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Table of Contents    
COMMENTARY
Year : 2019  |  Volume : 67  |  Issue : 4  |  Page : 1060-1061

The Saga of How to Stitch the Tear …


Department of Neurology, Neurosciences Center, AIIMS, New Delhi, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Prof. M V Padma Srivastava
Department of Neurology, Neurosciences Center, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.266270

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How to cite this article:
Padma Srivastava M V. The Saga of How to Stitch the Tear …. Neurol India 2019;67:1060-1

How to cite this URL:
Padma Srivastava M V. The Saga of How to Stitch the Tear …. Neurol India [serial online] 2019 [cited 2019 Nov 18];67:1060-1. Available from: http://www.neurologyindia.com/text.asp?2019/67/4/1060/266270




The abundance of confounding information can challenge medical practitioners, especially when the clinical condition is complex and heterogeneous. Extracranial dissections are integrally a conundrum of diverse etiologies and even more variable clinical presentations. Typically, they run a course across a full spectrum of least discernible problems to devastating strokes. As a general principle, the outcomes are much better than the other stroke subtypes.

The burgeoning literature on various aspects of extracranial dissections are welcome to help gain clarity on nebulous aspects of best management practices. The more evidence obtained, the more confident is a clinician to address an individual case.

Known to be among the most common causes of stroke in the young, dissections assume far more significance in Indian context on account of the sheer number of strokes in young in India (16% of all strokes).[1] Dissections occur when the structural integrity of the arterial wall is compromised, allowing an intramural hematoma to form.

Beyond the hyperacute period, antithrombotic therapy with either anticoagulation or antiplatelet drugs is accepted treatment for ischemic stroke or transient ischemic attacks caused by extracranial artery dissections, although controversy rages regarding the choice between the two regimes.

Added to this, endovascular and surgical repair strategies have emerged, though less often used. Endovascular and surgical repair have been used to treat dissections in those patients who have recurrent ischemia despite antithrombotic therapy.

Antithrombotic therapy with either anticoagulation or antiplatelet medicines are treatment options for ischemic events caused by cervical or vertebral artery dissections. Current evidence suggests no advantage of anticoagulation over antiplatelet regime.

The open-label, assessor-blind pilot trial of CADISS,[2] with 250 patients randomly assigned to antiplatelets or anticoagulants treatment for 3 months, found no difference at 12 months of follow-up in any of the outcome measures including rate of recurrent stroke (which remained uniformly low at 2.5%), hemorrhage, death, or angiographic recanalization rate.

A Meta-analysis of published non-randomized controlled trial in 2012 and 2015 with over 1300 patients found no difference in any outcome measures between the two regimes.[3],[4]

In view of a general low stroke rate, and rarity of outcome events with dissections, investigators estimate that a definitive trial would require approximately 10,000 patients!

The current study by Vineetha et al. elegantly reiterates the same concept that choice of antithrombotic regimen can be either of the antithrombotic regimens and probably driven by individual case-specific parameters, which include the presence of an intramural thrombus, clinical experience of the treating physician, patient values and preferences, comorbid conditions, and tolerance of these agents.



 
  References Top

1.
Dash D, Bhashin A, Pandit AK, Tripathi M, Bhatia R, Prasad K, et al. Risk factors and etiologies of ischemic strokes in young patients: A tertiary hospital study in north India J Stroke 2014;16:173-7.  Back to cited text no. 1
    
2.
CADISS trial investigators, Markus HS, Hayter E, Levi C, Feldman A, Venables G, Norris J. Antiplatelet treatment compared with anticoagulation treatmentfor cervical artery dissection (CVADISS): A randomized trial. Lancet Neurol 2015;14:361.  Back to cited text no. 2
    
3.
Markus HS, Levi C, King A, et al. Antiplatelet therapy vs anticoagulation therapy in Cervical Artery Dissection in Stroke Study (CADISS) randomized clinical trial final results. JAMA Neurol 2019; doi: 10.1001/jamaneurol. 2019.0072.  Back to cited text no. 3
    
4.
Kennedy F, Lanfranconi S, Hicks C, Reid J, Gompertz P, Price C, et al. Antiplatelets vs anticoagulation for dissection: CADISS non randomized arm and meta-analysis. Neurology 2012;79:686.  Back to cited text no. 4
    




 

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