Is Anticoagulation Beneficial in Occlusive Cervical Artery Dissection (CeAD)?
Date First Published:
July 29, 2025
Last Updated:
August 4, 2025
Report by:
Dr Polina Nikolaeva, Dr Vishal Patel, Foundation Doctor 2, Emergency Medicine Consultant (Jersey General Hospital)
Search checked by:
Dr Polina Nikolaeva, Dr Vishal Patel, Jersey General Hospital
Three-Part Question:
In [patients with occlusive cervical artery dissection], does [anticoagulation] reduce the risk of [stroke and adverse outcomes]?
Clinical Scenario:
A 42-year-old man presents with dysphagia, hemisensory loss and ispsilateral neck pain. CT angiography revealed an occlusive dissection of the left internal carotid artery.
Search Strategy:
Medline (1946 to July 2025), EMBASE (1974 to July 2025), Cochrane Database of Systematic Reviews, and manual review of references.
Search Details:
Search terms included: "cervical artery dissection", "occlusive dissection", "anticoagulation", "stroke prevention", "outcomes".
Outcome:
From over 1,000 titles screened, 11 studies including 2 randomized controlled trials (CADISS, TREAT-CAD) and multiple high-quality observational studies (STOP-CAD, systematic reviews) were included. The focus was on patients with occlusive dissection, not general cervical artery dissection.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Factors Associated With Stroke Recurrence After Initial Diagnosis of Cervical Artery Dissection Daniel M. Mandel, MD, Liqi Shu, MD, Christopher Chang, Naomi Jack et al Mar-25 United States | 4023 patients with CeAD (47.4 mean age) |
Post hoc analysis of STOP-CAD study Multicentre observational study |
Stroke at 180 days | Anticoagulation reduces stroke risk only in occlusive subgroup HR 0.37; 95% CI 0.15-0.89, p = 0.03 | Requires further validation by meta-analyses |
| The 6-months follow-up of the TREAT-CAD trial: Aspirin versus anticoagulation for stroke prevention in patients with cervical artery dissection Engelter ST, Traenka C, Gensicke H, et al Feb-25 Switzerland, Germany, Denmark | 122 in as treated analysis |
6 month follow up of TREAT-CAD RCT trial |
Aspirin vs Anticoagulation for stroke between 3 and 6 months | Aspirin (3.2%) vs Anticoagulation (3.4%) with an MRI outcome of haemorrhagic events. Absence of ischaemic events | Low sample size as pretermined by the TREAT-CAD trial Cross over from Vitamin K antagonist to aspirin (none in opposite direction)= allocation bias due to preferences of treating clinician |
| Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis. Yaghi S, Shu L, Fletcher L, et al Jun-24 United States | 11 studies, 5039 patients (meta-analysis) |
2 RCTs and 9 observational studies |
Subsequent ischaemic stroke and major bleed | Anticoagulation reduced ischemic stroke risk (RR 0.63), with an increased major bleeding risk (RR 2.25). Net clinical benefit demonstrated in selected patients (NNT ≈ 50; NNH ≈ 135). Subgroup of occlusive dissections showed particularly strong benefit. | Moderate risk of bias affecting generalisability Heterogeneity due to differences in definition of symptomatic intracranial haemorrhage |
| Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study Shadi Yaghi, MD, Liqi Shu, MD, Daniel Man et al Feb-24 United States | 3636 patients |
Multicentre observational studies |
Subsequent ischaemic stroke at 180 days (11% anticoagulation and 68% antiplatelet) | In occlusive dissections, anticoagulation reduced stroke risk significantly (HR 0.40; 95% CI 0.18–0.88; interaction=0.009). Bleeding risk at 30 days low HR 1.39 (95 % CI 0.35-5.45) but higher risk by day 180 (HR 5.56 (95% 1.53-20.13) Most recurrent strokes occurred within the first 30 days, supporting early benefit | Retrospective and observational nature causes recall bias Antiplatelet group involved different therapies, including aspirin and clopidogrel hence not generalizable to all antiplatelet |
| Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial Prof Stefan T Engelter, MD, Christopher Traenka, MD, Henrik Gensicke, MD et al May-21 | 194 patients; 52% Aspirin vs 48% Vitamin K antagonist group |
Non-inferiority, RCT in 10 stroke centres |
Composite of clinical outcomes (stroke, haemorrhage or death) at 14 and 90 days | Primary outcome: 23% in Aspirin vs 15% in Vitamin K antagonist group (AR 8% (95% CI -4 to 21), non inferiority p = 0.55 8% in Aspirin had stroke and none in Vitamin K group Major bleed one patient in Vitamin K group and none in Aspirin group | Not powered to address the superiority of either treatment |
| Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results Hugh S. Markus et al Feb-19 | 250 patients, 126 to Antiplatelets and 124 to anticoagulation Mean age 49 years |
Prospective, RCT international multicentre trial |
Ipsilateral stroke and death at 3 and 12 months | No differences in outcome 12 months any stroke/death 3.2% in Antiplts vs 1.6% in Anticoagulation, OR 0.56 (0.10-3.21) p = 0.51 | Different clinical imaging used to assess patients (CTA or MRA) |
Author Commentary:
There is compelling evidence that anticoagulation is beneficial in patients with occlusive cervical artery dissection, particularly in reducing the risk of ischemic stroke and/or its recurrence. Most of the benefit is seen within the first 30 days post-event. This is particular important as the risk of ischaemic stroke is highest during first days to weeks.
While anticoagulation has a slightly increased bleeding risk, especially after prolonged use (more than 30 days), the early stroke prevention benefit in occlusive cases is favourable
While anticoagulation has a slightly increased bleeding risk, especially after prolonged use (more than 30 days), the early stroke prevention benefit in occlusive cases is favourable
Bottom Line:
The evidence supports a strategy of short-term anticoagulation (30–90 days) followed by reassessment by a specialist to determine ongoing risk/benefit before continuing or switching to antiplatelet therapy. Anticoagulation should be considered standard in occlusive dissections when bleeding risk is manageable.
References:
- Daniel M. Mandel, MD, Liqi Shu, MD, Christopher Chang, Naomi Jack et al. Factors Associated With Stroke Recurrence After Initial Diagnosis of Cervical Artery Dissection
- Engelter ST, Traenka C, Gensicke H, et al. The 6-months follow-up of the TREAT-CAD trial: Aspirin versus anticoagulation for stroke prevention in patients with cervical artery dissection
- Yaghi S, Shu L, Fletcher L, et al. Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis.
- Shadi Yaghi, MD, Liqi Shu, MD, Daniel Man et al. Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study
- Prof Stefan T Engelter, MD, Christopher Traenka, MD, Henrik Gensicke, MD et al. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial
- Hugh S. Markus et al. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results