<b>Comparison of </b><b>Single Antiplatelet Therapy </b><b>and </b><b>Dual Antiplatelet Therapy </b><b>in the Treatment of Intracranial Aneurysms with Surface-modified Flow Diverters</b><b>: a Systematic Review and Meta-analysis</b>Item

<b>Objective:</b> The advent of surface-modified flow diverters (SMFDs) has enabled the potential application of single antiplatelet therapy (SAPT) as a partial replacement for dual antiplatelet therapy (DAPT) in treating intracranial aneurysms (IAs) with flow diverters (FDs). This study aimed to systematically evaluate the feasibility of substituting DAPT with SAPT for IA treatment.<b>Methods:</b> We comprehensively searched PubMed, Scopus, and Web of Science for studies reporting IA treatment with SMFDs. Two independent reviewers assessed study eligibility based on predefined criteria. Study quality was evaluated using the National Institutes of Health Quality Assessment Tool and Egger's test for publication bias. Safety outcomes of studies focusing on ruptured aneurysms were analyzed separately. All outcomes were pooled using the Freeman-Tukey arcsine transformation method, with heterogeneity assessed using the I² statistic.<b>Results:</b> The analysis included 12 SAPT studies (332 patients, 383 aneurysms) and 18 DAPT studies (1553 patients, 1728 aneurysms). At 6-month follow-up, complete and adequate occlusion rates were comparable between groups (SAPT: 79.8% and 89.0% vs DAPT: 72.2% and 86.6%, respectively). Among studies focusing on unruptured aneurysms, no significant differences between the SAPT and DAPT group were observed in all-cause mortality (0.2% vs 0.3%), treatment-related mortality (0% vs 0.1%), morbidity (0% vs 0.4%), ischemic complications (1.7% vs 4.6%), thrombosis formation (1.3% vs 2.3%) or intracranial hemorrhage rates (0% vs 0.9%). In ruptured aneurysms treated with SAPT, the treatment-related mortality, ischemic complication, and intracranial hemorrhage rates were 0.6%, 8.6%, and 1.0%, respectively. Cost analysis showed prasugrel monotherapy was similarly priced to standard DAPT regimens, while aspirin monotherapy was more economical but potentially higher-risk.<b>Conclusions:</b> For IA treatment with SMFDs, SAPT demonstrates marginally superior efficacy and comparable safety to DAPT for unruptured aneurysms, while showing favorable intracranial hemorrhage rates for ruptured aneurysms. These findings suggest SAPT as a viable and potentially advantageous alternative antiplatelet strategy, particularly for patients at higher hemorrhage risk.