Validity of the Cost-Effectiveness of Middle Meningeal Artery Embolization Following Hematoma Evacuation for Initial Chronic Subdural Hematoma.

BACKGROUND: Despite numerous articles about middle meningeal artery embolization (MMAE) highlighting its efficacy and safety for recurrent chronic subdural hematoma (CSDH), the appropriateness of adjunctive MMAE after hematoma evacuation for initial CSDH remains unclear from a cost-effectiveness perspective. METHODS: Patients with CSDH were enrolled in this study and were prospectively divided into two groups: the "conventional treatment" group, which was treated with hematoma evacuation alone, and the "MMAE" group, which was treated with adjunctive MMAE after hematoma evacuation. The proportion of patients requiring retreatment, length of hospital stay, economic costs, and modified Rankin Score (mRS) were compared between the two groups. RESULTS: In this study, 53 cases were included, with 30 classified into the conventional treatment group and 23 classified into the MMAE group. In the conventional treatment group, the proportion of patients who required surgical retreatment was higher than that in the MMAE group (16.7% vs. 8.7%). The relative risk was 0.522 (95% confidence interval, 0.111-2.45). Although the addition of MMAE increased the cost per hospitalization by 26%, the increase in cost per patient was limited to 12% owing to the reduction in patients who relapsed and required a second hospitalization. The increase in cost was not statistically significant. The MMAE group had a significantly higher proportion of patients with favorable outcomes (mRS 0-2) (56.7% vs. 87.0%, p = 0.0328). CONCLUSIONS: By minimizing the increase in hospitalization days and procedure costs, MMAE following hematoma evacuation for initial CSDH could decrease the retreatment rate and balance the total medical costs associated with MMAE.

Changes in the clinical spectrum of pediatric moyamoya disease over 40 years.

OBJECTIVE: To investigate the chronological changes in the clinical presentation and long-term prognosis of pediatric-onset moyamoya disease in our institute over 40 years. METHODS: We evaluated 282 pediatric-onset (≤ 15 years old) moyamoya disease patients who visited our institute from 1981 to 2020 (divided into the former period, 1981-2000, and the latter period, 2001-2020). Differences in the clinical presentation and the long-term outcome were compared between the periods. Multivariate analysis was also performed to reveal the risk factors for poor long-term outcomes. RESULTS: Compared to the former period, the total number of patients, the onset age and both the number of patients with family history and relatively older patients without symptoms or with headache were greater in the latter period (p < 0.05). The number of patients with poor long-term outcomes was significantly lower in the latter period (24.9% vs. 6.7%, p < 0.01). Multivariate analysis revealed that stroke onset, late cerebrovascular events and postoperative complications were independent risk factors for poor long-term outcomes (odds ratio = 31.4, 40.8 and 5.4, respectively). CONCLUSIONS: Over the last 40 years, the number of pediatric moyamoya disease patients has increased, especially in relatively older patients with mild presentation and favorable long-term outcomes. In clinical studies, these chronological changes and the inclusion period of the participants need to be accounted for. Whether the increased diagnostic rate in the recent era has led to a decrease in late cerebrovascular events and favorable outcomes throughout life remains unknown and should be evaluated in the future.

Neonatal spinal injury induces de novo projections of primary afferents to the lumbosacral intermediolateral nucleus in rats.

Complete spinal transection in adult rats results in poor recovery of hind limb function and severe urinary bladder dysfunction. Neonatal rats with spinal cord transection, however, exhibit spontaneous and significant recovery of micturition control. A previous study in which biotinylated-dextran amine (BDA) was used as an anterograde tracer demonstrated that primary afferent fibers from the fifth lumbar dorsal root ganglion (DRG) project more strongly and make more terminals in the ventral horn after neonatal spinal cord transection at the mid-thoracic level. In the present study, we injected BDA into the sixth lumbar (L6) DRG of neonatally spinalized rats to label primary afferent fibers that include visceral afferents. The labeled fibers projected to the intermediolateral nucleus (IML) in the intermediate zone on ipsilateral side of the L6 spinal segment, whereas no projections to the IML were observed in sham-operated or intact rats. The BDA-labeled fibers of neonatally spinalized rats formed varicose terminals on parasympathetic preganglionic neurons in the IML. These findings suggest that some primary afferent projections from the L6 DRG to the IML appear after neonatal spinal cord transection, and these de novo projections might contribute to the recovery of autonomic function such as micturition following spinal cord injury in the neonatal stage.