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Review
. 2021 Aug 12:14:17562864211037238.
doi: 10.1177/17562864211037238. eCollection 2021.

Cervical and intracranial artery dissections

Stefan T Engelter  1 , Philippe Lyrer  2 , Christopher Traenka  3
Affiliations
Review

Cervical and intracranial artery dissections

Stefan T Engelter et al. Ther Adv Neurol Disord. .

Abstract

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Keywords: cervical artery dissection; intracranial dissection; stroke; stroke-therapy.

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Conflict of interest statement

Conflict of interest statement: STE reports grants from the Swiss National Science Foundation, Swiss Heart Foundation, the Freiwillige Akademische Gesellschaft Basel, the University of Basel, the University Hospital Basel, outside of the submitted work. PL reports grants from Bayer GmbH Germany, Swiss National Science Foundation, ProPatient Foundation of the University Hospital Basel, travel grants from Bayer AG Switzerland, Pfizer AG Switzerland, advisory board compensation from Bayer AG Switzerland, Pfizer AG Switzerland, Daiichi Sankyo Switzerland, Bristol Myers Squibb Switzerland, Recordati SA Switzerland, Amgen Switzerland, and compensation for research activities from Sanofi Switzerland and Acticor SA France, all outside of the submitted work. CT reports grants from the Swiss Heart Foundation, the University of Basel, the Bangerter-Rhyner Foundation and the Freiwillige Akademische Gesellschaft Basel and travel honoraria from Bayer AG, all outside of the submitted work.

Figures

Figure 1.
Figure 1.
Color-coded duplex sonography depicting the right internal carotid artery in a female patient who suffered bilateral internal carotid artery dissection. The hypoechogenic mural hematoma is clearly visible (arrows). The reduced true lumen leads to stenotic, accelerated flow in the affected artery. ICA, internal carotid artery.
Figure 2.
Figure 2.
Color-coded duplex sonography depicting the right vertebral artery (V3 segment) in a female patient. The hypoechogenic mural hematoma is clearly visible (arrows). VA, vertebral artery.
Figure 3.
Figure 3.
T1-weighted, fat-saturated magnetic resonance imaging in a female patient who suffered bilateral internal carotid artery dissection. T1-weighted, fat-saturated magnetic resonance imaging: (a) coronal; (b) axial, in a female patient who suffered bilateral internal carotid artery dissection (also see Figure 1 for duplex sonography in the same patient). The T1-hyperintense mural hematoma in both internal carotid arteries is clearly visible (arrows).
See this image and copyright information in PMC

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