Cervical arterial dissection: time for a therapeutic trial?
OBJECTIVE
Cervical arterial dissection is a major cause of stroke in young adults, yet despite standard treatment with anticoagulants or antiplatelet drugs, its management remains uncertain. The goal of this study was to assess the natural history of the disorder and to decide on the feasibility of a therapeutic trial.


METHODS
Collaborating members of the Canadian Stroke Consortium prospectively enrolled consecutively referred patients with angiographically proven acute vertebral or carotid arterial dissection. Data recorded included clinical and radiological details, recurrence of ischemic cerebral events, and medical or surgical treatment.


RESULTS
Of 116 patients, 67 had vertebral and 49 had carotid dissections, with no difference in age or sex. In 68 (59%), trauma occurred at the time of dissection. During the course of a 1-year follow-up, at least 17 patients (15%) had recurrent transient ischemic attacks, stroke, or death, mainly in the weeks immediately after the dissection. In 105 patients with complete follow-up, the event rate in those treated with anticoagulants was 8.3% and in those treated with aspirin was 12.4%, a nonsignificant difference of 4.1%. Using these data, we calculate that for a 2-arm trial (aspirin versus anticoagulants) with 80% power and 5% significance, 913 patients are needed in each group.


CONCLUSIONS
From our data indicating an initial relatively high recurrence rate, a multicenter trial of anticoagulants versus aspirin involving a total of 2000 patients is feasible.
Beletsky
Vadim
V
University of Western Ontario, London, Ontario, Canada. vados@imaging.robarts.ca
Nadareishvili
Zurab
Z
Lynch
John
J
Shuaib
Ashfaq
A
Woolfenden
Andrew
A
Norris
John W
JW
D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D002545:Brain Ischemia / Q000209:etiology; D002170:Canada; D020215:Carotid Artery, Internal, Dissection / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D018450:Disease Progression; D004359:Drug Therapy, Combination; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D019838:Neck Injuries / Q000150:complications; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D012008:Recurrence; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D015996:Survival Rate; D016896:Treatment Outcome; D020217:Vertebral Artery Dissection / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors