Half-dose ticagrelor versus clopidogrel dual antiplatelet therapy in flow diverter-treated intracranial aneurysms: analysis of platelet reactivity and perioperative safety outcomes.

BACKGROUND

The safety and efficacy of half-dose ticagrelor (45 mg twice daily) dual antiplatelet therapy (DAPT) for flow diverter (FD) treatment of intracranial aneurysm (IA), particularly in Chinese patients and with PED (Pipeline embolization device) Flex Shield, remains uncertain. This study assessed whether this regimen maintains efficacy while improving safety, including its applicability to PED Flex Shield.

METHODS

This single-center retrospective study analyzed consecutive IA patients undergoing FD treatment between 2019-2024, comparing standard-dose clopidogrel (75 mg daily) plus aspirin (100 mg daily) with half-dose ticagrelor (45 mg twice daily) plus aspirin (100 mg daily). Outcomes included adenosine diphosphate-induced maximal platelet aggregation (ADPi-MPA) measured by light transmittance aggregometry, perioperative complications within 30 days post-procedure, and analysis of factors influencing ADPi-MPA levels.

RESULTS

The study included 405 IA patients (half-dose ticagrelor = 224, standard-dose clopidogrel = 181). The half-dose ticagrelor group demonstrated significantly lower ADPi-MPA (26.00 [17.45, 34.25] vs 37.70 [29.50, 43.60], P < 0.001), with comparable ischemic (3.1% vs 5.5%, P = 0.114) and hemorrhagic (2.1% vs 1.2%, P = 0.689) event rates. No significant differences in perioperative complications were found between FD types (PED/PED Flex/TED vs PED Flex Shield) when using the half-dose ticagrelor regimen (all P > 0.05). Similarly, complication rates were comparable between the two DAPT regimens across both FD subgroups (all P > 0.05).

CONCLUSION

This study demonstrates that half-dose ticagrelor DAPT achieves significantly lower platelet reactivity (ADPi-MPA) compared to standard-dose clopidogrel, with no statistically significant differences in ischemic or hemorrhagic complication rates observed among FD-treated IA patients. Importantly, the half-dose regimen shows consistent performance across different FD devices (including PED Flex Shield) without compromising perioperative safety.