Antithrombotic treatment of cervical artery dissection: A systematic review and meta-analysis

Though anticoagulation is a well-established treatment for stroke prevention in cervical artery dissection, antiplatelet agents could offer comparable effectiveness and lower bleeding risk. This meta-analysis assesses the incidence of stroke and hemorrhagic events following various antithrombotic treatments. A systematic search was conducted using PubMed, Scopus, and Cochrane Library databases, including comparative studies involving patients with cervical artery dissection treated with anticoagulants and antiplatelet agents, and was registered in the PROSPERO database. The primary outcomes were stroke and hemorrhagic events. Prespecified random effects subgroup analysis was conducted to examine the impact of different types of anticoagulants and various antiplatelet treatment schemes, indicating the antiplatelet group as the reference for the odds ratio (OR). A total of 22 studies reporting on 5180 patients treated with antiplatelets, vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs) for prevention of stroke fulfilled the inclusion criteria. The incidence of stroke (OR: 0.86, 95% CI: 0.62-1.20, p = 0.38), intracranial hemorrhage (OR: 0.66, 95% CI: 0.30-1.44, p = 0.30), and extracranial hemorrhage (OR: 0.74, 95% CI: 0.23-2.41, p = 0.62) was not statistically significantly different between the anticoagulant and antiplatelet groups. The comparison of antiplatelets to VKAs (OR: 1.46, 95% CI: 0.79-2.72, p = 0.23) and exclusively aspirin to VKAs (OR: 1.26, 95% CI: 0.48-3.29, p = 0.64) shows nonsignificant differences in terms of stroke. Overall, hemorrhagic events were less frequent in the antiplatelet compared to VKA groups (OR: 0.40, 95% CI: 0.17-0.91, p = 0.03). Anticoagulation demonstrates a comparable incidence of stroke events, intra- and extracranial hemorrhage, and mortality with antiplatelet therapy. (PROSPERO Registration No.: CRD42024535906).