Cervical Artery Dissection in Stroke Study | Clinical Trial - CADISS
Description:
The goal of the trial was to compare the relative effectiveness of antiplatelet therapy versus anticoagulation therapy in patients with extracranial carotid and vertebral artery dissection.
Contribution to the Literature: The CADISS trial suggests that there is no difference between the two strategies (antiplatelet vs. anticoagulation) in mitigating the risk of recurrent stroke at 3 months; the risk of recurrent stroke is also low.
Study Design
Patients were randomized to antiplatelet therapy with aspirin, clopidogrel, or dipyridamole (or a combination) (n = 126) versus anticoagulation with warfarin with an international normalized ratio (INR) goal of 2-3 (n = 124).
Inclusion criteria:
- Extracranial carotid or vertebral artery dissection
- Onset of symptoms within the past 7 days
- Imaging evidence of definite or probable dissection
- Total number of enrollees: 250
- Duration of follow-up: 3 months
- Mean patient age: 49.3 years
- Percentage female: 30%
- Percentage diabetics: 4%
- History of trauma to head or neck: 20%
- Presentation with ischemic stroke: 77%, transient ischemic attack (TIA): 18%, neck pain: 50%, amaurosis fugax: 4%, Horner’s syndrome: 24%
- Ever smoked: 52%
Exclusion criteria:
- Intracranial cerebral artery dissection
- Contraindications to either antiplatelet or anticoagulation drugs, including active peptic ulceration or bleeding peptic ulcer within 1 year
- Use of antiplatelet or anticoagulation drugs for other reasons (e.g., prosthetic heart valves) for which the treatment cannot be replaced with either antiplatelet or anticoagulant drugs
- Pregnancy
Principal Findings:
The primary outcome, ipsilateral stroke or all-cause mortality within 3 months, occurred in 2% of the antiplatelet group versus 1% of the anticoagulation group (p = 0.63).
Secondary outcomes:
- Any stroke: 2% vs. 1% (p = 0.63)
- Any stroke, death, or major bleed: 3% vs. 2% (p = 1.0)
- Major bleeding: 0% vs. 1%
There were 198 confirmed dissections on systematic analysis; the results of the per-protocol analysis were similar.
Interpretation:
Among patients with extracranial carotid or vertebral dissection, recurrent strokes at 3 months are rare, with no difference between antiplatelet and anticoagulant therapy. This is one of the first trials performing a head-to-head comparison between the two arms.
Extracranial carotid/vertebral dissection is a rare cause of ischemic stroke, but typically occurs in younger, physically active patients. Interesting observations from this trial include the fact that only two-thirds of patients with suspected dissection had confirmed angiographic/radiographic evidence on independent review, and that only 50% of patients presented with neck pain (typically considered an important sign for diagnosis of this condition). Further longer-term follow-up of this trial is awaited.
References:
The CADISS Trial Investigators. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol 2015;Feb 12:[Epub ahead of print].
Keywords: Stroke, Anticoagulants, Cerebral Arteries, Vertebral Artery Dissection, Platelet Aggregation Inhibitors, International Normalized Ratio, Ischemic Attack, Transient, Neck Pain, Dipyridamole, Aspirin, Warfarin, Amaurosis Fugax, Horner Syndrome, Smoking
< Back to Listings