Outcomes in the first year after cervical-artery dissection are similar with antiplatelet or anticoagulation therapy, according to results from the CADISS randomized clinical trial.
Cervical-artery dissection is an uncommon cause of stroke except in young patients, in whom it accounts for 10 to 25 percent of strokes. Clinicians commonly use antithrombotic therapy to reduce the risk of recurrent stroke in these patients, but it remains unclear whether anticoagulation or antiplatelet therapy is more effective in this setting.
Dr. Hugh S. Markus of the University of Cambridge, U.K., and colleagues in the Cervical Artery Dissection In Stroke Study (CADISS) earlier reported no difference in event rates at three months between patients treated with anticoagulation and those treated with antiplatelet agents.
In the current report, they present final results at one year for the 126 patients randomized to antiplatelet therapy and 124 randomized to anticoagulation.
During the first three months, there were four recurrent strokes (three in the antiplatelet group and one in the anticoagulant group), all ipsilateral, and no deaths. Between three and 12 months, there were two further strokes (one in each group), both ipsilateral, and one death in an antiplatelet-group patient who had experienced recurrent stroke in the first three months.
There were no significant differences between the groups for any of these endpoints in either intention-to-treat or per-protocol analyses, the researchers report in JAMA Neurology, online February 25.
Among the 181 patients with confirmed dissection and complete imaging at baseline and three months, the fraction of patients with residual narrowing or occlusion did not differ between those receiving antiplatelet therapy (56/92) and those receiving anticoagulation therapy (53/89).
Mural hematoma at baseline was the only imaging feature independently and positively associated with recanalization at three months.
Dr. Jonathan T. Lau, an emergency physician currently deployed overseas who recently reviewed the appropriate therapy for cervical-artery dissection, told Reuters Health by email, “As an emergency medicine physician, the medication that I start while a patient is in my care may not be the one they end up continuing throughout their hospital stay or when they are discharged to home or a facility. Based on the current data, either therapy may be appropriate; it’s determining which will cause the patient the least amount of harm based on that therapy.”
“The verdict is still out,” he said. “Therapy needs to be decided on a case by case basis and in consultation with your specialist. Shared decision making can certainly be considered – I imagine most patients would prefer antiplatelet therapy alone given the frequent need for INR sampling and dietary restrictions with anticoagulation (ie, warfarin).”
“The CADISS trial has certainly provided a great opener for future research,” added Dr. Lau, who was not involved in the study. “Specifically, what role do novel oral anticoagulants (NOACs) have in management of cervical-artery dissection? Will starting this therapy within zero to three months have any significant difference versus starting after three months? This was a relatively small study in the U.K. and Australia—how generalizable is it in your patient population?”
Dr. Lau noted that his responses solely reflect his own opinions and do not reflect those of the U.S. Government, the Department of Defense, or the Department of the Navy.
Dr. Markus did not respond to a request for comments.