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(Stroke. 2007;38:2605.)
© 2007 American Heart Association, Inc.

Comments, Opinions, and Reviews

Antiplatelets Versus Anticoagulation in Cervical Artery Dissection

Stefan T. Engelter, MD; Tobias Brandt, MD; Stéphanie Debette, MD; Valeria Caso, MD; Christoph Lichy, MD; Alessandro Pezzini, MD; Sherine Abboud, MD; Anna Bersano, MD; Ralf Dittrich, MD; Caspar Grond-Ginsbach, PhD; Ingrid Hausser, PhD; Manja Kloss, MD; Armin J. Grau, MD; Turgut Tatlisumak, MD, PhD; Didier Leys, MD, PhD; Philippe A. Lyrer, MD for the Cervical Artery Dissection in Ischemic Stroke Patients (CADISP) Study Group

From the Neurological Clinic and Stroke Unit (S.T.E., P.L.), University Hospital Basel, Switzerland; Clinics for Neurologic Rehabilitation (T.B.), Kliniken Schmieder, Heidelberg, Germany; Stroke Unit (S.D., D.L.), University Hospital of Lille, France; Stroke Unit (V.C.), Silvestrini San’Andrea delle Fratte Hospital, Perugia, Italy; Department of Neurology (C.L., C.G.-G., M.K.), University of Heidelberg, Germany; Department of Medical Sciences (A.P.), Neurological Clinic, University of Brescia, Italy; Department of Neurology (S.A.), Laboratory of Experimental Neurology, ULB-Erasme Hospital, Brussels, Belgium; Department of Neurological Science (A.B.), Hospital Maggiore di Milano, Milano, Italy; Department of Neurology (R.D.), University Hospital of Muenster, Germany; Department of Dermatology (I.H.), University of Heidelberg, Germany; Department of Neurology (A.J.G.), City Hospital Ludwigshafen, Germany; Department of Neurology (T.T.), University Central Hospital, Helsinki, Finland.

Correspondence to S.T. Engelter, MD, Neurological Clinic and Stroke Unit, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland. E-mail sengelter{at}uhbs.ch

Background and Purpose— The widespread preference of anticoagulants over antiplatelets in patients with cervical artery dissection (CAD) is empirical rather than evidence-based.

Summary of Review— This article summarizes pathophysiological considerations, clinical experiences, and the findings of a systematic metaanalysis about antithrombotic agents in CAD patients. As a result, there are several putative arguments in favor as well as against immediate anticoagulation in CAD patients.

Conclusions— A randomized controlled trial comparing antiplatelets with anticoagulation is needed and ethically justified. However, attributable to the large sample size which is required to gather meaningful results, such a trial represents a huge venture. This comprehensive overview may be helpful for the design and the promotion of such a trial. In addition, it could be used to encourage both participation of centers and randomization of CAD patients. Alternatively, antithrombotic treatment decisions can be customized based on clinical and paraclinical characteristics of individual CAD patients. Stroke severity with National Institutes of Health Stroke Scale score 15, accompanying intracranial dissection, local compression syndromes without ischemic events, or concomitant diseases with increased bleeding risk are features in which antiplatelets seem preferable. In turn, in CAD patients with (pseudo)occlusion of the dissected artery, high intensity transient signals in transcranial ultrasound studies despite (dual) antiplatelets, multiple ischemic events in the same circulation, or with free-floating thrombus immediate anticoagulation is favored.

Key Words: anticoagulation • antiplatelets • antithrombotic treatment • cervical artery • dissection • stroke