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Aspirin or Anticoagulation to Prevent Stroke in Carotid Dissection?

In a retrospective study, the incidence of stroke was similar between the two treatments.

Spontaneous extracranial internal carotid artery dissection is an uncommon cause of acute ischemic stroke. Treatment is aimed at prevention of subsequent ischemic stroke, and the choice of treatment is largely empirical and based almost exclusively on case series. Although anticoagulation with heparin followed by warfarin is the most common treatment, no prospective randomized trials have compared this regimen to antiplatelet therapy.

In a retrospective analysis of 298 consecutive adult patients who presented with spontaneous extracranial internal carotid artery dissection to two hospitals in Switzerland during an 18-year period, investigators compared rates of subsequent ischemic events and hemorrhagic complications between patients treated with anticoagulation alone (heparin followed by warfarin; 202 patients) and those treated with aspirin alone (96 patients). Treatment decisions were at the discretion of the treating neurologists. During 3 months of follow-up, no statistically significant differences between the anticoagulant and aspirin groups occurred in the frequency of ischemic events (5.9% and 2.1%) or the incidence of hemorrhagic complications (2.0% and 1.0%).

Comment: Previous studies, including a Cochrane systematic review, found no difference in the subsequent incidence of stroke among patients with spontaneous extracranial internal carotid artery dissection who were treated with anticoagulation, antiplatelet therapy, and even no therapy. Although the current study’s findings are consistent with the previous results, a large prospective randomized trial is needed before any single regimen, including no therapy, can be definitively recommended. In the meantime, instituting conventional anticoagulation or antiplatelet therapy in collaboration with the treating consultant makes sense.

— Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine June 26, 2009

Citation(s):

Georgiadis D et al. Aspirin vs anticoagulation in carotid artery dissection: A study of 298 patients. Neurology 2009 May 26; 72:1810.

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• Statistical interpretation
  Juan Matos, 8 Jul 2009 11:32 PM EST
  I would say that 6% versus 2% is a significant statistical difference.