Ticagrelor vs Clopidogrel in Flow Diversion for Unruptured Intracranial Aneurysms: Outcomes

Background Dual antiplatelet therapy is essential for patients undergoing flow diversion (FD) for unruptured intracranial aneurysms (UIA), but the optimal P2Y12 inhibitor, particularly ticagrelor versus clopidogrel, remains controversial. Methods We performed a retrospective propensity score‐matched analysis using the TrinetX platform, which houses a multicenter database of real‐world clinical records. Adult patients with UIA (ICD‐10‐CM: I67.1) who underwent flow diversion and were initiated on either ticagrelor or clopidogrel within 14 days before to 3 days after FD placement were included. Primary endpoints included ischemic stroke, major hemorrhage (intracranial hemorrhage [ICH] or hospitalization requiring blood transfusion), ICH, and all‐cause mortality within 180 days. Propensity score matching (PSM) was performed to balance baseline characteristics such as demographics, comorbidities, and use of other medications such as aspirin, other anti‐platelet agents, and anticoagulants. Log‐rank tests and Cox proportional hazard models were used to compare outcomes between groups. Results The study included 2,976 patients (1,047 ticagrelor, 1,929 clopidogrel). After PSM, 963 patients remained in each group; PSM performed well, with all matched variables demonstrating adequate balance as evidenced by absolute standardized differences < 0.10. At 180 days, ischemic stroke rates were similar between ticagrelor and clopidogrel groups (1.3% vs 1.3%, p=1.00; HR 1.00 [95%CI 0.45‐2.23]). Major hemorrhage rates were numerically higher for ticagrelor patients (2.4% vs. 2.0%, p=0.52; HR 1.23 [95%CI 0.66‐2.28]), as were ICH rates (1.4% vs 0.8%, p=0.18; HR 1.86 [95%CI 0.74‐4.67]). All‐cause mortality was significantly higher in the ticagrelor group (1.7% vs 0.6%, p=0.025; HR 3.01 [95%CI 1.10‐8.29]). Conclusions In real‐world practice, ticagrelor and clopidogrel for patients undergoing FD were equivalent in terms of ischemic stroke risk, though ticagrelor was associated with a numerically higher risk of hemorrhagic complications and a significantly higher risk of all‐cause mortality.