Comparative Safety and Efficacy of Dual Antiplatelet Therapy Regimens in Flow Diversion for Intracranial Aneurysms: a Systematic Review and Network Meta-Analysis.

PURPOSE: Dual antiplatelet therapy is required after flow-diverter treatment of intracranial aneurysms, but the comparative safety and efficacy of clopidogrel-, ticagrelor-, and prasugrel-based regimens remain uncertain. Therefore, the purpose of this study was to compare ischemic, hemorrhagic, functional, and mortality outcomes among different P2Y12 inhibitor-based dual antiplatelet therapy regimens after flow diversion for intracranial aneurysms. METHODS: A systematic review and frequentist random-effects network meta-analysis were performed according to PRISMA guidelines. PubMed, Embase, and CENTRAL were searched from inception through February 2026. Eligible studies included randomized and nonrandomized comparative studies evaluating clopidogrel-, ticagrelor-, or prasugrel-based dual antiplatelet therapy after flow-diverter treatment. Outcomes were expressed as odds ratios with 95% confidence intervals relative to clopidogrel. Heterogeneity, consistency, treatment ranking by P‑scores, risk of bias, publication bias, and certainty of evidence were assessed. RESULTS: Eleven studies including 2267 patients, at least 2285 procedures, and 2502 aneurysms were included. Compared with clopidogrel-based therapy, ticagrelor- and prasugrel-based regimens showed no statistically significant differences in early ischemic or hemorrhagic complications, ischemic or hemorrhagic complications at longest follow-up, or mortality. Ticagrelor was associated with lower odds of a good functional outcome compared with clopidogrel. Prasugrel ranked highest for ischemic outcomes at longest follow-up, hemorrhagic outcomes at longest follow-up, and good functional outcome. Certainty of evidence was low or very low. CONCLUSIONS: Current FD-specific evidence is insufficient to establish superiority, inferiority, or equivalence among clopidogrel-, ticagrelor-, and prasugrel-based DAPT regimens across ischemic, hemorrhagic, functional, and survival outcomes. Because treatment allocation was non-random and alternative regimens were preferentially used in patients with suspected clopidogrel hyporesponsiveness, these findings should not be read as supporting a clopidogrel-first hierarchy; regimen selection is likely to remain guided by local pharmacogenetic testing, and cost considerations pending higher-quality comparative data.