Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study

Shadi Yaghi, Liqi Shu, Daniel Mandel, Christopher R. Leon Guerrero, Nils Henninger, Jayachandra Muppa, Muhammad Affan, Omair Ul Haq Lodhi, Mirjam R. Heldner, Kateryna Antonenko, David Seiffge, Marcel Arnold, Setareh Salehi Omran, Ross Crandall, Evan Lester, Diego Lopez Mena, Antonio Arauz, Ahmad Nehme, Marion Boulanger, Emmanuel TouzeJoao Andre Sousa, Joao Sargento-Freitas, Vasco Barata, Paulo Castro-Chaves, Maria Teresa Brito, Muhib Khan, Dania Mallick, Aaron Rothstein, Ossama Khazaal, Josefin E. Kaufmann, Stefan T. Engelter, Christopher Traenka, Diana Aguiar De Sousa, Mafalda Soares, Sara Rosa, Lily W. Zhou, Preet Gandhi, Thalia S. Field, Steven Mancini, Issa Metanis, Ronen R. Leker, Kelly Pan, Vishnu Dantu, Karl Baumgartner, Tina Burton, Regina Von Rennenberg, Christian H. Nolte, Richard Choi, Jason Macdonald, Reza Bavarsad Shahripour, Xiaofan Guo, Malik Ghannam, Mohammad Almajali, Edgar A. Samaniego, Sebastian Sanchez, Bastien Rioux, Faycal Zine-Eddine, Alexandre Poppe, Ana Catarina Fonseca, Maria Fortuna Baptista, Diana Cruz, Michele Romoli, Giovanna De Marco, Marco Longoni, Zafer Keser, Kim Griffin, Lindsey Kuohn, Jennifer Frontera, Jordan Amar, James Giles, Marialuisa Zedde, Rosario Pascarella, Ilaria Grisendi, Hipolito Nzwalo, David S. Liebeskind, Amir Molaie, Annie Cavalier, Wayneho Kam, Brian Mac Grory, Sami Al Kasab, Mohammad Anadani, Kimberly Kicielinski, Ali Eltatawy, Lina Chervak, Roberto Chulluncuy-Rivas, Yasmin Aziz, Ekaterina Bakradze, Thanh Lam Tran, Marc Rodrigo-Gisbert, Manuel Requena, Faddi Saleh Velez, Jorge Ortiz Gracia, Varsha Mudassani, Adam De Havenon, Venugopalan Y. Vishnu, Sridhara Yaddanapudi, Latasha Adams, Abigail Browngoehl, Tamra Ranasinghe, Randy Dunston, Zachary Lynch, Mary Penckofer, James Siegler, Silvia Mayer, Joshua Willey, Adeel Zubair, Yee Kuang Cheng, Richa Sharma, João Pedro Marto, Vítor Mendes Ferreira, Piers Klein, Thanh N. Nguyen, Syed Daniyal Asad, Zoha Sarwat, Anvesh Balabhadra, Shivam Patel, Thais Secchi, Sheila Martins, Gabriel Mantovani, Young Dae Kim, Balaji Krishnaiah, Cheran Elangovan, Sivani Lingam, Abid Quereshi, Sebastian Fridman, Alonso Alvarado, Farid Khasiyev, Guillermo Linares, Marina Mannino, Valeria Terruso, Sofia Vassilopoulou, Vasilis Tentolouris, Manuel Martinez-Marino, Victor Carrasco Wall, Fransisca Indraswari, Sleiman El Jamal, Shilin Liu, Muhammad Alvi, Farman Ali, Mohammed Sarvath, Rami Z. Morsi, Tareq Kass-Hout, Feina Shi, Jinhua Zhang, Dilraj Sokhi, Jamil Said, Alexis N. Simpkins, Roberto Gomez, Shayak Sen, Mohammad Ghani, Marwa Elnazeir, Han Xiao, Narendra Kala, Farhan Khan, Christoph Stretz, Nahid Mohammadzadeh, Eric Goldstein, Karen Furie

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)

Abstract

BACKGROUND: Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation. METHODS: This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-Treated crossover approach and only included outcomes occurring with the above treatments. RESULTS: The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; Pinteraction=0.009). CONCLUSIONS: Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.

Original languageEnglish
Pages (from-to)908-918
Number of pages11
JournalStroke
Volume55
Issue number4
DOIs
Publication statusPublished - 1 Apr 2024

Keywords

  • anticoagulants
  • arteries
  • hemorrhage
  • ischemic stroke
  • stroke

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