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

Comparison of P2Y12 receptor inhibitors, clopidogrel efficacy depending on CYP2C19 bioactivation.

This PRISMA-compliant systematic review and network meta-analysis, searching PubMed, Embase and CENTRAL to February 2026, compares dual antiplatelet regimens based on clopidogrel, ticagrelor or prasugrel after flow-diverter treatment of intracranial aneurysms. Eleven studies totalling 2,267 patients, at least 2,285 procedures and 2,502 aneurysms were included. No significant difference emerged between regimens for early or longest-follow-up ischaemic or haemorrhagic complications, or mortality; ticagrelor was associated with lower odds of a good functional outcome than clopidogrel. Certainty of evidence was rated low to very low, and because allocation was non-random, alternatives were preferentially used in patients suspected of clopidogrel hyporesponsiveness.

Synthesis written by Geno'X. For the full original abstract, please refer to the source publication.

Indication bias is structural here and the authors are honest about it: patients switched to ticagrelor or prasugrel were precisely those judged clopidogrel hyporesponders, which prevents reading these results as an efficacy hierarchy. The paper interests the pharmacogeneticist by default — lacking quality comparative data, regimen choice will keep resting on local CYP2C19 genotyping and platelet function testing. Nothing here justifies changing practice, only a reminder that genotype-stratified randomised trials are missing in this indication.

Analysis by Dr Thibaut Benquey