Comparison of Prasugrel and Clopidogrel Used as Antiplatelet Medication for Endovascular Treatment of Unruptured Intracranial Aneurysms: A Meta-Analysis.

Abstract

Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance. Our aim was to analyze the efficacy of prasugrel compared with clopidogrel in the cerebrovascular field. A systematic search of 2 large databases was performed for studies published from 2000 to 2018. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel. Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel. In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74, P = .006; I2 = 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I2 = 83% versus 16/682 = 2%; 95% CI, 1%-5%; I2 = 73%; P = .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I2 = 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I2 = 60%) intraperiprocedural hemorrhages, respectively (P = .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I2 = 0%) delayed hemorrhagic events, respectively (P = .001). Retrospective series and heterogeneous endovascular treatments were limitations. In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.