Predictors of Citations in Neurosurgical Research.

OBJECTIVE: The number of citations an article receives is an important measure of impact for published research. There are limited published data on predictors of citations in neurosurgery research. We aimed to analyze predictors of citations for neurosurgical articles. METHODS: All articles published in 14 neurosurgical journals in the year 2015 were examined and data collected about their features. The number of citations for each article was tallied using both Web of Science (WoS) and Google Scholar (GS) 2.5 years after their publication in print. Negative binomial regression was then performed to determine the relationship between article features and citation counts for scientific articles. RESULTS: A total of 3923 articles were analyzed, comprising 2867 scientific articles (72.6%) and 1056 nonscientific (editorial, commentary, etc.) articles (27.4%). At 2.5 years, scientific articles had a median [interquartile range] number of citations per article of 3.0 [6.0] and 7.0 [9.0] found in WoS and GS, respectively; nonscientific articles had accumulated median 0.0 [2.0] in both WOS and GS. Articles with the study topic "Spine" had the highest citation count at 4.0 [5.0] and 8.0 [10.0] in WoS and GS, respectively. Significant predictors of citation count in scientific articles were level of evidence, number of centers, number of authors, and impact factor. CONCLUSIONS: This is the largest investigation analyzing predictors of citations in the neurosurgical literature. Factors found to be most influential on citation rates in scientific articles included the study's level of evidence, number of participating centers, number of authors, and the publishing journal's impact factor.

Impact of Procedure Time on Outcomes of Thrombectomy for Stroke.

BACKGROUND: Endovascular thrombectomy (ET) for acute ischemic stroke is the current standard of care. Although successful ET has high efficacy in improving functional outcomes, the decision to abort a long procedure remains a challenge. Longer procedure time (PT) has been associated with lower rates of functional independence. OBJECTIVES: The objective of this study was to evaluate the impact of PT on outcomes and complications after ET using different techniques at a multicenter level and to define the risk of procedure extension in different patient cohorts. METHODS: Patients undergoing ET with a stent retriever (SR) or a direct aspiration at first pass technique at 7 U.S. centers between June 2013 and February 2018 were reviewed from prospectively maintained databases that include baseline variables and technical and clinical outcomes. Multivariate analyses were used to assess impact of PT on 90-day modified Rankin scores, successful recanalization, post-procedural symptomatic hemorrhage (sICH), and complications. RESULTS: The study included 1,359 patients and demonstrated a decreased likelihood of good functional outcomes (modified Rankin score 0 to 2) when PT extended beyond 30 min (p < 0.01). Rates of sICH and complications increased exponentially with PT (doubling rates of 26 and 50 min, respectively). The cumulative rate of successful recanalization and good outcomes plateaued after 60 min of PT. In patients with PT >30 min, fewer attempts predicted the success of ET and good outcomes (p < 0.01). Successful recanalization was achieved faster with the direct aspiration at first pass technique than in SR. The direct aspiration technique was more sensitive to PT than SR, and posterior stroke was more sensitive to PT than anterior stroke. CONCLUSIONS: Longer ET procedures lead to lower rates of functional independence and higher rates of sICH and complications. Exceeding 60 min or 3 attempts should trigger careful assessment of futility and risks of continuing the procedure.

Outcomes of endovascular thrombectomy in the elderly: a 'real-world' multicenter study.

BACKGROUND: The efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial. OBJECTIVE: To evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients. METHODS: Data from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used. RESULTS: Rates of functional independence (mRS score 0-2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome. CONCLUSION: The large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk-benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection.

Occipital Condyle Fractures and Concomitant Cervical Spine Fractures: Implications for Management.

BACKGROUND: Occipital condyle fractures (OCFs) have traditionally been described based on anatomic characteristics; however, recent literature has proposed management based on biomechanical stability and neural element compression. The treatment of biomechanically stable fractures varies between observation and cervical immobilization. Before determining the best management approach, an understanding of concomitant cervical spine fractures in the presence of OCFs is important. The primary aim of this pilot study was to determine the rate of occurrence of biomechanically significant cervical spine fractures with OCFs. METHODS: A retrospective chart review was performed of 13,363 patients presenting to a level 1 trauma center between 2013 and 2017 with a diagnosis of OCF. RESULTS: Forty-six patients presented with OCFs, with an average Glasgow Coma Scale score of 12 on presentation and an average Injury Severity Score of 23. The average patient age was 42.1 years, and 4 patients had bilateral OCFs. Approximately 30% of these patients had associated intracranial injuries and 59% had an associated cervical spine injury. The overall rate of associated potentially biomechanically significant cervical spine fracture was 43.5%. Treatment of OCFs included collar immobilization (83%) and observation (17%). The average duration of follow-up was 3.37 months. CONCLUSIONS: This study characterizes cervical spine fractures that occur concomitantly with OCFs. The results indicate that more than one-half of patients with OCFs do not have biomechanically significant fractures elsewhere in the cervical spine. This subset of patients will be the cohort for a prospective study to assess whether collar immobilization is necessary.