Factors Associated With Stroke Recurrence After Initial Diagnosis of Cervical Artery Dissection
Daniel M. Mandel, Liqi Shu, Christopher Chang, Naomi Jack, Christopher R. Leon Guerrero, Nils Henninger, Jayachandra Muppa, Muhammad Affan, Omair Ul Haq Lodhi, Mirjam R. Heldner, Kateryna Antonenko, David Seiffge, Marcel Arnold, Setareh Salehi Omran, Ross Crandall, Evan Lester, Diego Lopez Mena, Antonio Arauz, Ahmad Nehme, Marion Boulanger, Emmanuel Touze, Joao Andre Sousa, Joao Sargento-Freitas, Vasco Barata, Paulo Castro-Chaves, Maria Teresa Brito, Muhib Khan, Dania Mallick, Aaron Rothstein, Ossama Khazaal, Josefin E. Kaufman, Stefan T. Engelter, Christopher Traenka, Diana Aguiar de Sousa, Mafalda Soares, Sara Rosa, Lily W. Zhou, Preet Gandhi, Thalia S. Field, Steven Mancini, Issa Metanis, Ronen R. Leker, Kelly Pan, Vishnu Dantu, Karl Baumgartner, Tina Burton, Regina von Rennenberg, Christian H. Nolte, Richard Choi, Jason MacDonald, Reza Bavarsad Shahripour, Xiaofan Guo, Malik Ghannam, Mohammad Almajali, Edgar A. Samaniego, Sebastian Sanchez, Bastien Rioux, Faycal Zine-Eddine, Alexandre Poppe, Ana Catarina Fonseca, Maria Fortuna Baptista, Diana Cruz, Michele Romoli, Giovanna De Marco, Marco Longoni, Zafer Keser, Kim Griffin, Lindsey Kuohn, Jennifer Frontera, Jordan Amar, James Giles, Marialuisa Zedde, Rosario Pascarella, Ilaria Grisendi, Hipolito Nzwalo, David S. Liebeskind, Amir Molaie, Annie Cavalier, Wayneho Kam, Brian Mac Grory, Sami Al Kasab, Mohammad Anadani, Kimberly Kicielinski, Ali Eltatawy, Lina Chervak, Roberto Chulluncuy Rivas, Yasmin Aziz, Ekaterina Bakradze, Thanh Lam Tran, Marc Rodrigo Gisbert, Manuel Requena, Faddi Saleh Velez, Jorge Ortiz Gracia, Varsha Muddasani, Adam de Havenon, Venugopalan Y. Vishnu, Sridhara Yaddanapudi, Latasha Adams, Abigail Browngoehl, Tamra Ranasinghe, Randy Dunston, Zachary Lynch, Mary Penckofer, James E. Siegler, Silvia Mayer, Joshua Willey, Adeel Zubair, Yee Kuang Cheng, Richa Sharma, João Pedro Marto, Vítor Mendes Ferreira, Piers Klein, Thanh N. Nguyen, Syed Daniyal Asad, Zoha Sarwat, Anvesh Balabhadra, Shivam Patel, Thais Secchi, Sheila Martins, Gabriel Mantovani, Young Dae Kim, Balaji Krishnaiah, Cheran Elangovan, Sivani Lingam, Abid Quereshi, Sebastian Fridman, Alonso Alvarado, Farid Khasiyev, Guillermo Linares, Marina Mannino, Valeria Terruso, Sofia Vassilopoulou, Vasileios Tentolouris-Piperas, Manuel Martinez Marino, Victor Carrasco Wall, Fransisca Indraswari, Sleiman El Jamal, Shilin Liu, Muhammad Alvi, Farman Ali, Mohammed Sarvath, Rami Z. Morsi, Tareq Kass-Hout, Feina Shi, Jinhua Zhang, Dilraj Sokhi, Jamil Said, Newnex Mongare, Alexis Simpkins, Roberto Gomez, Shayak Sen, Mohammad Ghani, Marwa Elnazeir, Han Xiao, Narendra Kala, Farhan Khan, Christoph Stretz, Nahid Mohammadzadeh, Eric Goldstein, Karen Furie, Shadi YaghiBACKGROUND:
Patients presenting with cervical artery dissection (CAD) are at risk for subsequent ischemic events. We aimed to identify characteristics that are associated with increased risk of ischemic stroke after initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals.
METHODS:
This was a preplanned secondary analysis of the STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), a multicenter international retrospective observational study (63 sites from 16 countries in North America, South America, Europe, Asia, and Africa) that included patients with CAD predominantly between January 2015 and June 2022. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Clinical and imaging variables were compared between those with versus without subsequent ischemic stroke. Significant factors associated with subsequent stroke risk were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type (anticoagulation versus antiplatelets) among patients with identified risk factors were explored using adjusted Cox regression.
RESULTS:
In all, 4023 patients (mean age was 47.4 years; 44.5% were women) were included. By day 180, subsequent ischemic stroke occurred in 5.3% of the cohort. In adjusted Cox regression, factors associated with increased risk of subsequent ischemic stroke were prior history of ischemic stroke (adjusted hazard ratio [aHR], 7.31 [95% CI, 1.61–33.13]; P =0.010), presentation within 7 days from first symptoms (aHR, 3.04 [95% CI, 1.04–8.91]; P =0.043), infarct on baseline 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 demonstrated a reduced risk of subsequent ischemic stroke when treated with anticoagulation versus antiplatelets (aHR, 0.36 [95% CI, 0.16–0.80]; P =0.01).
CONCLUSIONS:
In this post hoc analysis of the STOP-CAD study, several factors associated with subsequent ischemic stroke were identified among patients with CAD. Furthermore, we identified a potential benefit of anticoagulation in patients with CAD with occlusive dissection. These findings require validation by meta-analyses of prior studies to formulate optimal treatment strategies for specific high-risk CAD subgroups.