Clopidogrel versus ticagrelor in dual antiplatelet therapy for flow diversion of unruptured intracranial aneurysms: analysis of the Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry

OBJECTIVES: To evaluate the safety and efficacy of clopidogrel versus ticagrelor in patients undergoing flow diverting stent (FDS) placement for unruptured intracranial aneurysms (UIAs). METHODS: The Neurovascular Quality Initiative-Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry was queried for patients who underwent FDS placement for UIAs treated with clopidogrel or ticagrelor. Propensity score matching (1:1) was performed to balance demographics, comorbidities, and aneurysm characteristics. Primary outcomes were intraoperative thrombus formation and postoperative symptomatic intracranial hemorrhage (sICH). Secondary outcomes included modified Rankin Scale (mRS), aneurysm occlusion at discharge, and parent vessel stenosis or occlusion on long-term follow-up. RESULTS: 1387 patients (1088 clopidogrel, 299 ticagrelor) were analyzed. Ticagrelor was more frequently used in posterior circulation aneurysms (7.8% clopidogrel vs. 14.4% ticagrelor, P=0.0008) and cases requiring multiple FDS (8.7% clopidogrel vs. 28.2% ticagrelor, P<0.0001). Rates of intraoperative thrombus formation (0.5% clopidogrel vs 0.3% ticagrelor, P=1) and postoperative sICH (0.3% clopidogrel vs 0.5% ticagrelor, P=1) were similar, as were discharge mRS, aneurysm occlusion at discharge, last follow-up mRS, and rates of parent vessel occlusion or stenosis. After matching (180 per group), there were similar rates of intraoperative thrombus formation (0% clopidogrel vs 0.6% ticagrelor, P=1) and postoperative sICH (0.6% clopidogrel vs 0.6% ticagrelor, P=1). Functional outcomes, aneurysm occlusion at discharge, and rates of parent vessel stenosis or occlusion also remained similar. CONCLUSION: No significant differences in safety or efficacy were detected between clopidogrel and ticagrelor in patients undergoing FDS placement for UIAs.