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• Gunshot wounds that do not involve posterior fossa and ventricles favor survival. • A decision-tree model may help identify neurosurgical candidates. • Long-term functional outcomes for gunshot wounds are favorable after neurosurgery. Gunshot wounds (GSW) are one of the most lethal forms of head trauma. The lack of clear guidelines for civilian GSW complicates surgical management. We aimed to develop a decision-tree algorithm for mortality prediction and report long-term outcomes on survivors based on 15-year data from our level 1 trauma center. We retrospectively reviewed 96 consecutive patients who presented with cerebral GSWs between 2003 and 2018. Clinical information from our trauma database, EMR, and relevant imaging scans was reviewed. A decision-tree model was constructed based on variables showing significant differences between survivors and non-survivors. After excluding patients who died at arrival, 54 patients with radiologically confirmed intracranial injury were included. Compared to survivors (51.9%), non-survivors (48.1%) were significantly more likely to have perforating (entry and exit wound), as opposed to penetrating (entry wound only), injuries. Bi-hemispheric and posterior fossa involvement, cerebral herniation, and intraventricular hemorrhage were more commonly present in non-survivors. Based on the decision-tree, Glasgow Coma Scale (GCS) > 8 and penetrating, uni-hemispheric injury predicted survival. Among patients with GCS ≤ 8 and normal pupillary response, lack of 1) posterior fossa involvement, 2) cerebral herniation, 3) bi-hemispheric injury, and 4) intraventricular hemorrhage, were associated with survival. Favorable long-term outcomes (mean follow-up 34.4 months) were possible for survivors who required neurosurgery and stable patients who were conservatively managed. We applied clinical and radiological characteristics that predicted survival to construct a decision-tree to facilitate surgical decision-making for GSW. Further validation of the algorithm in a large patient setting is recommended. [ABSTRACT FROM AUTHOR]

Objective: Blister-like aneurysms (BLAs) are challenging to treat. Their friable nature makes them high risk for both traditional microsurgical and endovascular treatments. We discuss employing a single oversized self-expanding stent in the treatment of these treacherous lesions. Methods: A retrospective review from our institution was conducted. Five patients with BLAs were identified, who went on to be treated with a single oversized self-expanding stent, defined as 1 mm larger than the parent vessel, by the senior author (KRB), who is dual fellowship trained in both cerebrovascular/ skull base microsurgery and endovascular neurosurgery. Additionally, a literature review was performed on BLAs treated with sole stenting and outcomes discussed. Results: Our five patients had complete aneurysm occlusion at long-term follow-up and all had good neurological outcomes. The literature review demonstrated that most aneurysms at long-term follow-up were either completed occluded or progressively becoming occluded, with patients overall having a good functional outcome based on the modified Rankin scale (mRS). Conclusion: In our experience, oversized self-expanding stents are a treatment option that should be considered for BLAs. This strategy avoids the need for dual antiplatelet therapy and therefore increases its utility in the case of subarachnoid hemorrhage (SAH). [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit. Materials and methods: We used the Surveillance, Epidemiology, and End Results–Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004–2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group. Results: There were 10,686 men in the sample (mean age 74.2years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with a life expectancy<5years had higher rates of ncADT use than men with a life expectancy≥10years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving ncADT (odds ratio for men aged 80–84 compared to 67–69=1.93 (95% CI 1.37–2.70); 1.51 (95% CI 1.22–1.87); and 1.71 (95% CI 1.14–2.57) for high-, intermediate-, and low-risk groups, respectively). Conclusion: ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy. [Copyright &y& Elsevier]