<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>: Surface-modified flow diverters (SMFDs) may enable widespread application of single antiplatelet therapy (SAPT) for intracranial aneurysm (IA) treatment. This study systematically evaluated the feasibility of SAPT as an alternative to standard dual antiplatelet therapy (DAPT).<b>Methods</b>: PubMed, Scopus, and Web of Science were searched for SMFD studies. Two reviewers independently assessed eligibility. Study quality was evaluated using NIH tools and Egger’s test. Safety outcomes for studies focusing on ruptured aneurysms were analyzed separately. Outcomes were pooled via Freeman-Tukey arcsine transformation, with heterogeneity assessed by I².<b>Results:</b> The analysis included 12 SAPT studies (332 patients, 383 aneurysms) and 18 DAPT studies (1553 patients, 1728 aneurysms). At 6 months, 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 with SAPT, the treatment-related mortality, ischemic complication, and intracranial hemorrhage rates were 0.6%, 8.6%, and 1.0%, respectively. Prasugrel monotherapy cost matched standard DAPT regimens, while aspirin monotherapy was more economical but potentially higher-risk.<b>Conclusions:</b> SAPT shows marginally superior efficacy and comparable safety to DAPT for unruptured IAs, with favorable hemorrhage rates for ruptured aneurysms. SAPT may be a viable alternative, particularly for high-hemorrhage-risk patients.