Dual Antiplatelet Therapy with Aspirin and Clopidogrel Versus Aspirin and Ticagrelor for Cerebral Endovascular Procedures: A Propensity Score Matching Retrospective Cohort Study
Davi Neves Coelho1, Filipi Andreão2, Filipe Virgílio Ribeiro3, Arthur Marinho4, Paulo Otávio Neto4, Mariana Letícia Maximiano5, Wander Valentim6, Savio Batista7, Diogo Haddad Santos8
1Faculty of Medicine, CEUMA University, 2Federal University of Rio de Janeiro, 3Faculty of Medicine, Barão de Mauá University Center, 4Centro Universitário Tocantinense Presidente Antônio Carlos, 5Faculty of Medicine, Fluminense Federal University, 6Department of Neurology, Harvard University, Massachusetts General Hospital, 7Emory University, 8Department of Neurology, School of Medical Sciences of Santa Casa de São Paulo
Objective:
To assess and compare the safety and efficacy outcomes of ticagrelor- versus clopidogrel-based dual antiplatelet therapy in patients undergoing cerebral endovascular procedures using a large, real-world, propensity score–matched cohort.
Background:
Dual antiplatelet therapy (DAPT) is routinely prescribed for patients undergoing neuroendovascular procedures to minimize thromboembolic complications. While clopidogrel remains the standard agent, ticagrelor has emerged as an alternative, particularly for patients with clopidogrel resistance. However, comparative evidence on their clinical outcomes in neurointervention remains limited.
Design/Methods:
We conducted a retrospective cohort study using de-identified data from 102 U.S. healthcare organizations in the TriNetX Research Network. Adult patients undergoing cerebral endovascular procedures were categorized by DAPT regimen—aspirin plus clopidogrel or aspirin plus ticagrelor. A 1:1 propensity score matching (PSM) was applied to balance baseline demographics, comorbidities, and procedural characteristics. Outcomes, including ischemic stroke, transient ischemic attack (TIA), thrombosis, intracranial hemorrhage (ICH), mortality, and retreatment, were assessed at 30, 90, and 180 days post-procedure.
Results:
After PSM, 4,023 patients were included in each group. Ticagrelor-based DAPT was associated with a significantly higher risk of ischemic stroke (RR = 1.210, 95% CI 1.028–1.423) and retreatment (RR = 1.234, 95% CI 1.011–1.506) at 30 days. Thrombosis risk remained consistently higher across all follow-up intervals (RR = 2.042 at 30 days; 1.488 at 90 days; 1.522 at 180 days). No significant differences were observed for TIA, ICH, or mortality at any time point.
Conclusions:
In this large, multicenter, real-world analysis, ticagrelor-based DAPT was linked to increased early risks of ischemic stroke, thrombosis, and retreatment compared with clopidogrel-based DAPT, without differences in hemorrhagic or mortality outcomes. These findings suggest that ticagrelor may not offer superior clinical protection in neuroendovascular settings and underscore the need for prospective randomized trials to clarify the optimal DAPT regimen for cerebrovascular interventions.
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