What is the recommended initial anti-thrombotic therapy for intracranial dissection?

Antithrombotic Therapy for Intracranial Dissection

For patients with intracranial artery dissection, either antiplatelet therapy or anticoagulation can be used as initial antithrombotic therapy, with a slight preference for antiplatelet therapy due to the lower risk of hemorrhagic complications. 1, 2

Initial Management Approach

• For patients with intracranial dissection without subarachnoid hemorrhage, antiplatelet therapy is recommended as the first-line treatment due to its favorable safety profile 2
• Antiplatelet options include:
  • Aspirin 81-325 mg daily 3
  • Clopidogrel 75 mg daily 3
  • Aspirin + dipyridamole 25/200 mg daily 3
• Before initiating antithrombotic therapy, intracranial hemorrhage must be ruled out with neuroimaging 3

Evidence Supporting Antiplatelet Therapy

• In a study of 370 patients with carotid and vertebral artery dissections, patients with intracranial dissection on antiplatelet therapy had fewer ischemic and hemorrhagic events (8.5%) compared to those on anticoagulation (15.4%) or combined therapy (18.2%) 1
• Antiplatelet therapy has been associated with a lower risk of hemorrhagic complications compared to anticoagulation in patients with intracranial dissections 2
• For patients with non-aneurysmatic intracranial artery dissections, the risk of recurrent ischemic events is generally low regardless of antithrombotic treatment choice 4, 5

Role of Anticoagulation

• Anticoagulation may be considered in select cases of intracranial dissection without subarachnoid hemorrhage, particularly when there is evidence of thrombus formation or progressive ischemic symptoms despite antiplatelet therapy 4
• The TREAT-CAD study showed that aspirin was not non-inferior to vitamin K antagonists in cervical artery dissection, suggesting that anticoagulation might have benefits in certain cases 2
• If anticoagulation is chosen, it should be initiated after confirming the absence of subarachnoid hemorrhage or intracranial bleeding 4

Special Considerations

• Intracranial dissections with aneurysm formation and subarachnoid hemorrhage have significantly worse outcomes and require different management approaches 4
• For patients with aneurysmatic intracranial dissections presenting with subarachnoid hemorrhage, anticoagulation is contraindicated 4
• Dual antiplatelet therapy (DAPT) may be considered in the acute phase of intracranial dissection, particularly in patients with high-risk features, though evidence specific to dissection is limited 3, 2

Duration of Therapy

• Antithrombotic therapy should be continued for at least 3 months, similar to recommendations for extracranial dissections 3
• Long-term therapy may be needed based on individual risk factors and evidence of vessel healing on follow-up imaging 2

Monitoring and Follow-up

• Follow-up vascular imaging is recommended to assess healing of the dissection and to guide duration of antithrombotic therapy 2
• Clinical monitoring for recurrent ischemic symptoms or signs of hemorrhagic complications is essential 1, 4

Common Pitfalls to Avoid

• Failure to distinguish between intracranial dissections with and without subarachnoid hemorrhage, as management differs significantly 4
• Delaying antithrombotic treatment, as ischemic events often occur early after dissection diagnosis 2
• Using combined antiplatelet and anticoagulation therapy, which has been associated with higher rates of complications without clear benefit 1