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Ticagrelor versus clopidogrel dual antiplatelet therapy for unruptured intracranial aneurysms treated with
Jean Papaxanthos1, Federico Cagnazzo2, François-Louis Collemiche2
1Interventional Neuroradiology Department, CHRU Bordeaux, France.
Insights
Dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin is as safe and effective as clopidogrel plus aspirin for preventing thromboembolic events after flow diverter treatment for intracranial aneurysms.
Area of Science:
- Neuroendovascular procedures
- Cerebrovascular diseases
- Interventional neuroradiology
Background:
- Antiplatelet therapy (APT) is crucial for preventing thromboembolic events (TEE) in neuroendovascular procedures like flow diverter treatment for aneurysms.
- Dual APT (DAPT) with clopidogrel and aspirin is common, but limitations include resistance and variable efficacy.
- Ticagrelor is increasingly used as an alternative DAPT regimen.
Purpose of the Study:
- To compare the safety and efficacy of ticagrelor plus aspirin versus clopidogrel plus aspirin DAPT regimens.
- To evaluate the incidence of thromboembolic or major hemorrhagic events within six months post-treatment.
- To assess clinical outcomes in patients undergoing flow diverter treatment for intracranial aneurysms.
Main Methods:
- A multicentric retrospective study of 260 patients with unruptured intracranial aneurysms treated with flow diverters.
- Patients received either ticagrelor plus aspirin or clopidogrel plus aspirin DAPT.
- The primary endpoint was a composite of thromboembolic or major hemorrhagic events within six months.
Main Results:
- No significant difference in the primary composite outcome between the ticagrelor (11.5%) and clopidogrel (10.9%) groups (p=1.000).
- Secondary outcomes, including TEE (10.5% vs 9.0%), major hemorrhage (0.9% vs 1.2%), and clinical outcome (6.7% vs 8.3%), also showed no significant differences.
- Baseline characteristics were comparable, with adjustments for aneurysm location, size, and pre-treatment mRS.
Conclusions:
- First-line DAPT with ticagrelor plus aspirin demonstrates comparable safety and efficacy to clopidogrel plus aspirin.
- Both DAPT regimens appear suitable for patients undergoing flow diverter treatment for intracranial aneurysms.
- Further research may explore long-term outcomes and specific patient subgroups.
Background And Purpose:
Antiplatelet therapy (APT) is a key element limiting the risk of thromboembolic events (TEE) in neuroendovascular procedures, including aneurysm treatment with flowdiverter. Clopidogrel combined with aspirin is the mostly reported dual APT (DAPT). However, resistance phenomenon and intraindividual efficacy fluctuation are identified limitations. In recent years, ticagrelor has been increasingly used in this indication. We compared these two DAPT regimens for intracranial aneurysm treated with flowdiverter.
Methods:
We conducted a multicentric retrospective study from prospectively maintained databases in two high volume centers extracting consecutive patients presenting unruptured intracranial aneurysm treated with flowdiverter and receiving DAPT (May 2015 to December 2019). Two groups were compared according to their DAPT regimen: "ticagrelor+aspirin" and "clopidogrel+aspirin". Clopidogrel group was systematically checked with platelet test inhibition before endovascular procedure. The primary endpoint was composite, defined as any thrombo-embolic event (TEE) or major hemorrhagic event occurring the first 6 months during and after embolization RESULTS: 260 patients met our inclusion criteria. Baseline patients and aneurysms characteristics were comparable between groups, except for aneurysm location, median size and pre-treatment modified Rankin scale. No significant difference was observed regarding the primary composite outcome: 11.5% (12/104) in the ticagrelor group versus 10.9% (17/156) in the clopidogrel group (p = 1.000). There was also no significant difference in secondary outcomes including TEE (10.5 vs 9.0%; p = 0.673), major hemorrhage (0.9 vs 1.2%; p = 0.651) and clinical outcome (at least 1-point mRS worsening during follow up: 6.7% vs 8.3%; p = 0.813).
Conclusion:
First-line DAPT with ticagrelor+aspirin seems as safe and effective as clopidogrel+aspirin regimen.
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