Aspirin with Ticagrelor in Intracranial Stenosis

Primary Recommendation Framework

The American Heart Association/American Stroke Association recommends aspirin plus clopidogrel for patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70-99%) of a major intracranial artery, continued for up to 90 days, with a Class 2a recommendation 1
The American Heart Association/American Stroke Association recommends aspirin plus ticagrelor 90 mg twice daily for patients with recent minor stroke or high-risk TIA (within 24 hours) and concomitant ipsilateral >30% stenosis of a major intracranial artery, for up to 30 days, with a Class 2b recommendation 1

Among patients with ≥30% intracranial stenosis ipsilateral to the ischemic event, the risk of recurrent stroke or death at 30 days was 9.9% with ticagrelor 90 mg twice daily plus aspirin 100 mg daily versus 15.2% with aspirin alone (HR 0.66, 95% CI 0.47-0.93, P=0.016) 2, 3
Bleeding events in the ipsilateral atherosclerosis subgroup treated with ticagrelor and aspirin were not significantly higher than aspirin alone, contrasting with the overall THALES population without atherosclerosis 2, 3

Ticagrelor is specifically supported for hyperacute presentation (within 24 hours), while clopidogrel has broader evidence for use within 30 days 1
Clopidogrel has stronger evidence (Class 2a) for severe stenosis (70-99%), while ticagrelor evidence includes moderate stenosis (≥30%) 1
Ticagrelor regimen is limited to 30 days, while clopidogrel can be continued up to 90 days 1
Medication cost and dose frequency (ticagrelor requires twice-daily dosing versus once-daily clopidogrel) should be considered when choosing between ticagrelor and clopidogrel 2, 3

Aspirin maintenance dose should be limited to ≤100 mg daily when using ticagrelor, as higher doses both decrease effectiveness and increase bleeding risk 4
Ticagrelor is absolutely contraindicated in patients with active bleeding or history of intracranial hemorrhage per FDA boxed warning 4
Patients with prior stroke or TIA represent a high-risk group for intracranial bleeding when receiving DAPT 4
Ticagrelor should be discontinued at least 5 days before any surgical procedure to reduce bleeding risk 4

Aspirin plus cilostazol receives a Class 2b recommendation and may be considered to reduce recurrent stroke risk in patients with 50-99% stenosis 1

Aspirin 325 mg daily is recommended in preference to warfarin (Class 1 recommendation) to reduce recurrent ischemic stroke and vascular death in patients with 50-99% stenosis 1
Angioplasty and stenting should not be performed as initial treatment in patients with severe stenosis (70-99%), even for those already on antithrombotic therapy at the time of stroke or TIA (Class 3: Harm) 1, 2
Higher aspirin doses with ticagrelor increase bleeding without improving efficacy 4
Blood pressure control (SBP <140 mm Hg), high-intensity statin therapy, and at least moderate physical activity are Class 1 recommendations alongside antiplatelet therapy 1