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(Stroke. 2005;36:2041.)
© 2005 American Heart Association, Inc.

Controversies in Stroke

Extracranial Arterial Dissection

Anticoagulation Is the Treatment of Choice: For

From St George Hospital Medical School, London, United Kingdom.

Correspondence to John W. Norris, MD, FRCP; St Georges Hospital Medical School, Dept of Clinical Neurosciences, St. Georges Hospital, London, United Kingdom SW17 0RE. Email carotid@btopenworld.com

Section Editors: Geoffrey A. Donnan MD, FRACP Stephen M. Davis MD, FRACP

Key Words: treatment

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Anticoagulant therapy has been advocated consistently as the treatment of choice for cervical arterial dissection in numerous published studies and reviews,¹ but there is little evidence-based data to justify this assumption. Although dissection of the cervical arteries has long been established as a cause of ischemic and hemorrhagic stroke, the major obstacle to planning therapeutic studies has been the perception that this is a relatively rare phenomenon. However, rapid developments in accurate noninvasive imaging have shown cervical arterial dissection as a common, if not the most common, cause of ischemic stroke in persons <50 years of age. This has raised for the first time the realistic concept of a therapeutic trial of anticoagulants versus antiplatelet treatment. A recent Cochrane review² cited a figure of 1000 patients in each therapeutic arm, and similar figures were calculated from the only prospective study published to date.³

Arterial dissection can theoretically cause ischemic stroke either by embolism from the site of the intimal tear, or hemodynamically from luminal obstruction. Available evidence strongly favors artery-to-artery embolism as the most common cause, and the pattern of cerebral infarction in stroke from dissection is typical of that seen in other types of cerebral embolism.⁴ Even more interesting, microemboli have not only been detected by transcranial Doppler in acute cervical arterial dissections, but they also correlate with the presence of stroke in patients with traumatic and "spontaneous" dissections.⁵

All these factors intuitively favor the use of anticoagulant therapy, at least in the immediate poststroke phase, to minimize distal . . . [Full Text of this Article]

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