What is the role of anticoagulation in patients with dissections of internal carotid and vertebral arteries due to stroke?

Updated: Dec 18, 2018
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

The majority (85-95%) of ischemic symptoms after dissection of brain-supplying arteries are caused by emboli from the site of the dissection, while the remainder are due to vessel narrowing with hemodynamic insufficiency. Many experts recommend anticoagulation with IV heparin in the acute phase and subsequent oral anticoagulation for 3-24 months (target INR 2.5, range 2-3) followed by antiplatelet agents for at least 2 years.

No large randomized trials have been performed to determine optimal treatment. The practice of anticoagulation is supported only by several published case series demonstrating good outcome with low complication rates in patients undergoing anticoagulation. However, these studies do not have a control or comparative group to establish efficacy. The CADISS trial was a randomized trial but was not powered sufficiently to show differences between treatments.

Only in rare cases (eg, with persistent high-grade proximal stenosis of the internal carotid artery or with severe hemodynamic impairment) should an operation or stenting be considered. No evidence of a higher embolic activity of pseudoaneurysms due to dissection exists; after oral anticoagulation for 3-6 months, a platelet antiaggregant is sufficient in most cases. Only in selected cases, continuation of anticoagulation or interventional therapy may be preferable, but this practice is not supported by randomized, controlled studies.

Anticoagulation is contraindicated in intracranial dissections complicated by subarachnoid hemorrhage.


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