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Updated: Feb 25, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Ticagrelor vs Clopidogrel for Patients Undergoing Endovascular Flow Diversion for Unruptured Intracranial Aneurysms:
Huanwen Chen1, Dhairya A Lakhani2, Marco Colasurdo3
1From the Department of Neurology (H.C.), MedStar Georgetown University Hospital, Washington DC Alvin.huanwen.chen@gmail.com.
Insights
Ticagrelor and clopidogrel showed similar ischemic stroke and hemorrhage risks for patients undergoing flow diversion (FD) for unruptured intracranial aneurysms (UIA). However, ticagrelor was linked to a higher risk of all-cause mortality.
Area of Science:
- Neurology
- Cardiology
- Vascular Surgery
Background:
- Dual antiplatelet therapy is crucial after flow diversion (FD) for unruptured intracranial aneurysms (UIA).
- The choice between ticagrelor and clopidogrel as the P2Y12 inhibitor is debated.
- This study compares ticagrelor and clopidogrel in UIA patients undergoing FD.
Purpose of the Study:
- To compare the effectiveness of ticagrelor versus clopidogrel in patients undergoing FD for UIA.
- To evaluate risks of ischemic stroke, hemorrhage, and mortality associated with each P2Y12 inhibitor.
Main Methods:
- Retrospective propensity score-matched analysis of real-world clinical records from the TrinetX platform.
- Included adult patients with UIA who underwent FD and received ticagrelor or clopidogrel.
- Primary endpoint: ischemic stroke; Secondary endpoints: major hemorrhage (ICH or transfusion), ICH, all-cause mortality at 180 days.
Main Results:
- After matching, 963 patients were in each group (ticagrelor vs. clopidogrel).
- Ischemic stroke rates were similar (1.3% vs. 1.3%, p=1.00).
- Major hemorrhage (2.4% vs. 2.0%, p=0.52) and ICH (1.4% vs. 0.8%, p=0.18) rates were numerically higher with ticagrelor.
- All-cause mortality was significantly higher with ticagrelor (1.7% vs. 0.6%, p=0.025).
Conclusions:
- Ticagrelor and clopidogrel demonstrate equivalent risks for ischemic stroke and hemorrhage in UIA patients treated with FD.
- Ticagrelor use was associated with a significantly increased risk of all-cause mortality compared to clopidogrel.
- Real-world data suggest careful consideration of P2Y12 inhibitor choice in this patient population.
Background And Purpose:
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.
Materials And Methods:
We performed a retrospective propensity score matched analysis using the TrinetX platform, which contains a multicenter database of real-world clinical records. Adult patients with UIA (ICD-10-CM: I67.1) who underwent FD and were initiated on either ticagrelor or clopidogrel within 14 days before to 3 days after FD placement were included. The primary end point was ischemic stroke, and secondary end points included major hemorrhage (intracranial hemorrhage [ICH] or hospitalization requiring blood transfusion), ICH, and all-cause mortality at 180 days. Propensity score matching 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 2976 patients (1047 ticagrelor, 1929 clopidogrel). After propensity score matching, 963 patients remained in each group. At 180 days, ischemic stroke rates were similar between the ticagrelor and clopidogrel groups (1.3% versus 1.3%, P = 1.00; hazard ratio [HR], 1.00 [95% CI 0.45-2.23]). Major hemorrhage rates were numerically higher for ticagrelor patients (2.4% versus 2.0%, P = .52; HR, 1.23 [95% CI, 0.66-2.28]), as were ICH rates (1.4% versus 0.8%, P = .18; HR, 1.86 [95% CI, 0.74-4.67]). All-cause mortality was significantly higher in the ticagrelor group (1.7% versus 0.6%, P = .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 and hemorrhage risks, though ticagrelor was associated with a significantly higher risk of all-cause mortality.
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