Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections

Abstract

Background: American and European guidelines support antiplatelet agents and anticoagulants as reasonable treatments of cervical artery dissection (CAD), though randomized clinical trials are lacking. The utility of novel oral anticoagulants (NOAC), effective in reducing embolic stroke risk in non-valvular atrial fibrillation (NVAF), has not been reported in patients with CAD. We report on the use, safety, and efficacy of NOACs in the treatment of CAD. Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between January 2010 and August 2013. Patients were categorized by their antithrombotic treatment at hospital discharge with a NOAC (dabigatran, rivaroxaban, or apixaban), traditional anticoagulant (AC: warfarin or treatment dose low-molecular weight heparin), or antiplatelet agent (AP: aspirin, clopidogrel, or aspirin/extended-release dypyridamole). Using appropriate tests, we compared the baseline medical history, presenting clinical symptoms and initial radiographic characteristics among patients in the 3 treatment groups. We then evaluated for the following outcomes: recurrent stroke, vessel recanalization, and bleeding complications. p values <0.05 were considered significant. Results: Of the 149 included patients (mean age 43.4 years; 63.1% female; 70.5% vertebral artery CAD), 39 (26.2%), 70 (47.0%), and 40 (26.8%) were treated with a NOAC, AC, and AP, respectively. More patients with severe stenosis or occlusion were treated with NOAC than with AC or AP (61.8 vs. 60.0 vs. 22.5%, p = 0.002). Other baseline clinical and radiographic findings, including the presence of acute infarction and hematoma, did not differ between the 3 treatment groups. One hundred and thirty-five (90.6%) patients had clinical follow-up (median time 7.5 months) and 125 (83.9%) had radiographic follow-up (median time 5 months) information. There were 2 recurrent strokes in the NOAC group and 1 in each of the AC and AP groups (p = 0.822). There were more major hemorrhagic events in the AC group (11.4%) compared to the NOAC (0.0%) and AP (2.5%) groups (p = 0.034). Three patients treated with NOAC and none treated with AC or AP had a worsened degree of stenosis on follow-up imaging (8.6 vs. 0.0 vs. 0.0%, p = 0.019). Conclusion: Compared to traditional anticoagulants for CAD, treatment with NOACs is associated with similar rates of recurrent stroke, fewer hemorrhagic complications, but greater rates of radiographic worsening. These data suggest that NOACs may be a reasonable alternative in the management of CAD. Prospective validation of these findings is needed.

Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome

“…Despite that, anticoagulation therapy is still often used in practice as a stroke prevention strategy in patients with cervical artery dissection. 43 Anticoagulation has been historically used in stroke prevention without good scientific evidence, which triggered several randomized trials including Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) and Warfarin-Aspirin Recurrent Stroke Study (WARSS) that showed no benefit of Warfarin over Aspirin in reducing stroke recurrence 44-47 . The same argument likely holds for cervical arterial dissection where anticoagulation has been historically used in secondary stroke prevention despite the lack of evidence of superiority over aspirin.…”

Bilateral Vertebral Artery Dissection after a Chiropractic Therapy Session

“…Catheter angiography has been the gold standard for the diagnosis of arterial dissections. [21][22][23][24] The most common finding on angiography is the one called "string sign", a long segment of narrowed lumen. The pathognomonic features of dissection, such as an intimal flap or a double lumen, are found in less than 10% of cases.…”

“…Antiplatelet treatments included aspirin, dipyridamole, or clopidogrel alone or in combination. 14,[19][20][21][22] For patients assigned to anticoagulation, treatment with heparin (either unfractionated heparin or a therapeutic dose of low-molecular weight heparin) was followed by warfarin, aiming for an international normalized ratio of 2-3. Novel oral anticoagulants were not used.…”

Estimating the Quantitative Demand of NOAC Antidote Doses on Stroke Units

“…Currently, trials are underway to assess NOACs in secondary prevention after cryptogenic stroke. They may be used for stroke prevention in cervical artery dissection and cerebral venous sinus thrombosis [16] . If NOACs prove to be effective for these entities as well, the prevalence of anticoagulation may rise even further.…”