Ticagrelor versus Clopidogrel for Patients Undergoing Endovascular Flow Diversion for Unruptured Intracranial Aneurysms: A Multicenter Investigation

INTRODUCTION: 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. This study aims to assess the comparative effectiveness of ticagrelor and clopidogrel for patients undergoing FD treatment for UIAs. 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 endpoint was ischemic stroke, and secondary endpoints included major hemorrhage (intracranial hemorrhage [ICH] or hospitalization requiring blood transfusion), ICH, and all-cause mortality at 180 days. Propensity score matching (PSM) was performed to balance baseline characteristics. 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. 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]). CONCLUSION: In real-world practice, ticagrelor and clopidogrel for patients undergoing FD were equivalent in terms of ischemic stroke and hemorrhage risks, though ticagrelor was associated with a significantly higher risk of all-cause mortality.