Ticagrelor versus Clopidogrel for Patients Undergoing Endovascular Flow Diversion for Unruptured Intracranial Aneurysms: A Multicenter Investigation

Huanwen Chen; Dhairya A Lakhani; Marco Colasurdo; Ajay Malhotra; Dheeraj Gandhi

doi:10.3174/ajnr.A9257

Ticagrelor versus Clopidogrel for Patients Undergoing Endovascular Flow Diversion for Unruptured Intracranial Aneurysms: A Multicenter Investigation

AJNR Am J Neuroradiol. 2026 Feb 23:ajnr.A9257. doi: 10.3174/ajnr.A9257. Online ahead of print.

Authors

Huanwen Chen¹, Dhairya A Lakhani², Marco Colasurdo², Ajay Malhotra², Dheeraj Gandhi²

Affiliations

¹ From the Department of Neurology (H.C.), MedStar Georgetown University Hospital, Washington DC, USA; Department of Neuroradiology (D.A.L.), West Virginia University, Morgantown WV, USA; Department of Interventional Radiology (M.C.), Oregon Health & Science University, Portland OR, USA; Department of Radiology (A.M.), Yale New Haven Hospital, New Haven CT, USA and Departments of Radiology, Neurosurgery, and Neurology (D.G.), University of Maryland Medical Center, Baltimore MD, USA. Alvin.huanwen.chen@gmail.com.
² From the Department of Neurology (H.C.), MedStar Georgetown University Hospital, Washington DC, USA; Department of Neuroradiology (D.A.L.), West Virginia University, Morgantown WV, USA; Department of Interventional Radiology (M.C.), Oregon Health & Science University, Portland OR, USA; Department of Radiology (A.M.), Yale New Haven Hospital, New Haven CT, USA and Departments of Radiology, Neurosurgery, and Neurology (D.G.), University of Maryland Medical Center, Baltimore MD, USA.

PMID: 41730632
DOI: 10.3174/ajnr.A9257

Abstract

Introduction: 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.

Methods: We performed a retrospective propensity score-matched analysis using the TrinetX platform, which houses a multicenter database of real-world clinical records. Adult patients with UIA (ICD-10-CM: I67.1) who underwent flow diversion and were initiated on either ticagrelor or clopidogrel within 14 days before to 3 days after FD placement were included. Primary endpoint was ischemic stroke, and secondary endpoints included major hemorrhage (intracranial hemorrhage [ICH] or hospitalization requiring blood transfusion), ICH, and all-cause mortality at 180 days. Propensity score matching (PSM) 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 2,976 patients (1,047 ticagrelor, 1,929 clopidogrel). After PSM, 963 patients remained in each group. At 180 days, ischemic stroke rates were similar between ticagrelor and clopidogrel groups (1.3% vs 1.3%, p=1.00; HR 1.00 [95%CI 0.45-2.23]). Major hemorrhage rates were numerically higher for ticagrelor patients (2.4% vs. 2.0%, p=0.52; HR 1.23 [95%CI 0.66-2.28]), as were ICH rates (1.4% vs 0.8%, p=0.18; HR 1.86 [95%CI 0.74-4.67]). All-cause mortality was significantly higher in the ticagrelor group (1.7% vs 0.6%, p=0.025; HR 3.01 [95%CI 1.10-8.29]).

Conclusion: 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.