Hyperacute Treatment of Cervical Artery Dissection

Cervical artery dissection (CAD) is a leading cause of stroke in young adults. Despite its clinical relevance, guidance for acute diagnosis and treatment remains limited, partly due to the low incidence of the condition and the challenges of conducting large, high-quality studies. However, new evidence has recently emerged – and in this blog, we will explore the latest findings on the hyperacute management of cervical artery dissection, with a focus on intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and emergent stenting.

 

Intravenous Thrombolysis

IVT for CAD is considered a low-evidence intervention according to the 2021 ESO guidelines, with observational studies showing no significant improvement in functional outcomes in CAD patients treated with IVT.¹ In 2024, Liqi Shu et al. analyzed the benefits and harms of IVT in patients with CAD using data from the observational STOP-CAD dataset. Among 1,300 patients, 414 received IVT, showing a significant benefit with an age and baseline NIHSS-adjusted odds ratio (OR) of 1.67 (95% CI 1.223–2.28).² The intracranial hemorrhage rate was 4.1%, consistent with other thrombolysis studies involving non-CAD patients.³ These findings were further supported by the analysis of a larger U.S. claims dataset, which included 11,285 patients with CAD, 1,360 of whom received IVT. The study showed a higher likelihood of home discharge among IVT-treated patients (adjusted OR 1.49, 95% CI 1.09–2.05), with an intracerebral hemorrhage rate of 4%.⁴

These are the first studies to show a benefit regarding functional outcome of IVT in CAD.^2,4 However, since these data are observational, the results should be interpreted cautiously. Nevertheless, given the effectiveness of this treatment, IVT should not be withheld from CAD patients.

Mechanical Thrombectomy

MT for CAD patients is considered a very-low-evidence intervention according to the 2021 ESO guidelines.¹ That said, recent studies provide new insights. The CONCORDIA study, which includes stroke registry data from Austria, Germany, and Switzerland, analyzed outcomes in CAD patients with anterior circulation large vessel occlusion who underwent MT. ⁵ Among 1,023 patients, 516 received MT.⁵ The study found a significant benefit of MT for functional outcomes (adjusted RR 1.29, 95% CI 1.19–1.41), but also a higher risk of intracranial hemorrhage (adjusted RR 3.5, 95% CI 1.56–7.82).⁵ However, in patients with an NIHSS < 6, MT was associated with worse functional outcomes and higher rates of symptomatic intracranial hemorrhages compared to best medical treatment.⁵ These findings align with recent studies on thrombectomy in low NIHSS strokes.⁶ In summary, MT appears to be a reasonably beneficial and safe treatment for patients with CAD and large vessel occlusion, particularly for those with an NIHSS score of 6 or higher.⁵

 

To Stent or Not to Stent?

In CAD patients with a tandem occlusion (occlusion of both the dissected artery and intracranial large vessel), the decision to perform emergent stenting remains debated. Using the STOP-CAD dataset, Sousa et al. investigated 274 patients with occlusive ICA dissection and anterior circulation ischemic stroke, comparing 130 who received emergent stenting to those who did not.⁷ At 90 days, no significant difference in functional outcomes or symptomatic intracranial hemorrhage rates was observed.⁷ However, emergent stenting was associated with a significantly higher rate of any intracranial hemorrhage within the first 24 hours (adjusted OR 2.02, 95% CI 1.11–3.67), but not for symptomatic hemorrhage within the first 24 hours alone (adjusted OR 0.95, 95% CI 0.41-2.2).⁷ In conclusion, both treatment options appear valid. Yet, emergent stenting may present a less favorable safety profile due to the increased risk of early hemorrhage.⁷ One possible approach could be to consider emergent stenting in cases where perfusion imaging indicates hemodynamic instability, as the benefits of restoring blood flow may outweigh the risks.

References:

1. Debette S, Mazighi M, Bijlenga P, et al. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6(3): XXXIX-LXXXVIII.
2. Shu L, Akpokiere F, Mandel DM, et al. Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study. Neurology 2024; 103(7): e209843.
3. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384(9958): 1929-35.
4. Shu L, Lee E, Field TS, et al. Intravenous Thrombolysis in Cervical Artery Dissection-Related Stroke: A Nationwide Study. J Am Heart Assoc 2025; 14(5): e039662.
5. Sykora M, Poli S, Giannakakis M, et al. Thrombectomy in stroke due to carotid artery dissection. A pooled analysis of the CONCORDIA Collaboration. Accepted in Neurology 2025.
6. Safouris A, Palaiodimou L, Nardai S, et al. Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS. Stroke 2023; 54(9): 2265-75.
7. Sousa JA, Rodrigo-Gisbert M, Shu L, et al. Emergent Carotid Stenting During Thrombectomy in Tandem Occlusions Secondary to Dissection: A STOP-CAD Secondary Study. Stroke 2025.