Surface-modified flow diverters (SMFDs) enable application of single antiplatelet therapy (SAPT) for intracranial aneurysms (IAs) treatment. This study systematically evaluated the feasibility of SAPT as an alternative to dual antiplatelet therapy (DAPT).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. Outcomes were pooled via Freeman-Tukey arcsine transformation, with heterogeneity assessed by I2.The analysis included 6 SAPT studies (200 patients, 243 aneurysms) and 18 DAPT studies (1553 patients, 1728 aneurysms). All efficacy and safety outcomes-including 6-month complete occlusion rates (77.1% vs 72.2%), 6-month adequate occlusion rates (86.9% vs 86.6%), 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%), and intracranial hemorrhage rates (0% vs 0.9%)-exhibited no significant differences. For p48/64 HPC specifically, the remaining outcomes also exhibited no significant differences, with the exception of lower 6-month adequate occlusion rates in the SAPT group (85.5% vs 93.8%, P = .03). Compared to prasugrel monotherapy and DAPT regimens, aspirin was more economical yet poses higher safety risk.Limitations include the limited sample size of the SAPT group, the retrospective design of most included studies, and significant heterogeneity.SAPT shows comparable efficacy and safety to DAPT. Prasugrel monotherapy is a more preferable option compared with aspirin. SAPT may be a viable alternative, particularly for high-hemorrhage-risk patients.Copyright © 2025. Published by Elsevier Inc.