Antithrombotic therapy for cervical arterial dissection

• Published in: Lancet neurology 2021-05, Vol.20 (5), p.328-329
• Main Author: Kasner, Scott E
• Format: Article
• Language: English
• Subjects: Antagonists; Anticoagulants; Arteries; Aspirin; Biomarkers; Dissection; Fibrinolytic Agents - therapeutic use; Hemorrhage; Humans; Magnetic resonance imaging; Patients; Stroke; Transient ischemic attack; Veins & arteries; Vitamin K
• ISSN: 1474-4422; 1474-4465
• DOI: 10.1016/S1474-4422(21)00073-9

The investigators anticipated the challenge of low event rates and selected a composite outcome that included stroke, major haemorrhage, and death, as well as MRI-detected silent (or covert) cerebral infarctions and haemorrhages, with the hope that measuring MRI outcomes would augment the power of the study. 194 participants in the TREAT-CAD trial were randomly assigned (within 2 weeks of symptomatic MRI-verified cervical arterial dissection) to a 90-day course of aspirin 300 mg daily (n=100) or vitamin K antagonists (n=94), to test the non-inferiority of aspirin rather than the superiority of either treatment; 173 were included in the final per-protocol population. The composite endpoint occurred in 21 (23%) of 91 patients in the aspirin group compared with 12 (15%) of 82 patients in the vitamin K antagonist group, indicating that the clinical and silent hybrid outcome approach effectively resulted in increased event rates. The TREAT-CAD trial used aspirin only, whereas CADISS permitted alternative antiplatelet agents as well as dual antiplatelet therapy, which has been shown to reduce the risk of early stroke recurrence in people with transient ischaemic attack or minor stroke.8–10 The benefit of dual antiplatelet therapy appears particularly robust in individuals with large vessel disease, which might share some common pathophysiological features with arterial dissection, including intimal disruption.