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of dura, generally close to a large dural venous sinus In other cases, the dilated draining vessels may be seen only with the injection of dye or gadolinium Probably, many are not detected by these techniques The origin of these vascular lesions has not been settled several mechanisms may be involved Most evidence suggests that some of these lesions, unlike conventional cerebral AVMs and aneurysms, are not developmental in origin The best-de ned examples are those that arise adjacent to a venous sinus thrombosis or in association with a vascular atresia, most often in the transverse sigmoid sinus or adjacent to the cavernous sinus However, it is not clear whether the abnormality of the dural sinus is the cause or the result of the dural stula In a number of cases, a dural stula has appeared after a forceful head injury, often in a region remote from the site of impact A small group is associated with the Klippel-Trenaunay or Osler-Weber-Rendu syndromes, diseases in which a frequent conjunction with AVMs is well known Usually, all of these causes can be excluded and the largest group remains idiopathic A major obstacle to our understanding of the dural AVM has been the varied and confusing ways in which this lesion presents clinically Subdural hemorrhage is an infrequent mode of presentation, sometimes creating a large and fatal clot; another syndrome is a cerebral-subarachnoid hemorrhage, although this occurs with not nearly the frequency or severity as bleeding from brain AVMs However, our knowledge of the risk of bleeding from dural stulas and the evolution of the lesions is far less precise than it is for cerebral AVMs It appears that the dural lesions most at risk of bleeding are those located in the anterior cranial fossa and at the tentorial incisura Seizures are distinctly uncommon A special syndrome linked to dural AVMs, although it may occur also with high ow cerebral malformations, is of headache, vomiting, and papilledema namely, pseudotumor cerebri (Chap 30) A cranial bruit is infrequent In small children, the high- ow lesions may shunt so much blood as to cause congestive heart failure, similar to malformations of the vein of Galen Treatment is by surgical extirpation or endovascular embolization, a painstaking procedure because of the multitude of poten-.

tial feeding vessels Surgery seems preferable for the smaller lesions and embolization for larger and inaccessible ones The issue of anticoagulation, when there is slowed ow in a venous sinus draining a malformation, is unsettled Dural stulas of the spine, which are as common as the cerebral ones, represent a special problem, discussed on page 1070

also make excellent hedging instruments for systemic risk If you are a long investor in ETF or futures products in broad indices, option trading strategies for defense against negative economic conditions need to be looked at The dif culty with broad indices is the hedge cost versus the return Leaving out 2008 for the time being, we can fairly state that the S&P 500 has had an average annual return of around 10 percent There were years with 20 percent plus gains and a few with 20 percent or more lost In 2008 the S&P lost 386 percent, the third largest drop since inception Let s take the S&P 500 and look at three different strategies for systemic risk control that also could be utilized in narrow-based applications With an average annual return of 10 percent, we can use that 10 percent as our focus point for an option premium in a covered call style Let s say hypothetically the SPY ETF is trading at around 9200 Ten percent in either direction is just under 10 points We assume that the SPY 102 call option for September is trading at around 220 with 140 days left If we sell this call option, we bring in just over 2 percent of the value of 100 shares of SPY over 140 days Selling this call option caps the gain for the SPY shares during the period to 12 percent If the market rises beyond the 102 during the period of the option s life, you can be satis ed with the 12 percent or remove the option at expiration and allow the shares to continue Selling this call option also reduces the risk to the shares by 2 percent It is not a signi cant bene t, but in contrast to outright holding it is a minor improvement If you were able to execute this trade twice over the course of the year, you have the potential to increase the pro tability of the 10 percent average annual return by 4 percent If we take this a step further and bring the option premium closer to the market, we pick up a signi cantly larger premium The 94.

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