Engelter Stefan T, Lyrer Philippe, Traenka Christopher
Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland.
Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.
Ther Adv Neurol Disord. 2021 Aug 12;14:17562864211037238. doi: 10.1177/17562864211037238. eCollection 2021.
This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.
本综述总结了近期颈段动脉夹层（CeAD）和颅内动脉夹层（IAD）研究中的治疗进展。尽管疗效尚未得到证实，但在没有任何有害信号的情况下，对于因CeAD导致急性缺血性卒中的患者，应考虑静脉溶栓治疗，若存在大血管闭塞，则应考虑血管内血运重建治疗。未来的研究将阐明哪种治疗方式对哪些患者最有益。对于卒中预防，最近发表的随机对照TREAT-CAD研究表明，与最初的假设相反，阿司匹林并不优于维生素K拮抗剂（VKA）抗凝治疗。鉴于目前有两项随机对照试验（CADISS和TREAT-CAD）的结果，将阿司匹林作为CeAD标准治疗方法的证据并不充分。进一步的分析可能会阐明，特别是对于出现脑缺血（临床或磁共振成像替代指标显示的亚临床缺血）的患者，是否最能从VKA治疗中获益。反过来，对于表现为单纯局部症状且无血流动力学障碍的CeAD患者，抗血小板治疗是否足够，以及在治疗的最初几周内是否推荐双联抗血小板治疗，仍有待证实。在随机和观察性研究中一致观察到，CeAD诊断后很快就会发生（或复发）缺血性卒中，这支持了无论在每个具体病例中选择何种抗血栓药物，都应立即开始抗血栓治疗的建议。CeAD患者缺乏使用许可且数据稀少，这仍然是反对在CeAD中使用直接口服抗凝剂的理由。然而，鉴于其在房颤中已证实的有益安全性和疗效，这些药物是值得在进一步的CeAD治疗试验中进行测试的治疗选择。在IAD中，抗血栓药物的使用经验有限。由于IAD发生颅内出血的风险高于CeAD，IAD中抗血栓治疗的使用仍存在争议。
