Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia · 2026
Different duration of dual antiplatelet therapy after endovascular treatment for unruptured intracranial aneurysms.
СтатьяМногоцентровое исследованиеНаблюдательное исследованиеНазвание и аннотация: Перевод в очереди
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Guo Rui, Wang Kaiwen, Feng Yinghe, Zheng Kaige, Liu Qingyuan, Jiang Pengjun, Wu Jun, Wang Shuo, Tong Xianzeng
Аннотация
BACKGROUND: The evidence regarding the association between the duration of dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC) or flow diversion (FD) and clinical outcomes in unruptured intracranial aneurysms (UIAs) is constrained by small sample sizes and a lack of detailed subgroup analyses.
METHODS: This study included patients with UIAs who received DAPT after SAC or FD from a national, multicenter, prospective cohort from January 2012 to August 2024. DAPT consisted predominantly of aspirin (100 mg/d) plus clopidogrel (75 mg/d). Multinomial propensity score (MNPS) weighting was applied to adjust for baseline confounding. Weighted logistic regression was used to evaluate associations between DAPT duration and outcomes. Sensitivity analyses included center-adjusted models, landmark analyses at day 90 and 180, and inclusion of patients with DAPT < 30 days. Subgroup interaction P values were corrected using the Benjamini-Hochberg false discovery rate (FDR) method.
RESULTS: A total of 12,221 patients were included with 5,356 (44%) receiving DAPT for 30-90 days, 2,966 (24%) for 91-180 days, and 3,899 (32%) for more than 180 days. During 1-year follow-up, 2,041 (17%) experienced ischemic stroke and 419 (3.4%) had hemorrhagic events. After MNPS weighting, prolonged DAPT was not associated with a reduction in ischemic stroke risk (P for trend = 0.524) but was associated with increased hemorrhagic risk (P for trend < 0.001; MNPS-weighted absolute risk difference [ARD]: +1.3% for mid-term, +2.9% for long-term vs. short-term). These findings were consistent across landmark analyses, center-adjusted models, and sensitivity analyses including DAPT < 30-day patients. In subgroup analyses with FDR correction, three interactions remained significant for ischemic stroke (aneurysm size 10-15 mm, ICA involvement, and treatment modality).
CONCLUSION: In this observational study, longer DAPT duration was associated with higher hemorrhagic risk, whereas a clear overall reduction in ischemic stroke was not observed under the constraints of actual-duration exposure classification. These associative findings suggest that shorter DAPT durations may be reasonable in selected patients, although design limitations inherent in observational exposure classification preclude causal inference and confirmation from randomized trials is needed.
CLINICAL TRIAL REGISTRATION: ChTUIA cohort (China Treatment Trial for Unruptured Intracranial Aneurysm, unique identifier: NCT05844163, Clinicaltrials.gov registry) WHAT IS ALREADY KNOWN ON THIS TOPIC: The association between the duration of DAPT after SAC or FD and outcomes for UIAs remains uncertain, with several recent studies suggesting that a short duration may be sufficient, though these conclusions are limited by relatively small cohorts and the absence of robust subgroup analyses.
WHAT THIS STUDY ADDS: This large, national, prospective cohort study found that short-term DAPT (30-90 days) was associated with comparable ischemic outcomes and lower bleeding risk, although important design limitations preclude causal inference. Exploratory subgroup analyses suggested heterogeneity: prolonged DAPT was associated with lower ischemic risk in specific subgroups (aneurysm size 10-15 mm, ICA involvement, treatment modality), with three interactions surviving FDR correction.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY: These associative findings, while subject to design limitations inherent in observational studies, suggest that shorter DAPT durations may be reasonable in selected patients after SAC or FD, and underscore the need for prospective randomized trials to establish individualized antiplatelet strategies.
METHODS: This study included patients with UIAs who received DAPT after SAC or FD from a national, multicenter, prospective cohort from January 2012 to August 2024. DAPT consisted predominantly of aspirin (100 mg/d) plus clopidogrel (75 mg/d). Multinomial propensity score (MNPS) weighting was applied to adjust for baseline confounding. Weighted logistic regression was used to evaluate associations between DAPT duration and outcomes. Sensitivity analyses included center-adjusted models, landmark analyses at day 90 and 180, and inclusion of patients with DAPT < 30 days. Subgroup interaction P values were corrected using the Benjamini-Hochberg false discovery rate (FDR) method.
RESULTS: A total of 12,221 patients were included with 5,356 (44%) receiving DAPT for 30-90 days, 2,966 (24%) for 91-180 days, and 3,899 (32%) for more than 180 days. During 1-year follow-up, 2,041 (17%) experienced ischemic stroke and 419 (3.4%) had hemorrhagic events. After MNPS weighting, prolonged DAPT was not associated with a reduction in ischemic stroke risk (P for trend = 0.524) but was associated with increased hemorrhagic risk (P for trend < 0.001; MNPS-weighted absolute risk difference [ARD]: +1.3% for mid-term, +2.9% for long-term vs. short-term). These findings were consistent across landmark analyses, center-adjusted models, and sensitivity analyses including DAPT < 30-day patients. In subgroup analyses with FDR correction, three interactions remained significant for ischemic stroke (aneurysm size 10-15 mm, ICA involvement, and treatment modality).
CONCLUSION: In this observational study, longer DAPT duration was associated with higher hemorrhagic risk, whereas a clear overall reduction in ischemic stroke was not observed under the constraints of actual-duration exposure classification. These associative findings suggest that shorter DAPT durations may be reasonable in selected patients, although design limitations inherent in observational exposure classification preclude causal inference and confirmation from randomized trials is needed.
CLINICAL TRIAL REGISTRATION: ChTUIA cohort (China Treatment Trial for Unruptured Intracranial Aneurysm, unique identifier: NCT05844163, Clinicaltrials.gov registry) WHAT IS ALREADY KNOWN ON THIS TOPIC: The association between the duration of DAPT after SAC or FD and outcomes for UIAs remains uncertain, with several recent studies suggesting that a short duration may be sufficient, though these conclusions are limited by relatively small cohorts and the absence of robust subgroup analyses.
WHAT THIS STUDY ADDS: This large, national, prospective cohort study found that short-term DAPT (30-90 days) was associated with comparable ischemic outcomes and lower bleeding risk, although important design limitations preclude causal inference. Exploratory subgroup analyses suggested heterogeneity: prolonged DAPT was associated with lower ischemic risk in specific subgroups (aneurysm size 10-15 mm, ICA involvement, treatment modality), with three interactions surviving FDR correction.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY: These associative findings, while subject to design limitations inherent in observational studies, suggest that shorter DAPT durations may be reasonable in selected patients after SAC or FD, and underscore the need for prospective randomized trials to establish individualized antiplatelet strategies.