Antiplatelet Therapy after Endovascular Intracranial Aneurysm Surgery: Comparative Effectiveness and Safety Insights...

Endovascular treatment of intracranial aneurysms - particularly stent-assisted coiling and flow diversion (FD) - requires antiplatelet (AP) therapy to prevent thromboembolic complications. However, standard fixed-dose regimens may not account for individual variability in drug response or device-specific thrombogenicity. This systematic review and meta-analysis evaluate the comparative effectiveness and safety of tailored AP protocols versus standard regimens.

A comprehensive search of PubMed, Embase, and Cochrane Library identified 27 eligible studies (n = 8,452 patients) comparing tailored AP strategies - including platelet function testing (PFT)-guided adjustments, potent P2Y12 inhibitors, and surface-modified device protocols - with standard dual AP therapy. Primary outcomes were thromboembolic events and major hemorrhage within 30 days. Meta-analysis was performed using a random-effects model with a 2× scaling factor and 1.0 continuity correction to address zero-event cells ("Khanafer effect"). Subgroup and trial sequential analyses (TSAs) were conducted to assess robustness and certainty.

Tailored AP protocols significantly reduced thromboembolic events (RR 0.45; 95% CI: 0.37-0.54; p < 0.001), with TSA confirming adequate information size. Major hemorrhage was also reduced (RR 0.52; 95% CI: 0.32-0.83; p < 0.05), though heterogeneity was high (I2 = 77.5%). Subgroup analysis revealed the greatest benefit in surface-modified FD using single antiplatelet therapy (SAPT) (RR 0.06 for ischemia; RR 0.11 for hemorrhage). Tailored clopidogrel (PFT-guided) and potent P2Y12 inhibitors (prasugrel/ticagrelor) both demonstrated superior ischemic protection without increasing bleeding risk. Efficacy was consistent across ruptured and unruptured aneurysm cohorts.

Tailored AP therapy significantly improves ischemic outcomes without compromising safety in patients undergoing endovascular aneurysm treatment. Surface-modified devices enabling SAPT offer a promising evolution in neurointerventional care. These findings support a shift from fixed-dose regimens toward personalized protocols informed by platelet biology and device technology. Further large-scale trials are warranted to standardize individualized AP strategies into clinical guidelines.