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enlarging mass of vessels and by shunting of blood through greatly dilated vascular channels ( intracerebral steal ), resulting in hypoperfusion of the surrounding brain (Homan et al) When the vein of Galen is enlarged as a result of drainage from an adjacent AVM, hydrocephalus may result Not infrequently one or both carotid arteries pulsate unusually forcefully in the neck A systolic bruit heard over the carotid in the neck or over the mastoid process or the eyeballs in a young adult is almost pathognomonic of an AVM However, such bruits have been heard in fewer than 25 percent of our patients Exercise that increases the pulse pressure may bring out a bruit if none is present at rest The blood pressure may be elevated or normal; it is axiomatic that the occurrence of intracranial bleeding with a previously normal blood pressure should raise the suspicion of an AVM, but also of ruptured saccular aneurysm, bleeding diathesis, cerebral vessel amyloidosis, or hemorrhage into a tumor Rarely, inspection of the eye grounds discloses a retinal vascular malformation that is coextensive with a similar lesion of the optic nerve and basal portions of the brain Cutaneous, orbital, and nasopharyngeal AVMs may occasionally be found Rarely, skull lms show crescentic linear calci cations in the larger malformations The natural history of AVMs has been studied by Ondra and colleagues, who have presented data on a large and comprehensive series of untreated malformations in Finland over a 30-year period, and another similar series has been reported by Crawford and coworkers in Great Britain In the latter study, comprising 343 patients, 217 were managed without surgery and observed for many years (mean, 104 years) Hemorrhage occurred in 42 percent and seizures in 18 percent By 20 years after diagnosis, 29 percent had died and 27 percent of the survivors had a neurologic handicap Although the lesion is present from birth, onset of symptoms is most common between 10 and 30 years of age; occasionally it is delayed to age 50 or even beyond In almost half of patients, the rst clinical manifestation is a cerebral subarachnoid hemorrhage; in 30 percent, a seizure is the rst and only manifestation; and in 20 percent, the only symptom is headache Progressive hemiparesis or other focal neurologic de cit is present in about 10 percent of patients In a series of 1000 patients referred mainly for proton beam radiation of an AVM and studied by our colleague R D Adams, 464 had a hemorrhage as the rst manifestation and 218 had a seizure (mainly with frontal and frontoparietal lesions) In 139, the lesion came to attention as a result of a progressive neurologic de cit; most of these were situated in the posterior fossa or axially in the cerebrum Headaches were an early symptom in 212, but only 59 of these patients had a subsequent hemorrhage The combination of a prolonged history of headaches, seizures, and a progressive de cit almost always indicated a large malformation Fully 95 percent of AVMs are disclosed by CT scans if enhanced and an even larger number by MRI (Fig 34-25) Magnetic susceptibility MRI shows small areas of previous bleeding around AVMs Arteriography is usually necessary to establish the diagnosis with certainty and will demonstrate AVMs larger than 5 mm in diameter (Fig 34-26); MRI may fail to reveal smaller lesions Small ones may be obscured by hemorrhage; even at autopsy, a careful search under the dissecting microscope may be necessary to nd them Treatment The preferred approach in most centers is surgical excision Some 20 to 40 percent of AVMs are amenable to block dissection, with an operative mortality rate of 2 to 5 percent and a morbidity of 5 to 25 percent (see Fleetwood and Steinberg for a.

A summary of reported surgical results up to 2002) In the others, which are inaccessible, attempts have been made to obliterate the malformed vessels by ligation of feeding arteries or by the use of endovascular embolization with liquid adhesives or particular ma-

Delta Chart A delta chart outlines the development of a total value by displaying various interim values Important to note is that these interim values are not displayed as subtotals, but as deltas The delta chart only deals with flat data tables; this means the interim values are individual items If you have a hierarchical data table that is, if the interim values are made up of multiple single items the system automatically selects the waterfall chart variant to display the data The differences between the chart types delta chart and waterfall chart are outlined in Table 6-3 An example of a table for a delta chart is shown in Table 6-4 The critical concern here is that the table does not contain a hierarchy (hierarchy nodes), so any further drilldown is not possible The totals used in the chart are the items Cost of Goods Sold (start value), which is displayed on the debit side, and Revenue (end value), which is displayed on the credit side All remaining values are interim values, which are displayed in the chart as deltas The start and end values (including all interim values) are used to calculate the total sum (Overall Result) The results are displayed in the following illustration

Figure 34-25 A Left temporal arteriovenous malformation (AVM), demonstrated by MRI The patient was a 59-year-old woman with long-standing complaints of headache B Arteriogram showing large feeding and draining vessels and the characteristic vascular blush of the malformation

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