Commentary on the Cervical Artery Dissection in Stroke Study Trial.

Abstract

The incidence of cervical artery dissection (CeAD) in the general population is as low as 2.6 to 3.0 per 100 000 inhabitants per year and accounts for only a small proportion of all ischemic stroke, but it is a major cause of stroke among young and middle-aged adults.1–3 Cervicocerebral dissection was the second common cause (15%) preceded by cardioembolism (20%) in 1008 Finnish patients with ischemic stroke aged 15 to 49 years.4 The current guidelines recommend antithrombotic treatment at the acute phase of CeAD, especially in patients presenting with ischemic stroke or transient ischemic attack.5 However, the optimal strategy for prevention of stroke in patients with acute CeAD is controversial, and there is a lively debate around choice of antithrombotic drugs (anticoagulation versus antiplatelet therapy), duration of antithrombotic treatment, and indications for endovascular and surgical treatments. The recent Cervical Artery Dissection in Stroke Study (CADISS) trial6 published in the Lancet Neurology aimed to address one of these questions, namely, which antithrombotic therapy, out of anticoagulation or antiplatelet agents, should be preferred at the acute phase of CeAD. Many practitioners routinely treat CeAD patients with anticoagulants, and some guidelines are supporting this practice,5 mainly based on the empirical argument that the mechanism of ischemic stroke in CeAD is thromboembolic in the vast majority of cases (an assumption derived from the neuroimaging distribution of ischemic lesions).7 The CADISS trial was planned as a phase 2 feasibility trial.8 Patients with CeAD (extracranial carotid or vertebral artery dissection) with onset of symptom within the past 7 days and imaging evidence of definite or probable dissection were included. The sample size required for this feasibility phase was estimated at 250 based on the rates of recurrence reported in observational studies9–11 (details on the …