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Meta-Analysis
. 2024 Jul;55(7):1776-1786.
doi: 10.1161/STROKEAHA.124.047310. Epub 2024 Jun 7.

Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis

Shadi Yaghi  1 , Liqi Shu  1 , Lauren Fletcher  2 , Fayez H Fayad  1 , Asghar Shah  1 , Ana Herning  3 , Noail Isho  4 , Perla Mansour  5 , Kareem Joudi  1 , Bashar Zaidat  6 , Noor A Mahmoud  7 , Feras Abdul Khalek  8 , Han Xiao  9 , Eric Goldstein  1 , Malik Ghannam  10 , James E Siegler  11 , Setareh Salehi Omran  12 , Ekaterina Bakradze  13 , Thanh N Nguyen  14 , Zafer Keser  15 , Muhib Khan  15 , Reza Bavarsad Shahripour  16 , Adam de Havenon  17 , Nils Henninger  18 , Mirjam R Heldner  19 , Thalia S Field  20 , Yasmin Aziz  21 , Eva A Mistry  21 , Karen Furie  1 , Stefan Engelter #  22 , Hugh S Markus #  23
Affiliations
Meta-Analysis

Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis

Shadi Yaghi et al. Stroke. 2024 Jul.

Abstract

Background: It is uncertain whether antiplatelets or anticoagulants are more effective in preventing early recurrent stroke in patients with cervical artery dissection. Following the publication of the observational Antithrombotic for STOP-CAD (Stroke Prevention in Cervical Artery Dissection) study, which has more than doubled available data, we performed an updated systematic review and meta-analysis comparing antiplatelets versus anticoagulation in cervical artery dissection.

Methods: The systematic review was registered in PROSPERO (CRD42023468063). We searched 5 databases using a combination of keywords that encompass different antiplatelets and anticoagulants, as well as cervical artery dissection. We included relevant randomized trials and included observational studies of dissection unrelated to major trauma. Where studies were sufficiently similar, we performed meta-analyses for efficacy (ischemic stroke) and safety (major hemorrhage, symptomatic intracranial hemorrhage, and death) outcomes using relative risks.

Results: We identified 11 studies (2 randomized trials and 9 observational studies) that met the inclusion criteria. These included 5039 patients (30% [1512] treated with anticoagulation and 70% [3527]) treated with antiplatelets]. In meta-analysis, anticoagulation was associated with a lower ischemic stroke risk (relative risk, 0.63 [95% CI, 0.43 to 0.94]; P=0.02; I2=0%) but higher major bleeding risk (relative risk, 2.25 [95% CI, 1.07 to 4.72]; P=0.03, I2=0%). The risks of death and symptomatic intracranial hemorrhage were similar between the 2 treatments. Effect sizes were larger in randomized trials. There are insufficient data on the efficacy and safety of dual antiplatelet therapy or direct oral anticoagulants.

Conclusions: In this study of patients with cervical artery dissection, anticoagulation was superior to antiplatelet therapy in reducing ischemic stroke but carried a higher major bleeding risk. This argues for an individualized therapeutic approach incorporating the net clinical benefit of ischemic stroke reduction and bleeding risks. Large randomized clinical trials are required to clarify optimal antithrombotic strategies for management of cervical artery dissection.

Keywords: anticoagulation; antiplatelet; cervical artery dissection; stroke.

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Conflict of interest statement

Disclosures Dr Henninger has received funding from the National Institutes of Health ([NIH]; NS131756, NR020231) during the conduct of this study, unrelated to the present work. Dr Nguyen discloses advisory board for Brainomix and Aruna and is an Associate Editor for Stroke. Dr Siegler has served as a consultant for AstraZeneca and has received funding from the NIH (R61NS135583), vizai, Philips, and Medtronic, unrelated to this work. Dr Field has received in-kind study medication from Bayer and discloses advisory board participation for Bayer, AstraZeneca, Roche, HLS Therapeutics, and Novartis, is on the board of DESTINE Health, and has served as an expert witness. Dr Mistry receives funding from the NIH/National Institute of Neurological Disorders and Stroke and Patient Centered Outcomes Research Institute. She serves as a consultant for AbbVie and RAPID AI and serves on the steering committee for SilverCreek Pharmaceuticals. She reports a nonfinancial relationship with Translational Sciences Inc. She is also an Associate Editor for Stroke and is employed by the University of Cincinnati. Dr de Havenon is a consultant for Integra, TitinKM, and Novo Nordisk, own stocks in Certus, and receives grant support from the NIH. Dr Fletcher received funds from the Library association and is an officer of the Association of College and Research Libraries and the Medical Library Association. Dr Furie is a consultant for Janssen Biotech. Dr Markus receives infrastructural support provided by the Cambridge British Heart Foundation Centre of Research Excellence (RE/18/1/34212) and by the Cambridge University Hospitals NIHR Biomedical Research Centre (NIHR203312).

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