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.
Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: STE reports grants from Swiss National Science Foundation, Swiss Heart Foundation, FAG Basel, University of Basel, the Neurology Department of the University Hospital Basel, and the Science Fund Rehabilitation of the University Department of Geriatric Medicine Felix Platter Basel. He had travel grants, speaker honoraria, or scientific advisory board compensations from Bayer and Boehringer Ingelheim, and his institutions had received an educational grant from Pfizer and research support from Daiichi-Sankyo (outside this research).PL reports grants from Bayer, Swiss National Science Foundation, and ProPatient Foundation of the University Hospital Basel; the Neurology Department of the University Hospital Basel; compensation for research activities from Acticor, outside of the submitted work.All other authors report no disclosures.