Clopidogrel Versus Ticagrelor in Dual Anti-platelet Therapy for Intracranial Aneurysm Patients Undergoing Neuroendovascular Treatment: A Systematic Review and Meta-analysis

Patients with cerebral aneurysms often undergo neuro interventional treatments involving stent implantation or flow diversion. These treatment options are associated with a high risk of thromboembolic complications, which can partially be mitigated with the effective use of antiplatelet Therapy. However, there is some conflicting data regarding the use of more potent P2Y12 inhibitors (e.g., Ticagrelor) when compared to standard combination therapy with clopidogrel. We aimed to investigate the safety and effectiveness of administering clopidogrel versus ticagrelor in addition to aspirin as a part of the DAPT regimen after successful endovascular treatment of cerebral aneurysms. We searched PubMed, Web of Science, and Scopus for comparative studies that fit the eligibility criteria including observational studies and randomized controlled trials up to June 2025. We excluded reviews, case reports, and meta-analyses. The analysis was performed using a fixed effect model since no or minimal heterogeneity was present. We conducted a pooled analysis of the odds ratio (OR) at a confidence interval of 95% and p-value of 0.05. The search strategy and screening yielded a total of 18 eligible articles. There was no difference between clopidogrel and ticagrelor in thromboembolic complications, hemorrhagic complications, stroke, ischemic stroke, stent thrombosis, modified Rankin scale (mRs) 0–2, and all-cause mortality (OR = 0.92, 95% CI [0.74, 1.15], p = 0.47), (OR = 1.07, 95% CI [0.86–1.34], p = NS), (OR = 1.06, 95% CI [0.72, 1.57], p = 0.76), (OR = 1.06, 95% CI [0.67, 1.69], p = 0.79), (OR = 0.62, 95% CI [0.34, 1.1], p = 0.10), (OR = 0.86, 95% CI [0.51, 1.45], p = 0.56), and (OR = 1.06, 95% CI [0.63, 1.8], p = 0.82), respectively. The overall odds ratio for modified Rankin scale worsening favored clopidogrel (OR = 0.52, 95% CI [0.32, 0.83], p = 0.007). Comparable results were obtained regarding safety and efficacy outcomes between both drugs as used in DAPT regimens. Therefore, clopidogrel can be used as first-line according to the recommended guidelines, with the use of ticagrelor as an alternative for patients with inadequate response to clopidogrel due to the presence of polymorphism in CYP450 enzymes that activate clopidogrel to prevent the risk of thrombosis.