Antithrombotic drugs for carotid artery dissection: Updated systematic review

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.