Cervical artery dissection: Pathology, epidemiology and management

Background: Cervical artery dissection is often treated with anticoagulants to prevent ischemic stroke. The risk-benefit ratio of anticoagulation versus antiplatelet therapy is unclear. Objectives: To provide an educational review of current data on the disease to explain the rationale for the treatment options and to explore the results of management studies in order to determine if anticoagulation is justified. Methods: We searched the databases MEDLINE and EMBASE as well as bibliographies for information on anticoagulants and antiplatelet agents in cervical, i.e. carotid and/or vertebral artery, dissection. Results: There are no randomized controlled trials on the treatment. One systematic review from 2003 identified 20 case series or cohort studies. We identified 9 additional studies with a total of 1,033 patients. Of those, 731 received anticoagulation sometimes followed by platelet inhibition vs. 282 patients treated with antiplatelet agents alone. The rate of ischemic stroke was 2.3% vs. 6.9% and bleeding complications were reported in 0.7% vs. 0%. Conclusion: It cannot be excluded that there is a net benefit from anticoagulant therapy in cervical dissection, but the studies are flawed by considerable bias. Very ill patients at a high risk of ischemic stroke may have been given aspirin due to fear of hemorrhagic complications. A randomized controlled trial is planned and will be crucial to resolve this issue. (C) 2009 Elsevier Ltd. All rights reserved.