This review was conducted to establish whether a surgical operation or a keyhole endovascular treatment, such placement of stent in addition to blood-thinning medication would improve outcomes in people with cervical artery dissection for whom treatment with blood-thinning medication alone does not improve persistent or worsening symptoms of stroke. The outcomes which we wished to assess are permanent brain damage and long-term disability from stroke.
Cervical artery dissection is a tear in the wall of the blood vessels in the neck that supply blood to the brain. There are two of each artery, a carotid artery on the right and one on the left of the neck, and a vertebral artery on the right and one on the left of the neck. When tears occur in the walls of these arteries, clots can form inside the artery. These clots can then break away from the artery wall and travel to the brain to cause a stroke. The standard way of treating tears in these arteries is to give patients medications which thin the blood and reduce clot formation. However, sometimes patients continue to get symptoms of stroke, and their condition worsens despite being on maximum dose medication.
We performed a thorough and comprehensive review of the literature to look for clinical trials which could help us to answer the review question. The evidence is current to March 2020.
We looked for trials which were conducted in an objective way and designed specifically to compare either surgery or radiological intervention to medical therapy alone.
We did not find any trials that matched the criteria of the review. Therefore, there is no available objective evidence that an operation or a radiological procedure can benefit patients who continue to have symptoms of stroke despite medical therapy. We did find a number of reports from experienced groups of doctors that operations and radiological interventions were safe in their hands. However, we found no evidence that this could be applicable to other hospitals and clinical teams. Therefore, large scale, well-conducted studies are required to answer the review question.
Certainty of the evidence
There is no good quality evidence to guide clinicians on the best treatment for people with cervical artery dissection who remain symptomatic despite optimal medical therapy.
No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.
Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people.
To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection.
We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field.
Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data.
Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies.
We did not find any completed RCTs or CCTs undertaken in this area of research.