STOP-CAD study informs optimal treatment strategy for cervical artery dissection
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Key takeaways:
- Risk for stroke after cervical artery dissection was similar with an anticoagulation vs. antiplatelet treatment strategy.
- Switching to antiplatelet therapy after 30 days may lower major bleeding risk.
For patients with cervical artery dissection initially treated with anticoagulation, switching to antiplatelet therapy at 30 days may prevent bleeding events later, as stroke risk was lower by then, researchers reported.
The results of the STOP-CAD study were presented at the International Stroke Conference and simultaneously published in Stroke.
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“Cervical artery dissection accounts for about 2% of ischemic strokes, but up to 25% of ischemic strokes in young adults,” Shadi Yaghi, MD, associate professor of neurology and vascular neurology division chief at The Warren Alpert Medical School at Brown University, said during a presentation. “Cervical artery dissection leads to ischemic stroke by two mechanisms, distal artery embolization or impaired distal perfusion. The most common cause of stroke in cervical artery dissection is distal embolization. And this risk of subsequent stroke in clinical trials within 90 days is about 3%. It’s a little bit higher in observational studies. And current guidelines recommend antithrombotic therapy for about 3 to 6 months after cervical artery dissection, and they don’t specify which treatment to use, antiplatelets vs. anticoagulation.”
Yaghi and colleagues designed the STOP-CAD study to determine the risk for ischemic stroke and major hemorrhage in individuals with cervical artery dissection treated with antiplatelet therapy compared with anticoagulation.
STOP-CAD was a multicenter, international, retrospective observational study that included 3,636 patients with cervical artery dissection and treated with antiplatelet therapy, anticoagulation or both at 63 sites in 16 countries (mean age, 47 years; 54% men).
The primary outcome was subsequent ischemic stroke in the area of the index cervical artery dissection during follow-up. The primary safety outcome was major hemorrhage including major extracranial hemorrhage and symptomatic intracranial hemorrhage during follow-up.
The researchers noted that women, white individuals and those with partially occlusive thrombus were more likely to be treated with anticoagulation only compared with antiplatelet therapy alone, whereas Asian patients, patients with intracranial dissection and those who underwent endovascular treatment were more likely to receive antiplatelet therapy alone.
Overall, 4.4% experienced a subsequent ischemic stroke by day 180, with 87% of ischemic strokes having occurred by day 30.
After inverse probability weighting, Yaghi reported that individuals with cervical artery dissection treated with anticoagulation had increased risk for major hemorrhage at 180 days compared with those treated with antiplatelet therapy (HR = 5.56; 95% CI, 1.53-20.13; P = .009), but no other differences were observed at any time point for either ischemic stroke of hemorrhage risk.
The findings were consistent across subgroup analyses, including in analyses comparing antiplatelet therapy with parenteral anticoagulation, direct oral anticoagulants or vitamin K antagonists.
Moreover, in interaction analyses, occlusive cervical artery dissection was associated with lower risk for ischemic stroke (HR = 0.4; 95% CI, 0.18-0.88) in the overall cohort compared with nonocclusive dissection (HR = 1.34; 95% CI, 0.83-2.14; P for interaction = .009).
“The STOP-CAD study cannot exclude the benefit of anticoagulation over antiplatelet therapy in lowering ischemic stroke risk following cervical artery dissection, particularly in patients with occlusive dissection,” Yaghi said during the presentation. “There was an increased risk of major bleeding with anticoagulation when used for up to 180 days. If anticoagulation is chosen initially, it may be reasonable to switch to antiplatelet therapy at 30 days to lower the risk of major bleeding, particularly that the majority of subsequent ischemic strokes happened in the first 30 days. Our study could inform design of prospective registry with systematic data collection [and] pragmatic trials, as well to help further address this important clinical question and validate our study findings.”
Reference:
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Yaghi S, et al. Closing main event: LB 30. Presented at: International Stroke Conference; Feb. 7-9, 2024; Phoenix.
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