Key Points:
- Study looks at use of intra-arterial therapy for stroke caused by cervical artery dissection
- Complications low, outcomes “excellent” according to single-center study
Intra-arterial therapy for strokes that arise from cervical artery dissection produces outcomes as good as those seen for other common treatments, reports a retrospective study published online June 10, 2016, ahead of print in Journal of NeuroInterventional Surgery. The endovascular approach also seems to be as effective in this clinical scenario as it is in acute ischemic stroke from other causes.
David Bar-Or, MD, of the Swedish Medical Center (Englewood, CO), and colleagues report that cervical artery dissection is “characterized by intramural hematoma produced by subintimal tear of the carotid and vertebral arterial walls.” It accounts for approximately 2 to 2.5% of all acute ischemic stroke overall but is far more common in younger patients, in whom it is responsible for 10 to 25% of such strokes.
The investigators analyzed data on all 161 patients treated for cervical artery dissection at their high-volume comprehensive stroke center between January 2010 and May 2015. Among these patients, 24 were treated with intra-arterial therapy (11 with the addition of IV thrombolysis and 13 without). Another 11 were treated with IV thrombolysis alone. The remaining 125 patients were treated with either anticoagulation or antiplatelet therapy.
Among the 24 patients treated with intra-arterial therapy, dissections were more common in the internal carotid (n = 18) than in the vertebral arteries (n = 6). All but one patient had intracranial embolus.
Overall, 19 patients were treated with thrombectomy, 17 with intra-arterial thrombolysis, 14 with a stent, and 7 with angioplasty.
A favorable outcome, defined as a 90-day mRS 0-2, was achieved in 63% of patients. There were 4 deaths, 1 symptomatic intracerebral hemorrhage, and 3 procedural complications.
Patients treated with intra-arterial therapy had more severe stroke than those not receiving this therapy (median National Institutes of Health Stroke Scale [NIHSS] score 13 vs. 3, P < .001) and compared with those treated with IV thrombolysis alone (median NIHSS score 10, P = .04). After adjusting for this confounder, there was no difference in the likelihood of having a favorable outcome at 90 days (mRS score 0-2) for either of the 2 comparisons.
Compared with 445 patients who received intra-arterial therapy for other types of stroke, those with cerebral artery dissection were younger (median age 52 vs. 70, P < 0.001) and had less severe stroke (median NIHSS 13 vs 18, P = .03) at baseline. Once again, after controlling for these differences, the likelihood of having favorable outcomes at 90 days was similar for both groups (table 1).
“Patients presenting with [cervical artery dissection] are traditionally managed with antithrombotic therapy, including anticoagulants and antiplatelet aggregation agents,” write the authors. “There is debate as to whether anticoagulation is superior to antiplatelet aggregation agents.” In addition, they report, case series and small reports have suggested that intra-arterial therapy may be a safe and effective option.
The investigators conclude from their data, and the major advances recently seen for acute ischemic stroke in general, that intra-arterial therapy is a solid alternative therapeutic option for this subgroup. “[Our] outcomes appear to be similar to those presented in large [randomized controlled trials] with stroke from all causes, and to the comparison populations at our high volume comprehensive stroke center,” they write.
They encourage others to report on their experiences using intra-arterial therapy for cervical artery dissection and highlight the need for larger randomized trials to confirm their findings.
Source:
Jensen J, Salottolo K, Frei D, et al. Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection. J NeuroInterv Surg. 2016;Epub ahead of print.
Disclosures:
Dr. Bar-Or reports no relevant conflicts of interest.
