Ticagrelor versus Clopidogrel in the Dual Antiplatelet Regimen for Intracranial Stenting or Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center Cohort Study

Abstract

BACKGROUND AND PURPOSE: Ticagrelor is a novel P2Y12 antagonist, and little is known about its efficacy and safety in the endovascular treatment of aneurysms. This study evaluated the efficacy and safety of ticagrelor versus clopidogrel for stent-assisted coiling or flow-diversion treatment in patients with unruptured cerebral aneurysms. MATERIALS AND METHODS:From November 2003 to February 2019, two hundred one patients (mean age, 57.5 years; 156 women) with 233 unruptured aneurysms underwent stent-assisted coiling or flow-diversion treatment. All patients received antiplatelet therapy of aspirin plus clopidogrel (clopidogrel group, 121 patients with 140 aneurysms) or aspirin plus ticagrelor (ticagrelor group, 80 patients with 93 aneurysms). The clinical and radiologic data in each group were retrospectively reviewed and compared.RESULTS: Two hundred thirty-six procedures were performed, including stent-assisted coiling (n ¼ 101) and flow diversion (n ¼ 135). At 90 days, the primary outcome-a composite of any stroke and death-occurred in 9.9% of the clopidogrel group and 8.6% of the ticagrelor group (P ¼ .822). Ischemic stroke occurred in 10 (7.0%) of the clopidogrel group and 7 (7.5%) of the ticagrelor group (P . .999). Disabling stroke occurred in 4 (2.8%) in the clopidogrel group and in 4 (4.3%) in the ticagrelor group (P ¼ .716). Ninety-day death occurred in 3 (2.1%) in the clopidogrel group and 1 (1.1%) in the ticagrelor group (P . .999). Any bleeding at 90 days occurred in 13 (9.2%) in the clopidogrel group and 6 (6.5%) in the ticagrelor group (P ¼ .479).

The Effect of Ticagrelor for Endovascular Intervention of Intracranial Aneurysm Patients with or without Clopidogrel Resistant: A Meta-Analysis

“…All studies were published between 2017 and 2021. Of the 10 studies, 2 [ 21 , 22 ] were multicenter and 8 [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ] were single-center, involving a total of 1377 patients receiving endovascular therapies for aneurysms from six countries with sample sizes ranging from 78 to 321, including 1 [ 24 ] RCT study, 1 [ 23 ] prospective cohort study and 8 [ 21 , 22 , 25 , 26 , 27 , 28 , 29 , 30 ] retrospective cohort studies. Endovascular therapies contain spring coil embolization, stent assisted coil embolization and flow diverter procedures, perioperative and postoperative with clopidogrel or ticagrelor antiplatelet therapy; 4 [ 22 , 23 , 28 , 29 ] of the studies tested for platelet function and changed the antiplatelet regimen to ticagrelor in patients with clopidogrel resistance.…”

“…In the meta-analysis of perioperative and postoperative application of clopidogrel or ticagrelor in patients with aneurysms after endovascular interventional surgery, 10 studies were included in the thromboembolic complications analysis; 5 [ 21 , 22 , 24 , 26 , 30 ] studies showed a decreased trend toward thromboembolic complications compared with the clopidogrel group, and 5 [ 23 , 25 , 27 , 28 , 29 ] studies showed a poorer trend. The results of the pooled 10 studies showed that, like clopidogrel, ticagrelor had a good prevention efficacy in the analysis of the efficacy of thromboembolic events; there was no significant difference (RR = 1.14, 95% CI: 0.76–1.72, p = 0.52).…”

“…A total of 7 [ 22 , 24 , 26 , 27 , 28 , 30 ] studies were conducted to monitor hemorrhagic complications, and 2 [ 26 , 28 ] of them showed that ticagrelor had a tendency to cause bleeding complications compared with clopidogrel, but the results of 5 [ 21 , 22 , 24 , 27 , 30 ] studies were opposite, and there was no significant statistical difference. Meta-analysis of the 7 studies did not show that ticagrelor increased the incidence of perioperative and postoperative hemorrhagic complications after endovascular treatment of aneurysms compared with clopidogrel (RR = 0.87, 95% CI: 0.48–1.59, p = 0.66).…”

“…A total of 4 [ 21 , 27 , 29 , 30 ] studies were included in the study of neurologic disability, among which 1 [ 29 ] study tested platelet function; although ticagrelor showed a good trend in neurological function recovery, the difference was not significant. Overall meta-analysis showed that ticagrelor had the same efficacy as clopidogrel in neurologic disability events (RR = 0.74, 95% CI: 0.28–1.95, p = 0.55).…”

Small Unruptured Intracranial Aneurysms Can Be Effectively Treated With Flow-Diverting Devices

“…Three to 5 days before the endovascular procedure, dual antiplatelet therapy was administered for all patients with clopidogrel (75 mg/d) and aspirin (100 mg/d) ( 24 ). The endovascular procedure was conducted under general anesthesia and heparinization.…”