From the Guidelines
The treatment for cervical artery dissection should involve antiplatelet therapy, as it has been shown to be equally effective as anticoagulation in preventing stroke and other complications, according to the most recent guidelines. When considering the management of cervical artery dissection, several key points must be taken into account to minimize morbidity, mortality, and improve quality of life.
- The use of antiplatelet agents such as aspirin (81-325mg daily) or clopidogrel (75mg daily) is supported by recent evidence, including the CADISS trial, which found no significant difference in outcomes between antiplatelet and anticoagulant therapy 1.
- Anticoagulation with heparin followed by warfarin or direct oral anticoagulants like apixaban may also be considered, but the choice between antiplatelet and anticoagulant therapy should be individualized based on patient-specific factors, such as the presence of contraindications to anticoagulation or a high risk of bleeding 1.
- Treatment duration is typically 3-6 months, after which patients are usually transitioned to aspirin for long-term stroke prevention.
- Pain management with analgesics is important during the acute phase, and blood pressure control is essential, targeting levels below 140/90 mmHg.
- In rare cases with severe stenosis, expanding pseudoaneurysms, or failed medical therapy, endovascular stenting or surgical intervention may be necessary, although the evidence for these interventions is largely based on small series and expert opinion 1. The rationale for antiplatelet or anticoagulant therapy is to prevent thrombus formation at the dissection site, which could lead to embolism and stroke, and most cervical artery dissections heal spontaneously within 3-6 months with appropriate medical management.
From the Research
Treatment Options for Cervical Artery Dissection
The treatment for cervical artery dissection is a topic of ongoing debate, with two primary antithrombotic treatment options: antiplatelet agents and anticoagulants.
- Antiplatelet agents, such as aspirin, are often preferred due to their ease of use and lower cost 2.
- Anticoagulants, such as vitamin K antagonists, are also commonly used, although their use is not entirely evidence-based 3, 2, 4, 5.
Comparison of Treatment Options
Studies have compared the efficacy and safety of antiplatelet agents and anticoagulants in patients with cervical artery dissection.
- The TREAT-CAD trial, a randomized controlled trial, compared aspirin to vitamin K antagonists in patients with symptomatic cervical artery dissection 3, 2.
- The results of the TREAT-CAD trial showed that aspirin was not non-inferior to vitamin K antagonists in preventing stroke, major hemorrhage, or death 2.
- A 6-month follow-up study of the TREAT-CAD trial found that outcomes between 3 and 6 months after randomization occurred rarely and were similar in both treatment groups, with exclusively hemorrhagic events 6.
Rationale and Design of Treatment Studies
The Cervical Artery Dissection in Stroke Study (CADISS) is a prospective multicenter randomized-controlled trial that aims to compare antiplatelet therapy to anticoagulation therapy in patients with acute carotid and vertebral artery dissection 4.
- The primary endpoint of the CADISS trial is ipsilateral stroke or death within 3 months from randomization.
- The trial also includes secondary endpoints, such as any transient ischemic attack or stroke, major bleeding, and presence of residual stenosis at 3 months.
Clinical Considerations
Clinical considerations, such as stroke severity, accompanying intracranial dissection, and concomitant diseases with increased bleeding risk, may influence the choice of antithrombotic treatment in patients with cervical artery dissection 5.
- Antiplatelet agents may be preferred in patients with severe stroke, accompanying intracranial dissection, or concomitant diseases with increased bleeding risk.
- Anticoagulants may be favored in patients with (pseudo)occlusion of the dissected artery, high intensity transient signals in transcranial ultrasound studies, or multiple ischemic events in the same circulation.