Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting

Serkin, Zakhar; Le, Scott; Sila, Cathy A.

doi:10.1007/s11940-019-0589-7

Cited by 14 publications

(9 citation statements)

References 38 publications

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“…The small sample size precluded subgroup analysis between anticoagulation and antiplatelet therapy. Therefore, the superiority of one method of antithrombotic therapy over the other is yet to be established and remains a topic worthy of investigation [8,10,12].…”

Section: Discussionmentioning

confidence: 99%

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Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry

et al. 2020

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Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. Objective: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. Methods: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/ recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0-2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). Conclusions: We report diagnostic characteristics, as well as short-and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

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Section: Discussionmentioning

confidence: 99%

“…Because CeAD is relatively rare in the general population, it has been difficult to establish a clear management strategy [7][8][9][10][11][12]. Patients are often managed with anticoagulation or antiplatelet therapy for at least 3-6 months, but a standard regimen has yet to be defined.…”

Section: Introductionmentioning

confidence: 99%

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry

et al. 2020

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“…Cranio‐cervical artery dissection (CeAD) is a vascular process characterized by the separation of the intimal, medial, or adventitial layers of the vertebral or internal carotid arteries of the brain (intracranial) or neck (extracranial) 1–3 . The creation of a false lumen and thus disruption of normal blood flow creates a favorable environment for thrombus formation, which can then embolize and result in stroke 2,3 .…”

Section: Introductionmentioning

confidence: 99%

“…The creation of a false lumen and thus disruption of normal blood flow creates a favorable environment for thrombus formation, which can then embolize and result in stroke 2,3 . Although incidence is low in the general population, CeAD is recognized as a common cause of ischemic stroke in the young patient population, causing approximately 25% of strokes in patients 45 years‐old or younger 1,4,5 . Dissection is often a result of precipitating events, such as trauma and chiropractic neck manipulations, including motor vehicle accidents, but also may occur spontaneously 3,4,6 .…”

Section: Introductionmentioning

confidence: 99%

Stenting as a treatment for cranio‐cervical artery dissection: Improved major adverse cardiovascular event‐free survival

Vezzetti

Rosati

Lowe

et al. 2021

Cathet Cardio Intervent

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Introduction Cranio‐cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. Methods COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high‐volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2‐year period. Patients were ≥ 18 years of age with confirmed extra‐ or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint. Results One‐hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician's discretion along with medical management. Reasons for stent placement were early development of high‐grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in‐hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year. Conclusion In this single high‐volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high‐grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

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“…If obvious injuries are identified prior to onset, including minor injuries (e.g., sudden neck rotation and cervical spine manipulation), the dissection is regarded as "traumatic". At present, the optimal therapy for patients with CAD has not been determined [5]. Antiplatelets or anticoagulants are usually recommended to prevent primary or recurrent ischemic events.…”

Section: Introductionmentioning

confidence: 99%

Predisposing factors and radiological features in patients with internal carotid artery dissection or vertebral artery dissection

Chen

Xing

et al. 2020

BMC Neurol

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Background Cervicocerebral artery dissection is an important cause of ischemic stroke in young and middle-aged individuals. However, very few studies have compared the differential features between internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD), including both cervical and intracranial artery dissections. We conducted a study to investigate the predisposing factors and radiological features in patients with ICAD or VAD. Methods All cases diagnosed with cervicocerebral artery dissection, ICAD, or VAD were identified through a medical records database, between January 2010 and January 2020. Baseline characteristics, predisposing factors, and radiological features of ICAD versus VAD were compared. Results A total of 140 patients with cervicocerebral artery dissection were included in the study, including 84 patients in the ICAD group and 56 in the VAD group. The mean age of patients in the ICAD and VAD groups was 43.37 ± 14.01 and 41.00 ± 12.98 years old, respectively. Patients with ICAD were more likely to be men compared with VAD (85.71% vs. 67.86%, p = 0.012). The frequency of hypertension, diabetes, smoking, drinking, and cervical trauma did not differ between ICAD and VAD. Dissections of ICAD were more frequently at the extracranial portions of the artery compared with those of VAD (70.24% vs. 44.64%, p = 0.003). In contrast, dissections of VAD were more common in the intracranial artery (55.36% vs. 29.76%, p = 0.003). Radiologically, double lumen (36.90% vs. 19.64%, p = 0.029) and intimal flap (11.90% vs. 1.79%, p = 0.029) were more frequently observed in ICAD than in VAD, and dissecting aneurysms were less frequent (13.10% vs. 26.79%, p = 0.041). Conclusions The distributions of cervical and intracranial artery dissections were different between ICAD and VAD. The frequencies of radiological features detected in patients with ICAD and VAD also differed.

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Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting

Cited by 14 publications

References 38 publications

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry

Stenting as a treatment for cranio‐cervical artery dissection: Improved major adverse cardiovascular event‐free survival

Predisposing factors and radiological features in patients with internal carotid artery dissection or vertebral artery dissection

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