical School of Rowan University, UNITED STATES
| | - James E Siegler
- Department of Neurology, University of Chicago, UNITED STATES
| | | | | | | | | | | | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, PORTUGAL
| | | | - Piers Klein
- Neurology, Boston University Chobanian & Avedisian School of Medicine, UNITED STATES
| | - Thanh N Nguyen
- Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, UNITED STATES
| | | | | | - Anvesh Balabhadra
- Neurology, Hartford Hospital & University of Connecticut, UNITED STATES
| | - Shivam Patel
- Neurology, UConn School of Medicine, UNITED STATES
| | | | - Sheila Co Martins
- Stroke Unit, Neurology Service, Hospital de Clinicas de Porto Alegre, BRAZIL
| | | | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, KOREA, REPUBLIC OF
| | - Balaji Krishnaiah
- Neurology, University of Tennnessee Health Science Center, UNITED STATES
| | | | | | - Abid Y Qureshi
- Department of Neurology, University of Kansas Medical Center, UNITED STATES
| | - Sebastian Fridman
- Department of Clinical Neurological Sciences, University of Western Ontario - London Health Science Centre, CANADA
| | | | - Farid Khasiyev
- Neurology, Saint Louis University School of Medicine, UNITED STATES
| | - Guillermo Linares
- Souers Stroke Institute, Saint Louis University School of Medicine, UNITED STATES
| | | | | | - Sofia Vassilopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, GREECE
| | | | | | | | | | - Sleiman El Jamal
- Neurology, Rhode Island Hospital & Alpert Medical School of Brown University, UNITED STATES
| | - Shilin Liu
- University of Science and Technology, CHINA
| | | | | | | | - Rami Z Morsi
- Department of Neurology, University of Chicago, UNITED STATES
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, UNITED STATES
| | - Feina Shi
- Department of Neurology, Sir Run Run Shaw Hospital of Zhejiang University, School of Medicine, CHINA
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, CHINA
| | | | | | | | | | - Shayak Sen
- Cedars Sinai Medical Center, UNITED STATES
| | | | - Marwa Elnazeir
- Department of Neurology, University of Louisville, UNITED STATES
| | - Han Xiao
- Economics, University of California Santa Barbara, UNITED STATES
| | | | - Farhan Khan
- Neurology, Alpert Medical School, Brown University, UNITED STATES
| | - Christoph Stretz
- Neurology, Warren Alpert Medical School of Brown University, UNITED STATES
| | | | - Eric D Goldstein
- Neurology, Warren Alpert Medical School of Brown University, UNITED STATES
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, UNITED STATES
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