Safety of Ticagrelor Use in Elective Endovascular Treatment of Unruptured Intracranial Aneurysms

BACKGROUND AND OBJECTIVES: Intracranial stent placement typically requires dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. The standard combination of aspirin and clopidogrel has raised concerns because of the variability in clopidogrel's effectiveness, potentially leading to an increased risk of ischemic events. Ticagrelor presents a viable alternative; however, there are concerns about a higher risk of intracranial hemorrhage. The aim of this study was to evaluate the safety of combining ticagrelor with aspirin in patients undergoing aneurysm embolization with intracranial stenting. METHODS: We conducted a retrospective study of patients with unruptured intracranial aneurysms treated with stents and DAPT, combining ticagrelor and aspirin, between 2013 and 2021. Clinical and radiological outcomes were collected to assess the safety and efficacy of ticagrelor. The primary outcome was composite and included intracranial hemorrhagic complication and death. Univariable and adjusted multivariable regression analyses were conducted to report factors associated with the primary outcome. RESULTS: Data from 511 patients who underwent 540 stent-assisted embolization procedures were analyzed. Hemorrhagic neurological complications were observed in 13 patients (2.4%). Multivariate analysis revealed that a lower perioperative heparin dose (50 UI/Kg) was independently associated with fewer hemorrhagic complications compared with heparin dose of 70 UI/Kg (adjusted odds ratio [aOR] 0.28, 95% CI 0.09-0.83). In addition, older age (aOR 1.06, 95% CI 1.01-1.10) and use of multiple stents (aOR 4.21, 95% CI 1.42-12.49) were linked to higher rates of hemorrhagic events and death. CONCLUSION: The use of DAPT with aspirin and ticagrelor seems to be a safe alternative to clopidogrel for unruptured aneurysm embolization using intracranial stent.