Coronal Deformity is Associated With Uptake on Single Photon Emission Computed Tomography in Patients With Low Back Pain.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) is emerging as a valuable imaging test for identifying pain generators within the lumbar spine. The relationship between radiotracer uptake on SPECT/CT and anatomic biomechanical parameters has not been previously studied. METHODS: We performed a retrospective review of all patients seen at our institution between 2021-2023 who obtained SPECT/CT scans for workup of thoracolumbar back pain. Patient data including demographic, clinical symptoms, and surgical history were collected. Radiology reports were reviewed for evidence of pathologic degeneration and increased bone metabolism on SPECT/CT. Biomechanical parameters were measured from standing scoliosis plain radiographs. Patients were stratified into two cohorts by either presence or absence of asymmetric coronal uptake on SPECT/CT. RESULTS: 160 patients met inclusion criteria. Patients were primarily male (55%) with average age 55 ± 15 years. 87 (54%) patients demonstrated asymmetric uptake on SPECT/CT. These patients were older (P < 0.001), but with similar gender, prior fusion history, sacroiliitis, adjacent segment degeneration, and pseudoarthrosis (P > 0.05). This cohort had more disc disease, facet arthropathy, and greater degree of coronal scoliosis and coronal imbalance (P < 0.001). There were significantly more sites of uptake in the asymmetric cohort, and uptake was preferentially observed in the concavity of the lumbar curve (P < 0.001). There were no significant differences in sagittal balance or spinopelvic mismatch between cohorts (P > 0.05). CONCLUSION: Asymmetric uptake on SPECT/CT was associated with coronal deformity in patients with low back pain. Further prospective studies are warranted to assess the effect of coronal deformity on pain generation.

Biomechanical Predictors of Sacroiliac Joint Uptake on Single-Photon Emission Computed Tomography/Computed Tomography.

OBJECTIVE: Single-photon emission computed tomography/computed tomography (SPECT/CT) is an emerging imaging modality that identifies sites of heightened bone metabolism in response to increased stresses. The relationship between sacroiliac (SI) joint radiotracer uptake and anatomic biomechanical parameters is poorly understood. METHODS: Adult patients with SPECT/CT scans performed at our institution between 2021 and 2023 for the workup of low back pain were included. Patient charts were reviewed for demographic factors including age, gender, and prior thoracolumbar fusion history. Biomechanical spinopelvic parameters were measured from standing scoliosis radiographs. SPECT/CT scans were reviewed for uptake at the SI joint. Patients were stratified into 2 cohorts; patients with SI uptake greater than iliac crest uptake were designated "hot," whereas those with less or equal uptake were labeled "cold." RESULTS: One-hundred and sixty patients met inclusion criteria. Patients were slightly more male (55%) with average age 55 ± 14.9 years. Sixty-eight patients (43%) had evidence of increased SI activity. Interrater reliability showed substantial agreement (kappa = 0.62). The hot cohort demonstrated greater pelvic incidence (54.8 ± 14.0 degrees vs. 51.0 ± 11.0 degrees, P = 0.031) and pelvic tilt (20.8 ± 9.5 degrees vs. 18.4 ± 8.6 degrees, P =0.047) compared with the cold cohort. Patients were otherwise similar between cohorts (P > 0.05). CONCLUSIONS: Increased pelvic incidence and pelvic tilt angles are associated with SPECT/CT uptake at the SI joint, which may reflect altered biomechanics at the spinopelvic junction. SPECT/CT may be a valuable tool to assess SI degeneration. Future studies are warranted to better characterize the clinical applications of these findings.

Association of geographical disparities and segregation in regional treatment facilities for Black patients with aneurysmal subarachnoid hemorrhage in the United States.

Background and objectives: This study investigates geographic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care for Black patients and aims to explore the association with segregation in treatment facilities. Understanding these dynamics can guide efforts to improve healthcare outcomes for marginalized populations. Methods: This cohort study evaluated regional differences in segregation for Black patients with aSAH and the association with geographic variations in disparities from 2016 to 2020. The National Inpatient Sample (NIS) database was queried for admission data on aSAH. Black patients were compared to White patients. Segregation in treatment facilities was calculated using the dissimilarity (D) index. Using multivariable logistic regression models, the regional disparities in aSAH treatment, functional outcomes, mortality, and end-of-life care between Black and White patients and the association of geographical segregation in treatment facilities was assessed. Results: 142,285 Black and White patients were diagnosed with aSAH from 2016 to 2020. The Pacific division (D index = 0.55) had the greatest degree of segregation in treatment facilities, while the South Atlantic (D index = 0.39) had the lowest. Compared to lower segregation, regions with higher levels of segregation (global F test p < 0.001) were associated a lower likelihood of mortality (OR 0.91, 95% CI 0.82-1.00, p = 0.044 vs. OR 0.75, 95% CI 0.68-0.83, p < 0. 001) (p = 0.049), greater likelihood of tracheostomy tube placement (OR 1.45, 95% CI 1.22-1.73, p < 0.001 vs. OR 1.87, 95% CI 1.59-2.21, p < 0.001) (p < 0. 001), and lower likelihood of receiving palliative care (OR 0.88, 95% CI 0.76-0.93, p < 0.001 vs. OR 0.67, 95% CI 0.59-0.77, p < 0.001) (p = 0.029). Conclusion: This study demonstrates regional differences in disparities for Black patients with aSAH, particularly in end-of-life care, with varying levels of segregation in regional treatment facilities playing an associated role. The findings underscore the need for targeted interventions and policy changes to address systemic healthcare inequities, reduce segregation, and ensure equitable access to high-quality care for all patients.

Race and socioeconomic disparities persist in treatment and outcomes of patients with cervical spinal cord injuries: An analysis of the national inpatient sample from 2016 - 2020.

Objective: Previous literature has described race and socioeconomic disparities in both treatment and outcomes following cervical spinal cord injuries (SCI). The goal of this study is to investigate the current state of parity in management and outcomes following SCI. Methods: We surveyed the National Inpatient Sample database (NIS) for patients admitted with primary diagnosis of cervical SCI. 49,320 patients were identified. Univariate and multivariate analyses were performed to evaluate racial and socioeconomic differences in SCI care and outcomes. Results: Compared to white patients, minority race was associated with a longer time from presentation to operative intervention (p < 0.001) and longer length of stay following admission for cervical SCI (16 vs 13 days, p < 0.001). Minority patients were more likely to have an unfavorable discharge (skilled nursing facility, against medical advice, death) status than white patients (p < 0.001). Patients in the bottom quartile of median household income were associated with more unfavorable discharges than the top two quartiles (p < 0.001). Patients with the lowest median household income quartile also had higher total costs than those in the top quartiles ($221,654 vs 191,723, p < 0.001). Black, Hispanic, and Asian/Pacific Islander incurred higher treatment costs than White patients. Conclusion: Minority and lower socioeconomic status are independently associated with unfavorable discharge and LOS in cervical SCI. Furthermore, racial and economically disadvantaged groups have longer wait times from admission to surgical intervention. These disparities persist despite being highlighted by previous publications and increased societal awareness of healthcare inequities, necessitating further work to reach parity.

Aneurysm of the Artery of Wollschlaeger and Wollschlaeger.

The Artery of Wollschlaeger and Wollschlaeger (AWW) is a non-eloquent, tentorial branch of the superior cerebellar artery (SCA). Coursing posteriorly from an intradural origin, the AWW passes through the ambient cistern and supplies the medial tentorium. Due to its small diameter, the AWW is often only identified in the context of secondary dilation from pathologies such as dural arteriovenous fistulas (DAVF). Herein, we report the first case, to our knowledge, of an aneurysm of the AWW associated with a posterior fossa DAVF Swift identification and diagnosis followed by cautious treatment of both the aneurysm and fistula were critical to avert rupture and optimize outcomes, avoiding potential hemorrhagic complications.

A review of the top 100 most influential articles on basilar artery aneurysms.

Basilar artery aneurysms account for approximately 5% of all intracranial aneurysms. This bibliometric analysis summarizes the most-cited articles on basilar artery aneurysms and highlights the contributing articles to today's evidence-based practice. In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "basilar artery aneurysm" or "basilar aneurysm" was used. Our results were arranged in descending order based on the article's citation count. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact Per Paper (SNIP), and Hirsch index. The keyword-based search showed that 699 articles were published between 1888 and 2022. The top 100 articles were published between 1961 and 2019. The top 100 most cited articles collected a total of 8869 citations with an average of 89 citations per paper. The rate of self-citations accounted for an average of 4.85% of the total number of citations. The bibliometric analysis provides a quantitative overview of how medical topics and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in basilar artery aneurysms by finding the top 100 most cited papers.

Technical advantages of a novel flow diverter in complex flow diversion: patient series.

BACKGROUND: The Surpass Streamline flow diverter (SSFD) possesses 4 attributes that may offer an important advantage in the treatment of complex pathologies: (1) utilization of an over-the-wire (OTW) delivery system, (2) greater device length, (3) larger potential diameter, and (4) propensity to open in tortuosity. OBSERVATIONS: Case 1 leveraged device diameter to embolize a large, recurrent vertebral artery aneurysm. Angiography at 1 year posttreatment showed complete occlusion with a patent SSFD. Case 2 leveraged device length and opening in tortuosity to manage a symptomatic 20-mm cavernous carotid aneurysm. Magnetic resonance imaging at 2 years demonstrated aneurysm thrombosis and patent stents. Case 3 utilized diameter, length, and the OTW delivery system to treat a giant intracranial aneurysm previously treated with surgical ligation and a high-flow bypass procedure. Angiography at 5 months postprocedure demonstrated the return of laminar flow, as the vein graft had healed around the stent construct. Case 4 used diameter, length, and the OTW system to treat a giant, symptomatic, dolichoectatic vertebrobasilar aneurysm. Twelve-month follow-up imaging revealed a patent stent construct with no change to the aneurysm size. LESSONS: Increased awareness of the unique attributes of the SSFD may allow a larger number of cases to be treated with the proven mechanism of flow diversion.

Flow diversion jet: A dangerous mechanism in the flow diversion treatment of giant intracranial aneurysms.

BACKGROUND: Cerebral hyperperfusion syndrome (CHS) occurs after the restoration of blood flow to a previously low-flow, low-pressure region of the cerebral vasculature, which subsequently responds with chronic compensatory vasodilation, leading to a dysregulated state. Sudden restoration of normal blood flow can overwhelm the vasculature leading to intracranial hemorrhage (ICH). Separately, the Windkessel phenomenon describes the capacity for elastic vessels to expand with systolic pressure and decompress with diastole, thereby suppressing distal pulse pressure. We encountered a case involving giant basilar aneurysms in which we believe the Windkessel phenomenon precipitated a catastrophic manifestation of CHS at treatment. OBSERVATION: We present a 60-year-old female found to have marked dolichoectasia of the right cervical internal carotid, vertebral, and basilar arteries concurrent with two large vertebrobasilar dissecting-type fusiform aneurysms. Managed conservatively for ten years before developing gait ataxia, new imaging revealed dramatic interval growth of the larger aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. The patient suffered intra-procedural catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A meticulous review of the case data was undertaken. Our findings suggest that giant aneurysms can act as a Windkessel reservoir, depressing the distal pulse pressure. Flow diversion bypasses the reservoir, increasing the distal pulse pressure beyond the autoregulatory capacity, resulting in ICH analogous to CHS. LESSONS: CHS and Windkessel phenomenon can contribute to catastrophic sequelae in the treatment of giant intracranial aneurysms with flow diversion. Awareness of this mechanism can protect future patients from harm.

Endovascular Management of Pediatric Traumatic Intracranial Pseudoaneurysms: A Systematic Review and Case Series.

OBJECTIVE: This study aims to systematically review the management and outcomes of pediatric patients who develop intracranial pseudoaneurysm (IPA) following head trauma or iatrogenic injury. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed. Additionally, a retrospective analysis was conducted on pediatric patients who underwent evaluation and endovascular treatment for IPA originating from head trauma or iatrogenic injury at a single institution. RESULTS: Two hundred twenty-one articles in the original literature search. Fifty-one met inclusion criteria resulting in a total of 87 patients with 88 IPAs including our institution. Patients ranged in age from 0.5 months to 18 years. Parent vessel reconstruction was used as first-line treatment in 43 cases, parent vessel occlusion in 26, and direct aneurysm embolization (DAE) in 19. Intraoperative complications were observed in 3.00% of procedures. Complete aneurysm occlusion was achieved in 89.61% of cases. 85.54% of cases resulted in favorable clinical outcomes. The mortality rate after treatment was 3.61%. The DAE group had higher rates of aneurysm recurrence than other treatment strategies (P = 0.009). Patients with SAH had overall worse outcomes compared to patients who did not (P = 0.024). There were no differences in favorable clinical outcomes (P = 0.274) or complete aneurysm occlusion (P = 0.13) between primary treatment strategies. CONCLUSIONS: IPAs were successfully obliterated, and favorable neurological outcomes were achieved at a high rate regardless of primary treatment strategy. DAE had a higher rate of recurrence than the other treatment groups. Each described treatment method in our review is safe and viable for the treatment of IPAs in pediatric patients.

A Bibliometric and Visual Analysis of the Most Cited Articles on Disc Arthroplasty.

STUDY DESIGN: Bibliometric literature review. OBJECTIVE: Total disc arthroplasty (TDA) is an evolving technique used by surgeons to preserve neural elements and range of motion in patients with degenerative disc disease, spondylosis and more. In comparison to discectomy, disc arthroplasty has been shown to decrease morbidity, reduce adjacent-level disease, and preserve pre-operative range of motion. The objective of this manuscript is to provide a bibliometric analysis of the use of disc arthroplasty in scientific literature and highlight the main contributing authors and their publication characteristics. METHODS: The Scopus database was used to perform a title-specific, keyword-based search for all publications until June 2022. The keyword "total disc arthroplasty" was used. The most-cited 100 articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty first author, institution, country of origin, publishing journal, Source Normalized, Impact Per Paper (SNIP), and Hirsch index. RESULTS: Our search on disc arthroplasty yielded 580 articles that were published, with the first publication on the topic found in 1966. The most cited 100 articles received a total of 8694 citations, with an average of 86.94 citations per article. After assessing countries with the greatest contributions, United States, China, and Germany were top 3 with 54, 14, and 7 articles, respectively. CONCLUSION: The bibliometric analysis provides an overview of how medical research is analyzed in academic medicine. In the present study, we evaluated the global trends in disc arthroplasty for the treatment of degenerative disc disease.

Unique magnetic resonance spectroscopy profile of intracranial meningiomas compared to gliomas: a systematic review.

BACKGROUND AND PURPOSE: The goal of this study was to systematically review the metabolic profile of meningiomas using magnetic resonance spectroscopy in comparison to gliomas, as measured by mean metabolite ratios. METHODS: Following the PRISMA guidelines, a systematic literature review was performed using the PubMed, Ovid Embase, Web of Science, and the Cochrane databases from inception to May 2021. Studies were selected based on predetermined inclusion and exclusion criteria. RESULTS: Eight studies were ultimately selected with 207 patients included. Fifty-nine patients were diagnosed with meningioma (age = 48.4, 66.7% female) and 148 patients diagnosed with glioma (age = 56.4, 49.2% female). Three studies reported elevated Cho/Cr in meningiomas compared to gliomas (5.71 vs. 1.46, p < 0.05, 7.02 vs. 2.62, p < 0.05, and 4.64 vs. 2.52, p = 0.001). One study reported Ala/Cr to be significantly elevated in meningiomas compared to gliomas (1.30 vs. undetectable, p < 0.001). One study reported myo-Inositol/Cr to be significantly elevated in meningiomas in comparison to gliomas (1.44 vs. 1.08, p < 0.05). One study reported Glu/Cr to be significantly elevated in meningiomas in comparison to gliomas (3.47 vs. 0.89, p = 0.002). Two studies reported Cho/NAA to be significantly elevated in meningiomas in comparison to gliomas (4.46 vs. 2.6, p = 0.004, and 5.8 vs. 2.55, p < 0.05). Two studies reported NAA/Cr was significantly elevated in gliomas compared to meningiomas (undetectable vs. 1.54, p < 0.001 and undetectable vs. 0.58, p < 0.05). CONCLUSIONS: Significant differences in metabolite ratios between tumor types were reported in Cho/Cr, Ala/Cr, Glu/Cr, Cho/NAA, myoI/Cr and NAA/Cr between meningiomas and gliomas.

A Bibliometric Analysis of the Top 50 Most Influential Articles on External Ventricular Drains.

OBJECTIVE: External ventricular drains (EVDs) are commonly used to remove cerebrospinal fluid and monitor intracranial pressure in patients with neurological dysfunction. Often the first invasive procedure learned in training, ventricular drain placement is the quintessential neurosurgical procedure. This bibliometric analysis highlights the top contributing EVD articles in current evidence-based practice. METHODS: The Scopus database was used to perform a title-specific, keyword-based search for all publications until September 2022. The keywords "external ventricular drain" or "EVD" or "external ventriculostomy" were used. The 50 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS: The keyword-based search showed that 8464 articles on EVDs were published between 1991 and 2022. The top 50 articles were published between 1999 and 2019. The top 50 articles acquired a total of 3343 citations with an average of 66.86 citations per paper. The rate of self-citations accounted for an average of 5.16% of the total number of citations. A majority of the top 50 articles focused on EVD infection and placement accuracy. The first and second most cited papers were authored by Zabramski et al and Fried et al, respectively. CONCLUSIONS: The bibliometric analysis provides a quantitative overview of how topics and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in EVDs by analyzing the top 50 most cited papers.

An Analysis of Landmark Articles Regarding Aneurysms of the Middle Cerebral Artery.

OBJECTIVE: Aneurysms located on the middle cerebral artery (MCA) range from 22% to 31.5% in prevalence of all aneurysms in the anterior cerebral circulation. This bibliometric analysis summarizes the most cited articles on MCA aneurysms and highlights the landmark publications that contributed to evidence-based practice. METHODS: In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "(middle cerebral artery OR MCA) AND aneurysm" was used. Our results were arranged in descending order based on the citation count of the article. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS: The keyword-based search showed that 1206 articles on MCA aneurysms were published up to August 2022. The top 100 articles were published between 1940 and 2019. The top 100 most cited articles collected a total of 6232 citations with an average of 62.3 citations per article. The rate of self-citations accounted for an average of 5.75% of the total number of citations. CONCLUSIONS: The bibliometric analysis provides a quantitative overview of how medical literature and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in research regarding MCA aneurysms by finding the top 100 most cited articles.

A Bibliometric Analysis of the Top 100 Most Influential Articles on Cerebral Cavernous Malformations.

OBJECTIVE: Cerebral cavernous malformations (CCMs) or cavernomas, are low-flow sinusoidal vascular anomalies of the central nervous system comprised of capillary networks filled with blood in various stages of thrombosis. This bibliometric analysis summarizes the most-cited articles on CCM and highlights the contributing articles to today's evidence-based practice. METHODS: In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until June 2022. The keyword "cerebral cavernous malformations" OR "cerebral cavernous hemangioma" OR "cerebral cavernous angioma" OR "cerebral cavernoma." was used. Our results were arranged in descending order based on the article's citation count. The 100 most-cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index were collected. RESULTS: The keyword-based search showed that 806 articles were published between 1974 and 2022 on CCMs. The top 100 articles were published between 1980 and 2018. The top 100 most cited articles collected a total of 12,928 citations with an average of 129.3 citations per paper. The rate of self-citations accounted for an average of 2.79% of the total number of citations. CONCLUSIONS: The bibliometric analysis provides a quantitative overview of how medical topics and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in CCMs by analyzing the top 100 most cited papers.

Ruptured aneurysm of the artery of Davidoff and Schechter: illustrative case.

BACKGROUND: The artery of Davidoff and Schechter (ADS) is an uncommonly encountered meningeal branch originating from the posterior cerebral artery typically identified in the setting of pathology, often dural arteriovenous fistulas (DAVFs). Here, the authors describe the first reported case of an ADS aneurysm, discovered in the setting of subarachnoid hemorrhage (SAH) and complicating a high-grade DAVF. OBSERVATIONS: A 57-year-old female presented after experiencing the worst headache of her life. Noncontrast computed tomography scanning of the head demonstrated SAH. Angiography revealed a high-grade DAVF centered around the anterior straight sinus, consistent with the Galenic subtype of tentorial DAVF. Predominant arterial supply was from the bilateral middle meningeal and occipital arteries. Vertebral artery imaging revealed a 12-mm irregular aneurysm. The prospect that the target artery represented the noneloquent ADS was confirmed by Wada testing. Given the fusiform nature of the aneurysm, treatment required concomitant coil embolization of the aneurysm and parent artery sacrifice. A week later, the DAVF was treated with liquid embolic. The patient tolerated treatment without neurological compromise. LESSONS: The authors describe the first reported case of an ADS aneurysm discovered in the setting of SAH complicating a high-grade DAVF and the lessons learned during our experience managing this unique pathology.

Treatment Options for Pseudoaneurysm After Carotid Endarterectomy: A Systematic Review and Illustrative Case.

BACKGROUND: The goal of this study was to systematically review the management and outcomes of patients who developed pseudoaneurysm (PA) after carotid endarterectomy (postendarterectomy PA [PEPA]). METHODS: Following the PRISMA guidelines, a systematic literature review was performed using PubMed, Scopus, and Web of Science databases from date of inception to June 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective review was conducted of patients who underwent neurosurgical evaluation of suspected PEPA at our institution. RESULTS: Of the 321 articles in the original literature search, 62 were selected. A total of 143 patients (93 men, 27 women; mean age, 70.7 years) diagnosed with PEPA were included. Mean time from carotid endarterectomy to PA diagnosis was 41.8 months. Primary repair data were available for 135 patients, including 19 with primary closures, 112 with patch or graft repairs, and 4 with eversion procedures. Fifty-five patients with PA (39%) presented with infection. Staphylococcal species were the most common causative organism. Of infected PAs, 89.1% were treated with open procedures. Overall complication rates of PAs treated via open, endovascular, and hybrid methods were 31%, 15.4%, and 0%, respectively. Open ligation (42.9%) and aneurysmectomy with grafting (36.4%) resulted in the highest rates of complications. CONCLUSIONS: Despite higher complication rates after open repair strategies, use of these techniques remains a viable option in situations requiring removal of infected patches or evacuation of large extravascular collections. Endovascular treatment options are associated with low numbers of complications and can be considered for primary PEPA treatment when infection is not present.

A Bibliometric Analysis of the Top 100 Most Influential Articles on Carotid Cavernous Fistulas.

OBJECTIVE: A carotid-cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or indirect. This bibliometric analysis summarizes the most-cited articles on CCFs and highlights the contributing articles to today's evidence-based practice. METHODS: In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until June 2022. The keyword "carotid cavernous fistula" was used. Our results were arranged in descending order based on the article's citation count. The 100 most-cited articles were selected for analysis. Parameters such as title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index were collected. RESULTS: The keyword-based search showed that 1832 articles were published between 1963 and 2022 on CCFs. The top 100 articles were published between 1963 and 2018. The top 100 most-cited articles collected a total of 8797 citations with an average of 88 citations per paper. The rate of self-citations accounted for an average of 4.71% of the total number of citations. CONCLUSION: The bibliometric analysis provides a quantitative overview of how medical topics and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in CCFs by finding the top 100 most-cited papers.

Brain Metastasis from Pancreatic Cancer: Our Experience and Systematic Review.

OBJECTIVE: To systematically review existing literature on the neurosurgical management and outcomes of brain metastasis from pancreatic cancer in comparison with our institutional experience of this patient cohort. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was performed using PubMed, Ovid Embase, Scopus, and Web of Science databases from date of database inception to March 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective analysis was conducted of patients who underwent neurosurgical evaluation and treatment for intracranial metastatic lesions from pancreatic origin at a single institution. RESULTS: The original literature search yielded 292 articles, of which 17 studies comprising 23 patients with brain metastases of pancreatic origin were ultimately selected. Median overall survival from primary diagnosis of pancreatic cancer was 22 months (interquartile range: 3-84) and 3 months (interquartile range: 1-36) after diagnosis of brain metastasis. In our institutional cohort, 4 patients were identified with a median overall survival of 30.5 months (interquartile range: 2-108). Our institutional cohort experienced a prolonged median overall survival (3 months vs. 30.5 months, P = 0.03) compared with the literature. CONCLUSIONS: Brain metastasis from pancreatic cancer is rare and associated with a fatal outcome. However, based on the data presented in this review, patient-specific and treatment-related factors could signal better prognosis. Further studies are needed to elucidate multimodal therapy and survival to suggest a more personalized decision-making process.

Dose Adjustment Associated Complications of Bone Morphogenetic Protein: A Longitudinal Assessment.

OBJECTIVE: Bone morphogenetic protein (BMP) is a growth factor that aids in osteoinduction and promotes bone fusion. There is a lack of literature regarding recombinant human BMP-2 (rhBMP-2) dosage in different spine surgeries. This study aims to investigate the trends in rhBMP-2 dosage and the associated complications in spinal arthrodesis. METHODS: A retrospective study was conducted investigating spinal arthrodesis using rhBMP-2. Variables including age, procedure type, rhBMP-2 size, complications, and postoperative imaging were collected. Cases were grouped into the following surgical procedures: anterior lumbar interbody fusion/extreme lateral interbody fusion (ALIF/XLIF), posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), posterolateral fusion (PLF), anterior cervical discectomy and fusion (ACDF), and posterior cervical fusion (PCF). RESULTS: A total of 1209 patients who received rhBMP-2 from 2006 to 2020 were studied. Of these, 230 were categorized as ALIF/XLIF, 336 as PLIF/TLIF, 243 as PLF, 203 as ACDF, and 197 as PCF. PCF (P < 0.001), PLIF/TLIF (P < 0.001), and PLF (P < 0.001) demonstrated a significant decrease in the rhBMP-2 dose used per level, with major transitions seen in 2018, 2011, and 2013, respectively. In our sample, 129 complications following spinal arthrodesis were noted. A significant relation between rhBMP-2 size and complication rates (χ2= 73.73, P = 0.0029) was noted. rhBMP-2 dosage per level was a predictor of complication following spinal arthrodesis (odds ratio = 1.302 [1.05-1.55], P < 0.001). CONCLUSIONS: BMP is an effective compound in fusing adjacent spine segments. However, it carries some regional complications. We demonstrate a decreasing trend in the dose/vertebral level. A decrease rhBMP-2 dose per level correlated with a decrease in complication rates.

Machine learning approach for distinguishing malignant and benign lung nodules utilizing standardized perinodular parenchymal features from CT.

PURPOSE: Computed tomography (CT) is an effective method for detecting and characterizing lung nodules in vivo. With the growing use of chest CT, the detection frequency of lung nodules is increasing. Noninvasive methods to distinguish malignant from benign nodules have the potential to decrease the clinical burden, risk, and cost involved in follow-up procedures on the large number of false-positive lesions detected. This study examined the benefit of including perinodular parenchymal features in machine learning (ML) tools for pulmonary nodule assessment. METHODS: Lung nodule cases with pathology confirmed diagnosis (74 malignant, 289 benign) were used to extract quantitative imaging characteristics from computed tomography scans of the nodule and perinodular parenchyma tissue. A ML tool development pipeline was employed using k-medoids clustering and information theory to determine efficient predictor sets for different amounts of parenchyma inclusion and build an artificial neural network classifier. The resulting ML tool was validated using an independent cohort (50 malignant, 50 benign). RESULTS: The inclusion of parenchymal imaging features improved the performance of the ML tool over exclusively nodular features (P < 0.01). The best performing ML tool included features derived from nodule diameter-based surrounding parenchyma tissue quartile bands. We demonstrate similar high-performance values on the independent validation cohort (AUC-ROC = 0.965). A comparison using the independent validation cohort with the Fleischner pulmonary nodule follow-up guidelines demonstrated a theoretical reduction in recommended follow-up imaging and procedures. CONCLUSIONS: Radiomic features extracted from the parenchyma surrounding lung nodules contain valid signals with spatial relevance for the task of lung cancer risk classification. Through standardization of feature extraction regions from the parenchyma, ML tool validation performance of 100% sensitivity and 96% specificity was achieved.