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Original research
Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis
  1. Anna Podlasek1,2,
  2. Abdul Aziz Al Sultan3,
  3. Zarina Assis4,
  4. Nima Kashani4,
  5. Mayank Goyal4,5,
  6. Mohammed A Almekhlafi3,5
  1. 1 Stroke, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
  2. 2 Neuroscience and Vascular Simulation, Anglia Ruskin University, Chelmsford, UK
  3. 3 Clinical Neuroscience, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  4. 4 Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  5. 5 Radiology, Hotchkiss Brain Institute, Calgary, Alberta, Canada
  1. Correspondence to Dr Mohammed A Almekhlafi, Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada; mohammed.almekhlafi1{at}


Background Thromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.

Objective To explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.

Methods We performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.

Results Of 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).

Conclusions Evidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.

  • flow diverter

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  • Contributors AP, MAA, AAAS took part in planning, conduct and reporting, MG, ZA, NK took part in reporting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.