Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with high recurrence rates. Repeated microbleedings from fragile neo-vessels supplied by peripheral branches of the middle meningeal artery (MMA) are believed to be responsible for the growth and recurrence of CSDH. Thus, MMA embolization might be a promising method to prevent re-bleedings and recurrences. This study aims to assess the efficacy, complication rates, and mid-term outcome of MMA embolization with or without burr hole irrigation compared with burr hole irrigation alone. METHODS: Patients diagnosed with CSDH who underwent MMA embolization and/or surgical treatment were retrospectively recruited to this single-center study. The outcome variables were defined as treatment-related complications, clinical outcome at discharge, rate of revision surgery, and CT findings during the follow-up period. RESULTS: A total of 132 patients with CSDH were included in the study. The use of antiplatelet/anticoagulant medication was significantly higher in the combined treatment and embolization group (p<0.001). A trend towards fewer revision surgeries was found in the group of patients who received MMA embolization combined with burr hole irrigation (p=0.083). Follow-up was available for 73 patients (55.3%) with a mean follow-up period of 3.4±2.2 months. Eight patients (15.1%) of the surgery group showed hematoma re-accumulation and needed surgical rescue, whereas only one patient (5.0%) of the combined treatment group needed revision surgery. In all patients treated with only MMA embolization, complete hematoma resolution was found. CONCLUSION: MMA embolization is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate.

Deep Brain Stimulation in KMT2B-Related Dystonia: Case Report and Review of the Literature With Special Emphasis on Dysarthria and Speech.

Objective: KMT2B-related dystonia is a progressive childhood-onset movement disorder, evolving from lower-limb focal dystonia into generalized dystonia. With increasing age, children frequently show prominent laryngeal or facial dystonia manifesting in dysarthria. Bilateral deep brain stimulation of the globus pallidus internus (GPi-DBS) is reported to be an efficient therapeutic option. Especially improvement of dystonia and regaining of independent mobility is commonly described, but detailed information about the impact of GPi-DBS on dysarthria and speech is scarce. Methods: We report the 16-months outcome after bilateral GPi-DBS in an 8-year-old child with KMT2B-related dystonia caused by a de-novo c.3043C>T (p.Arg1015*) non-sense variant with special emphasis on dysarthria and speech. We compare the outcome of our patient with 59 patients identified through a PubMed literature search. Results: A remarkable improvement of voice, articulation, respiration and prosodic characteristics was seen 16 months after GPi-DBS. The patients' speech intelligibility improved. His speech became much more comprehensible not only for his parents, but also for others. Furthermore, his vocabulary and the possibility to express his feelings and wants expanded considerably. Conclusion: A positive outcome of GPi-DBS on speech and dysarthria is rarely described in the literature. This might be due to disease progression, non-effectiveness of DBS or due to inadvertent spreading of the electrical current to the corticobulbar tract causing stimulation induced dysarthria. This highlights the importance of optimal lead placement, the possibility of horizontal steering of the electrical field by applying directional stimulation with segmented leads as well as the use of the lowest possible effective stimulation intensity.

La primera reforma tributaria en la historia de la humanidad / A primeira reforma tributária na história da humanidade / The first tax reform of humanity

Resumen El presente acápite trata acerca del relato milenario de la primera reforma social, descrito por Noah Kramer en el libro La historia empieza en Sumer y que ha sido traducido por el autor directamente de las tablillas sumerias. El artículo presenta un apólogo, sobre el contexto en el cual se dio esa primera reforma social, que sin lugar a dudas fue una verdadera reforma tributaria en favor del pueblo. El texto comienza describiendo las características de la civilización sumeria, el entorno geográfico en el cual se desarrolló, sus invenciones como la escritura, la rueda, la cerveza, la organización del comercio, los sistemas políticos y los sistemas tributarios y aduaneros. Es en medio de ese auge que los sumerios terminan siendo dominados por los Acadios. Cabe anotar que en el contexto descrito en el párrafo anterior se hace alusión a que una ciudad prospera como Lagash en tiempos de los sumerios, termina empobreciendo a sus habitantes con una exagerada y desordenada carga tributaria y un sistema tributario caótico en manos de los Acadios. Es en este testimonio que se realizó una de las primeras reformas sociales, que por sus características es considerada como la primera reforma tributaria de la cual tiene conocimiento la humanidad. Clasificación JEL: N, N9, N95.

Abstract This section deals with the millennial account of the first social reform, described by Noah Kramer in the book History begins in Sumer and which has been translated by the author directly from the Sumerian tablets. The article presents an apologue; about the context in which this first social reform took place, which without a doubt was a true tax reform in favor of the people. The text begins by describing the characteristics of Sumerian civilization, the geographical environment in which it developed its inventions such as writing, wheel, beer trade organization, political systems and tax and customs systems. It is in the midst of that boom that the Sumerians end up being dominated by the Akkadians. It should be noted that the context described in the previous paragraph refers to the fact that a city prospers like Lagash in the times of the Sumerians, ends impoverishing its inhabitants with an exaggerated and disorderly tax burden and a chaotic tax system in the hands of the Akkadians. It is in this testimony that one of the first social reforms was carried out, which due to its characteristics is considered as the first tax reform of which humanity is aware. JEL Classification: N, N9, N95.

Resumo Esta seção trata do relato milenar da primeira reforma social, descrita por Noah Kramer no livro História começa na Sumeria, e que foi traduzida pelo autor diretamente das tábuas sumérias. O artigo apresenta um apologê, sobre o contexto em que esta primeira reforma social ocorreu, que sem dúvida foi uma verdadeira reforma tributária em favor do povo. O texto começa descrevendo as características da civilização suméria, o ambiente geográfico em que ela se desenvolveu, suas invenções como escrita, roda, cerveja, organização comercial, sistemas políticos e sistemas tributários e aduaneiros. É no meio desse boom que os sumérios acabam sendo dominados pelos acádios. Note-se que, no contexto descrito no parágrafo anterior referindo-se a uma cidade prospera como Lagash em tempos dos sumérios é acaba por empobrecer seu povo com um sistema de carga tributária e fiscal exagerada e desordenada caótico nas mãos dos Akkadians. É neste testemunho que se realizou uma das primeiras reformas sociais, que devido às suas características é considerada como a primeira reforma tributária da qual a humanidade está ciente. Classificações JEL: N, N9, N95.