Half-Dose (45 mg Twice Daily) Ticagrelor Versus Clopidogrel in Neuroendovascular Dual Antiplatelet Therapy: A Single-Center Cohort Study.

Background: Cardiovascular literature has found aspirin-based dual antiplatelet therapy using half-dose ticagrelor (45 mg BID [T45]) to be superior to standard-dose clopidogrel (75 mg once daily) in achieving lower P2Y12 reaction units without resulting in an increased incidence of intracranial hemorrhage. We present the first neuroendovascular experience based on T45 versus standard-dose clopidogrel dual antiplatelet therapy in patients undergoing stent-assist coiling/flow diversion as treatment for unruptured intracranial aneurysms. Methods: This was a retrospective cohort study comparing patients receiving dual antiplatelet therapy with T45+aspirin 81 mg daily (group 1) with those receiving standard-dose clopidogrel+aspirin 325 mg daily (group 2). The primary outcome was ischemic stroke occurring intraoperatively or within 48 hours postoperatively. The secondary outcomes were delayed ischemic stroke, intracranial hemorrhage, and 6-month angiographic result. Results: A total of 111 patients met the final inclusion criteria: group 1/T45 (37.8%, n=42) and group 2/standard-dose clopidogrel (62.2%, n=69). The median (interquartile range) P2Y12 reaction units was significantly lower in group 1 (69; 37-124) versus group 2 (135; 75.5-175.5; P=0.027). However, there was no significant difference in the number of patients achieving therapeutic preprocedural P2Y12 reaction units (<194 at our institution's laboratory; 85.3% versus 81.2%; P=0.643). Primary outcome was comparable: group 1, 7.1% (n=3) versus group 2, 1.5% (n=1; P=0.149). All secondary outcomes were also comparable: delayed ischemic stroke (9.8% versus 4.4%; P=0.270), intracranial hemorrhage (4.1% versus 0%; P=0.129), access-site bleeding requiring transfusion (0% versus 2.9%; P=0.526), and 6-month Raymond-Roy score (P=0.642). Conclusions: T45-based dual antiplatelet therapy may be feasible in neuroendovascular interventions with comparable ischemic and hemorrhagic outcomes. This hypothesis needs to be further explored in larger prospective clinical trials.