Antithrombotic Treatment for Cervical Artery Dissection
Josefin E. Kaufmann, Eric L. Harshfield, Henrik Gensicke, Susanne Wegener, Patrik Michel, Georg Kägi, Krassen Nedeltchev, Lars Kellert, Sverre Rosenbaum, Christian H. Nolte, Hanne Christensen, Marcel Arnold, Philippe Lyrer, Christopher Levi, Philip M. Bath, Stefan T. Engelter, Christopher Traenka, Hugh S. Markus, CADISS and TREAT-CAD Investigators, Mohd Nor Azlisham, Rose Boswell, Neil Baldwin, Anthoy Rudd, Isle Burger, Lalit Kalra, Ahamed Hassan, Christopher Price, Anand Dixit, Ronald S. MacWalter, David Cohen, Richard T. Davey, Tim Cassidy, G Gunathilagan, Damian Jenkinson, Frances Harrington, Martin James, G.S. Venables, Nigel Smyth, Hedley Emsley, Louise Shaw, Joanna Lovett, Paul Guyler, Hugh S. Markus, Patrick Gompertz, Debs Kelly, Isam Salih, Brendan Davies, Hamsaraj Shetty, Amit Mistri, David Hargrovers, Khalid Rashed, Brian Clarke, David Collas, Bridget Colam, Rustam Al‐Shahi Salman, Richard Gerraty, Jon Sturm, Christopher Levi, Timothy Kleinig, Andrew Wrong, Peter J. Hand, Candice Delcourt, Alice King, Jeremy Madigan, Atkinson Morley, John W. Norris, Jennifer Peycke, Melina Wilson, Cara Hicks, Elizabeth Hayter, Ranjit Menon, Fiona Kennedy, Usman Khan, Adina L. Feldman, Matt Hollocks, Graham S Venebales, Sally Kerry, Ahames Hassan, Gary A. Ford, Philip M. Bath, Christopher J. Weir, D. Briley, Ajay Bhalla, Stefan T. Engelter, Christopher Traenka, Sabine Schaedelin, Philippe Lyrer, M. Kloss, Dirk W. Droste, Tobias Brandt, MN Psychogius, Alexander Brehm, A Grau, Peter S. Sándor, Stefanie von Felten, Arlette Hammann, Thomas Fabbro, Martina Maurer, Klaus Ehrlich, Astrid Rösler
Abstract
Importance: Cervical artery dissection is the most common cause of stroke in younger adults. To date, there is no conclusive evidence on which antithrombotic therapy should be used to treat patients. Objective: To perform an individual patient data meta-analysis of randomized clinical trials comparing anticoagulants and antiplatelets in prevention of stroke after cervical artery dissection. Data Sources: PubMed.gov, Cochrane database, Embase, and ClinicalTrials.gov were searched from inception to August 1, 2023. Study Selection: Randomized clinical trials that investigated the effectiveness and safety of antithrombotic treatment (antiplatelets vs anticoagulation) in patients with cervical artery dissection were included in the meta-analysis. The primary end point was required to include a composite of (1) any stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up. Data Extraction/Synthesis: Two independent investigators performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and inconsistencies were resolved by a principal investigator. Main Outcomes and Measures: The primary outcome was a composite of (1) ischemic stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up. The components of the composite outcome were also secondary outcomes. Subgroup analyses based on baseline characteristics with a putative association with the outcome were performed. Logistic regression was performed using the maximum penalized likelihood method including interaction in the subgroup analyses. Results: Two randomized clinical trials, Cervical Artery Dissection in Stroke Study and Cervical Artery Dissection in Stroke Study and the Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection, were identified, of which all participants were eligible. A total of 444 patients were included in the intention-to-treat population and 370 patients were included in the per-protocol population. Baseline characteristics were balanced. There were fewer primary end points in those randomized to anticoagulation vs antiplatelet therapy (3 of 218 [1.4%] vs 10 of 226 [4.4%]; odds ratio [OR], 0.33 [95% CI, 0.08-1.05]; P = .06), but the finding was not statistically significant. In comparison with aspirin, anticoagulation was associated with fewer strokes (1 of 218 [0.5%] vs 10 of 226 [4.0%]; OR, 0.14 [95% CI, 0.02-0.61]; P = .01) and more bleeding events (2 vs 0). Conclusions and Relevance: This individual patient data meta-analysis of 2 currently available randomized clinical trial data found no significant difference between anticoagulants and antiplatelets in preventing early recurrent events.