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Insertable cardiac monitors (ICMs) are often implanted after cryptogenic stroke (CS) to detect atrial fibrillation (AF) and guide anticoagulation. However, the impact of this practice on stroke recurrence remains unclear. This study sought to compare stroke recurrence between CS patients with and without ICM-detected AF and identify predictors of recurrent stroke. A retrospective analysis was conducted of consecutive patients admitted to a stroke center with no history of AF who received an ICM for CS or transient ischemic attack. Among 840 patients (median follow-up 990 days), AF was detected in 235. Recurrent strokes occurred in 112 patients, of which 70.5% occurred in patients without AF ever being detected. Patients with AF were observed to have increased stroke recurrence when analyzing AF as a time-varying exposure (adjusted HR: 2.73; 95% CI: 1.33-5.59), despite most patients with AF being started on anticoagulation (97.9%). Other covariates associated with increased risk of recurrent stroke in multivariable analyses included an elevated CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, history of Stroke or transient ischemic attack, VAscular disease, Age 65-74 years, and Sex category [female]) score ≥4 and male sex. In exploratory subgroup analysis of patients with a CHA2DS2-VASc score <4 and age of <65 years (n = 107), only 1 patient with a recurrent stroke had AF detected (<1%). Despite the high rate of detection of AF following CS by ICMs, most strokes occurring in this population may not be due to AF. Further randomized trials are needed to verify these observations and clarify the benefit of routine ICM implantation for secondary CS prevention.

Posterior fossa decompression, with or without duraplasty, is effective for the treatment of pediatric patients with symptomatic Chiari malformation type I (CM-I). The aim of this study was to compare effectiveness and clinical outcomes of Y-shaped vs linear techniques during posterior fossa decompression with duraplasty (PFDD) for CM-I patients. Retrospective review of data for pediatric patients (≤21 years old) with CM-I and surgically managed with PFDD with or without C1 laminectomy was performed. Clinical characteristics, including presence of a syrinx and presentation, were recorded. Patients were dichotomized into 2 propensity score-matched (PSM) groups based on whether a Y-shaped or linear dural incision was used. All statistical tests were 2-tailed, and a P-value <.05 was significant. A total of 228 patients met the inclusion criteria, with 124 undergoing linear and 104 undergoing Y-shaped dural incision. After PSM, each group had 66 patients who were well-matched for age, sex, presentation, and extent of tonsillar herniation. Patients in the linear incision group had significantly lower estimated blood loss (Y-shaped: 66.5 ± 75.8 mL vs linear: 33.9 ± 18.9 mL, P < .01). Although the rate of complete symptom resolution was higher in the linear group before PSM (Y-shaped: 28.8% vs linear: 57.3%, P < .001), this difference was not significant after PSM (Y-shaped: 31.8% vs linear: 47%, P = .205). Similarly, fewer repeat decompression procedures were needed in the linear group before PSM (Y-shaped: 13.5% vs linear: 0.8%, P < .001) but not after (Y-shaped: 10.6% vs linear: 1.5%, P = .062). Linear and Y-shaped dural incisions are safe and effective for PFDD in pediatric CM-I patients. Linear incisions were associated with reduced blood loss, although neither group had a clinically significant blood loss and overall clinical outcomes were comparable after PSM. These findings can help guide surgical decision-making for CM-I. Further studies are warranted to validate these results and explore the influence of surgeon experience and preference on the associated outcomes.

Mucositis involving the gastrointestinal, vaginal, and nasal mucosa is one of the primary dose-limiting toxicities of hematopoietic stem cell transplantation (HSCT) and its conditioning regimen. The oropharyngeal mucosa is commonly affected, which can be detrimental to patient health and quality of life. Despite its significant prevalence and deleterious effects, we have an inadequate understanding of the risk factors and outcomes associated with oral mucositis (OM). We performed a literature search through PubMed and EBSCO (inception to 31 March 2024) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data was extracted from eligible studies using a pre-specified data extraction form. Quality of the data was assessed using the Newcastle-Ottawa Scale for non-randomized, observational studies and the Cochrane Collaboration Tool for randomized controlled trials. Our initial search identified 1677 articles, 34 of which were included in our study. Of those 34, 30 were included in the qualitative assessment of clinical risk factors in the development of OM, and 4 were included in the meta-analysis assessing the relationship between OM and infectious complications following HSCT. Across both HSCT modalities and cancer cohorts, female sex and high-intensity conditioning were common risk factors in the development of OM. When stratified by allogeneic and autologous HSCT, methotrexate, younger age, and longer duration of neutropenia were associated with increased OM risk in allogeneic HSCT recipients, while renal dysfunction, HSV-1 reactivation, and longer neutrophil engraftment were associated with increased OM risk in autologous HSCT recipients. Longer neutrophil engraftment was a common risk factor across different cancer cohorts; however, renal dysfunction was a distinct risk factor for OM in multiple myeloma patients. Additionally, our meta-analysis revealed that patients with OM have an increased risk of developing infectious complications following HSCT compared to those without OM, with an odds ratio of 3.84 (95% CI: 2.51-5.86). The development of OM is related to various risk factors, and individuals with OM are at greater risk of infectious complications. Knowledge of these risk factors and outcomes will help clinicians identify high-risk individuals, prevent OM, and protect an immunocompromised population from subsequent life-threatening complications.

Active cerebrospinal fluid exchange (ACE) through the dual-lumen IRRA flow catheter is a technique that has been used in the treatment of intraventricular hemorrhage and subarachnoid hemorrhage, ventriculitis, and others. Previous reports have consisted of small numbers of patients and focused on particular conditions. Our objective was to complete a multi-institutional retrospective cohort study to evaluate the safety and clinical outcomes of ACE therapy through the IRRA flow catheter. Multiple academic neurocritical care units from the United States and Europe contributed patients treated with either ACE or external ventricular drainage to a retrospective database. Complications including failure to drain, inadvertent removal, infection, cerebrospinal fluid leak, insertional hemorrhage, and early replacement were compared. Shunt dependence and modified Rankin score were also compared. A total of 401 treated with external ventricular drainage and 118 treated with ACE were included. Diagnoses included were subarachnoid hemorrhage, intraventricular hemorrhage, and ventriculitis. ACE therapy showed fewer overall complications (odds ratio [OR] = 0.29, P < .0001), failures to drain (OR = 0.21, P = .0004), infections (OR = 0.2, P < .0001), cerebrospinal fluid leak (OR = 0.26, P = .017), and early replacements (OR = 0.4, P = .036). There was no difference in insertional hemorrhage or inadvertent removal. ACE therapy was associated with a lower rate of shunt dependence (OR = 0.28, P < .0001) and higher likelihood of discharge with an modified Rankin score of 0 to 2 (OR = 2.47, P = .001). ACE therapy with the IRRA flow catheter is associated with fewer complications and improvement in some clinical outcomes. These results need to be confirmed with prospective and randomized trials.

The management of moyamoya disease during pregnancy and recommendations for the mode of delivery remain controversial. We investigated factors associated with neurologic events during pregnancy in women with moyamoya disease and its association with prepregnancy surgical revascularization. We performed a literature search from January 1, 1970, through September 30, 2021, using Embase, Web of Science, Medline, and Cochrane to identify cases of moyamoya disease with pregnancy. Primary outcome was neurologic events during pregnancy and were subcategorized into antepartum, intrapartum (within 24 hours of delivery), and postpartum events. Univariate and multivariate regression analyses using pooled results were performed to assess risk factors associated with neurologic events. Fifty-two relevant studies with 182 individuals diagnosed with moyamoya before pregnancy, and 229 pregnancies were included in the study. 59% underwent surgical revascularization before pregnancy. Of the 229 pregnancies, 22 (9.6%) patients had ischemic events and 3 (1.3%) had hemorrhagic events. In addition, there were 7 (3%) seizures and 4 (1.7%) other neurologic events not associated with ischemia or hemorrhage. There were fewer neurologic events during pregnancy in patients treated with surgery than those without surgery (11% surgical vs 24% medical, P = .009). Multivariable regression analysis demonstrated prior surgical revascularization as the only factor associated with lower number of neurologic events during pregnancy (odds ratio 0.42 [95% CI 0.19-0.96]). Mode of delivery (vaginal vs cesarean section) was not associated with a difference in overall intrapartum and postpartum neurologic events. We found that prior revascularization surgery was the only factor associated with fewer neurologic events during pregnancy in women with moyamoya disease. Mode of delivery was not associated with increased neurologic events during or after delivery.

The recent introduction of the Woven EndoBridge (WEB) has presented an alternative treatment modality for intracranial bifurcation and wide-neck aneurysms with a growing body of literature evaluating its efficacy. However, no previous systematic review has focused on comparing WEB with previously using endovascular approaches, specifically primary coiling (PC) and stent-assisted coiling (SAC). Herein, the authors present the first systematic review summarizing available literature to reach a consensus regarding the safety and effectiveness of WEB. A systematic review of articles identified through a search of PubMed, Embase, Scopus, and Web of Science was conducted. Studies were included if they compared WEB with PC or SAC from any aspect for intracranial aneurysms. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies-of Interventions tool. Meta-analyses of the outcomes based on stent use and rupture status were performed. A total of 16 studies were included. The three endovascular approaches were comparable in terms of baseline characteristics except for older age and smaller aneurysm neck in the PC group (p < 0.05). Moreover, the follow-up duration was shorter in the WEB group (p < 0.05). Although the WEB group demonstrated lower complete and adequate immediate occlusion rates (p < 0.01), the rates at follow-up evaluations were comparable with SAC and PC (p = 0.61 and p = 0.27, respectively). The WEB group experienced significantly fewer unfavorable neurological outcomes than the SAC group (p = 0.04), while comparable to the PC group (p = 0.36). Retreatment rates were comparable between WEB and coiling (p = 0.92). The WEB group had fewer hemorrhagic and thromboembolic complications (p < 0.01 and p = 0.01, respectively), with similar neurological and procedure-related complications compared with combined PC and SAC groups. Lastly, mortality was comparable among the different endovascular approaches. This study provides evidence on the noninferiority of WEB compared with PC and SAC in terms of angiographic outcomes. Meanwhile, our findings on lower complication rates, cost, and improved operative aspects associated with WEB establish this novel endovascular treatment as a safe and effective alternative for the treatment of bifurcation and wide-neck aneurysms.