Antithrombotic drugs for carotid artery dissection: Updated systematic review

Nikolaos S Avramiotis; Fabian Schaub; Sebastian Thilemann; Philippe Lyrer; Stefan T Engelter

doi:10.1177/23969873241292278

Antithrombotic drugs for carotid artery dissection: Updated systematic review

Eur Stroke J. 2024 Oct 26:23969873241292278. doi: 10.1177/23969873241292278. Online ahead of print.

Authors

Nikolaos S Avramiotis^{1

2}, Fabian Schaub³, Sebastian Thilemann^{1

2}, Philippe Lyrer^{1

2}, Stefan T Engelter^{1

2

4}

Affiliations

¹ Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
² Department of Clinical Research, University of Basel, Basel, Switzerland.
³ Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
⁴ Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.

Abstract

Introduction: Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients. In this Cochrane Review update we compared benefits and harms of eICAD-patients treated with either antiplatelets or anticoagulants.

Patients and methods: Eligible studies were identified through Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, and EMBASE and personal search until December 2023. We included randomized-controlled trials (RCTs) and non-randomized studies comparing anticoagulants with antiplatelets in eICAD-patients. Co-primary outcomes were (i) death (all causes) and (ii) death or disability. Secondary outcomes were ischemic stroke, symptomatic intracranial hemorrhage, and major extracranial hemorrhage. Odds ratios (OR) with 95% CIs were calculated for (i) all studies and (ii) separately for RCTs and non-randomized studies.

Results: We meta-analyzed a total of 42 studies (2624 patients) including 2 RCTs (213 patients) for the primary outcome of death and 31 studies (1953 patients) including 1 RCT (115 patients) for the primary outcome of death or disability. Antiplatelet-treated patients had higher odds for death (OR_all-studies 2.70, 95% CI 1.27-5.72; OR_RTCs 6.80, 95% CI 0.14-345; OR_{non-randomized studies} 2.60, 95% CI 1.20-5.60) and death or disability (OR_all-studies 2.1, 95% CI 1.58-2.66; OR_RTCs 2.2, 95% CI 0.29-16.05; OR_{non-randomized studies} 2.1, 95% CI 1.58-2.66) than anticoagulated patients. Antiplatelet-treated patients had also higher odds for ischemic stroke, though this reached statistical significance only in the subgroup of RCTs (OR_RTC 4.60, 95% CI 1.36-15.51). In turn, antiplatelet-treated patients had less symptomatic intracranial hemorrhage (OR_all-studies 0.25, 95% CI 0.07-0.86) and a tendency toward less major extracranial hemorrhage (OR_all-studies 0.17, 95% CI 0.03-1.03).

Discussion and conclusion: The evidence considering antiplatelets as standard of care in eICAD is weak. Individualized treatment decisions balancing risks versus harms seem recommendable.

Keywords: Dissection; anticoagulants; antiplatelets; carotid; death; disability; stroke.