Predictors of Stroke Recurrence After Initial Diagnosis of Cervical Artery Dissection
Authors: Mandel Daniel M. , Shu Liqi , Chang Christopher , Jack Naomi , Leon Guerrero Christopher R. , Henninger Nils , Muppa Jayachandra , Affan Muhammad , Haq Lodhi Omair Ul , Heldner Mirjam R. , Antonenko Kateryna , Seiffge David , Arnold Marcel , Omran Setareh Salehi , Crandall Ross , Lester Evan , Mena Diego Lopez , Arauz Antonio , Nehme Ahmad , Boulanger Marion , Touze Emmanuel , Sousa Joao Andre , Sargento-Freitas Joao , Barata Vasco , Castro-Chaves Paulo , Brito Maria Teresa , Khan Muhib , Mallick Dania , Rothstein Aaron , Khazaal Ossama , Kaufman Josefin E. , Engelter Stefan T. , Traenka Christopher , de Sousa Diana Aguiar , Soares Mafalda , Rosa Sara , Zhou Lily W. , Gandhi Preet , Field Thalia S. , Mancini Steven , Metanis Issa , Leker Ronen R. , Pan Kelly , Dantu Vishnu , Baumgartner Karl , Burton Tina , von Rennenberg Regina , Nolte Christian H. , Choi Richard , MacDonald Jason , Shahripour Reza Bavarsad , Guo Xiaofan , Ghannam Malik , Almajali Mohammad , Samaniego Edgar A. , Sanchez Sebastian , Rioux Bastien , Zine-Eddine Faycal , Poppe Alexandre , Fonseca Ana Catarina , Baptista Maria Fortuna , Cruz Diana , Romoli Michele , De Marco Giovanna , Longoni Marco , Keser Zafer , Griffin Kim , Kuohn Lindsey , Frontera Jennifer , Amar Jordan , Giles James , Zedde Marialuisa , Pascarella Rosario , Grisendi Ilaria , Nzwalo Hipolito , Liebeskind David S. , Molaie Amir , Cavalier Annie , Kam Wayneho , Grory Brian Mac , Al Kasab Sami , Anadani Mohammad , Kicielinski Kimberly , Eltatawy Ali , Chervak Lina , Rivas Roberto Chulluncuy , Aziz Yasmin , Bakradze Ekaterina , Tran Thanh Lam , Gisbert Marc Rodrigo , Requena Manuel , Velez Faddi Saleh , Gracia Jorge Ortiz , Muddasani Varsha , de Havenon Adam , Vishnu Venugopalan Y , Yaddanapudi Sridhara , Adams Latasha , Browngoehl Abigail , Ranasinghe Tamra , Dunston Randy , Lynch Zachary , Penckofer Mary , Siegler James E. , Mayer Silvia , Willey Joshua , Zubair Adeel , Cheng Yee Kuang , Sharma Richa , Marto João Pedro , Ferreira Vítor Mendes , Klein Piers , Nguyen Thanh N. , Asad Syed Daniyal , Sarwat Zoha , Balabhadra Anvesh , Patel Shivam , Secchi Thais , Martins Sheila , Mantovani Gabriel , Kim Young Dae , Krishnaiah Balaji , Elangovan Cheran , Lingam Sivani , Quereshi Abid , Fridman Sebastian , Alvarado Alonso , Khasiyev Farid , Linares Guillermo , Mannino Marina , Terruso Valeria , Vassilopoulou Sofia , Tentolouris Vasilis , Marino Manuel Martinez , Wall Victor Carrasco , Indraswari Fransisca , El Jamal Sleiman , Liu Shilin , Alvi Muhammad , Ali Farman , Sarvath Mohammed , Morsi Rami Z. , Kass-Hout Tareq , Shi Feina , Zhang Jinhua , Sokhi Dilraj , Said Jamil , Mongare Newnex , Simpkins Alexis , Gomez Roberto , Sen Shayak , Ghani Mohammad , Elnazeir Marwa , Xiao Han , Kala Narendra , Khan Farhan , Stretz Christoph , Mohammadzadeh Nahid , Goldstein Eric , Furie Karen , Yaghi Shadi 
Published: August 2024

Objective

Patients with cervical artery dissection (CAD) are at increased ischemic stroke risk. We aimed to identify characteristics that are associated with increased risk of ischemic stroke following initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals.

Methods

This was a secondary analysis of the Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection (STOP-CAD) study, a multicenter retrospective observational study. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Patient characteristics were compared between those with vs. without subsequent ischemic stroke. Significant predictors were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type in high-risk patients were explored using adjusted Cox regression.

Results

4,023 patients (mean age 47.4 years; 44.5% were women) were included. By day 180, 5.3% experienced a subsequent ischemic stroke. In adjusted Cox regression, factors associated with increased subsequent ischemic stroke risk were prior ischemic stroke (aHR 7.31, 95% CI 1.61-33.13, p=0.010), presentation within seven days from symptoms, (aHR 3.04, 95% CI 1.04-8.91, p=0.043), infarct on imaging (aHR 9.85, 95% CI 3.65-26.58, p<0.001), and occlusive dissection (aHR 2.34, 95% CI 1.03-5.34, p=0.043). Only patients with occlusive dissection had reduced subsequent ischemic stroke risk with anticoagulation versus antiplatelets (HR 0.37; 95% CI 0.15-0.89, p=0.03).

Interpretation

This study identified several predictors of subsequent ischemic stroke among patients with CAD but only patients with occlusive dissection demonstrated a benefit from anticoagulation. These findings require validation by meta-analyses of prior studies.