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].

Clinical Topics: Anticoagulation Management, Prevention, Vascular Medicine, Statins, Smoking

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


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