artery dissection blog 16.01.2018

Comment Author: Linxin Li

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry

Cervical artery dissection (CeAD) is a common cause of stroke in young adults, with an annual incidence rate of 2.6-2.9 per 100,000.1 A large proportion of patients with CeAD would present with acute ischaemic stroke, and ESJmany have occlusions of large arteries with or without tandem occlusion. Given the potential disabling nature of such occlusions, optimising acute treatment would be crucial.

In this issue of ESJ, Traenka et al reported findings from a prospective registry in Switzerland, comparing endovascular treatment (EVT) to intravenous thrombolysis (IVT) regarding the three-month outcome, recanalization and complications in patients with acute stroke attributable to CeAD presenting within 6 hours after symptom of onset.2

Using data from the multicentre SWISS registry (2007-2012), the authors included 62 CeAD patients, among which 38 received EVT and 24 received IVT alone. At 3 month, 23.7% of the patients in the EVT group had a modified Rankin Scale (mRS) of 0 to 1, compared to 20.8% of the patients in the IVT group (adjusted odds ratio 2.23, 95%CI 0.52-9.59, p=0.278). Recanalization was achieved in 84.2% of the EVT group versus 66.7% of the IVT group (p=0.065). Symptomatic intracranial haemorrhage occurred only in 5 patients treated with EVT and 4 out of the 5 patients had bridging therapy.

The authors also performed a sensitivity analysis in patients presented within 4.5 hours after symptom of onset. Although as expected, this group of patients had a higher recanalization rate overall, the study was again not powered to show any statistically significant difference between the EVT and IVT groups for the primary and secondary outcomes.

Combining the findings from the SWISS registry with seven other studies, the authors then showed in a meta-analysis including 212 patients with CeAD that proportions of patients achieving a mRS of 0-2 at 3 months were similar between those treated with EVT and those treated with IVT (pooled odds ratio 0.97, 0.38-2.44, p=0.96).

Based on this largest cohort of EVT-treated CeAD stroke patients, the authors had two important conclusions.

  • There was no clear signal of superiority of EVT over IVT in CeAD stroke patients. However, given the small sample size and recruiting period (2007- 2012), ongoing larger studies using contemporary EVT technique/devices are still needed to reliably investigate the efficacy of EVT vs. IVT in this patient group. It would also be interesting to see if any such efficacy would differ by carotid vs. vertebral artery dissection.
  • The observation that symptomatic intracranial haemorrhage occurred predominantly in patients receiving bridging therapy also warrants further investigation.

Reference

  1. Lee VH, Brown RD Jr. Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: A population-based study. Neurology. 2006; 67:1809–1812.
  2. Traenka C, Jung S, Gralla J, et al. Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry. European Stroke Journal. DOI: 10.1177/2396987317748545

Original research article
Traenka C, Jung S, Gralla J, et al. Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke – Results from the SWISS registry
European Stroke Journal DOI: 10.1177/2396987317748545