on July 26, 2007
Published online before print July 26, 2007, doi: 10.1161/STROKEAHA.107.489666
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Submitted on March 29, 2007
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. * To whom correspondence should be addressed. 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
Accepted on April 17, 2007
Antiplatelets Versus Anticoagulation in Cervical Artery Dissection
Stefan T. Engelter*;
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