Prognosis of carotid dissecting aneurysms: Results from CADISS and a systematic review.

OBJECTIVE: To determine the natural history of dissecting aneurysm (DA) and whether DA is associated with an increased recurrent stroke risk and whether type of antithrombotic drugs (antiplatelets vs anticoagulants) modifies the persistence or development of DA. METHODS: We included 264 patients with extracranial cervical artery dissection (CAD) from the Cervical Artery Dissection in Stroke Study (CADISS), a multicenter prospective study that compared antiplatelet with anticoagulation therapy. Logistic regression was used to estimate age- and sex-adjusted odds ratios. We conducted a systematic review of published studies assessing the natural history of DA and stroke risk in patients with non-surgically-treated extracranial CAD with DA. RESULTS: In CADISS, DA was present in 24 of 264 patients at baseline. In 36 of 248 patients with follow-up neuroimaging at 3 months, 12 of the 24 baseline DAs persisted, and 24 new DA had developed. There was no association between treatment allocation (antiplatelets vs anticoagulants) and whether DA at baseline persisted at follow-up or whether new DA developed. During 12 months of follow-up, stroke occurred in 1 of 48 patients with DA and in 7 of 216 patients without DA (age- and sex-adjusted odds ratio 0.84; 95% confidence interval 0.10-7.31; p = 0.88). Published studies, mainly retrospective, showed a similarly low risk of stroke and no evidence of an increased stroke rate in patients with DA. CONCLUSIONS: The results of CADISS provide evidence suggesting that DAs may have benign prognosis and therefore medical treatment should be considered.

Anticoagulants versus antiplatelet drugs for cervical artery dissection: case for anticoagulants.

There are no reliable data from randomised trials to decide whether anticoagulants or antiplatelet agents are better to prevent further thromboembolic events after cervical arterial dissection. Most neurologists favour anticoagulants based on the underlying pathology and the likely course of acute post-dissection thromboembolism.

Cervical arterial dissection: current concepts .

The increasing use and safety of noninvasive imaging in recent years has revealed the surprising frequency of dissection of the carotid and vertebral arteries (cervical arterial dissection [CAD]) as a cause of ischemic and hemorrhagic stroke. This review is an overview of current concepts and practice of patients with CAD, but our ideas are constantly evolving with new discoveries from neurovascular imaging and medical and surgical management in this area.

Management of cervical arterial dissection.

BACKGROUND: Clinical, pathological and radiological advances in recent years have considerably advanced our understanding of the incidence and underlying mechanisms producing dissection of the cervical arteries, which should have implications for medical and, surgical therapy in the near future. This review is a summary of progress to date. SUMMARY OF REVIEW: Numerous published studies, primarily over the last decade, have generated a rapidly evolving data base especially in the areas of etiology, neuroimaging and more recently, arterial pathology and its genetic basis. CONCLUSION: Dissection of the carotid and vertebral arteries, both intracranially and extracranially, is a major and frequently underdiagnosed cause of stroke, especially in the young. These advances in clinical epidemiological observations, and new radiological and pathological data, are gradually providing an evidence-based rationale for future trials of therapeutic interventions, using both drugs and devices.

Antiplatelet agents in secondary prevention of stroke: a perspective.

BACKGROUND AND PURPOSE: Antiplatelet agents are widely used in the secondary prevention of stroke and other vascular events. The purpose of this review is to give a perspective of the factors involved in clinical practice for selecting antiplatelet drugs appropriate to the patient population. SUMMARY OF REVIEW: Aspirin remains the most popular drug, because it is modestly effective (approximately 25% risk reduction); however, it has undesirable side effects that are sometimes serious. The nonaspirin compounds are marginally more effective but are much more expensive and subject to commercial pressures from industry. A completely new look at these compounds is necessary, rather than spending more precious resources on "drug wars" that are expensive in time and money. CONCLUSIONS: A "polypill" has been previously proposed, and possibly a combination of drugs targeted at the major vascular risk factors that is given to patients within 24 hours of initial stroke symptoms and to clearly defined patient populations may prove a solution.

Electronic medical record tobacco use vital sign.

OBJECTIVE: Determination of the prevalence of tobacco use and impact of tobacco prevention/treatment efforts in an electronic medical record enabled practice utilizing a defined tobacco vital sign variable. DESIGN AND MEASUREMENTS: Retrospective cohort study utilizing patient data recorded in an electronic medical record database between July 15, 2001, and May 31, 2003. Patient-reported tobacco use status was obtained for each of 6,771 patients during the pre-provider period of their 24,824 visits during the study period with the recorder blinded to past tobacco use status entries. RESULTS: An overall current tobacco use prevalence of 27.1% was found during the study period. Tobacco use status was recorded in 96% of visits. Comparison of initial to final visit tobacco use status demonstrates a consistency rate of 75.0% declaring no change in tobacco status in the 4,522 patients with two or more visits. An 8.6% net tobacco use decline was seen for the practice (p value < 0.001). CONCLUSION: Self reported tobacco use status as a vital sign embedded within the workflow of an electronic medical record enabled practice was a quantitative tool for determination of tobacco use prevalence and a measuring stick of risk prevention/intervention impact.