Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3644_Библиотеки_им_академика_М_И_Перельмана

As was mentioned in Chap. 2 of this volume,this would suggest a spec­trum of natural history rather then a single one. In other words, the nat­ural history after presentation is likely determined by the individual host response to the presence of the AVF, systemically (heart, liver, kidney, etc.), regionally (brain, dural sinus, CSF, etc.), and the decompensation that may occur at the level of the AVF itself (hemorrhage, etc.). The in utero demonstration of CAVF is rare and by itself does not have any clin­ical implications. Noninvasive imaging by ultrasound or MRI may, how­ever, demonstrate evidence in utero or at neonatal age of regional,hemi­spheric, or diffuse cerebral malacia. Such findings in our experience are not reversible,despite curative treatment,and in fact are a contraindica­tion to active treatment when extensive encephalomalacia is present, as the natural history under those circumstances is extremely poor (Figs. 4.20–4.23).

The indications, the time,and the method of treatment chosen for man­agement of CAVFs depend on a variety of factors such as the age at pre­sentation,presenting symptoms,the status of the brain, and the status of the other organs. Treatment may be contraindicated because of already existing severe brain damage: melting brain syndrome (cortical or subependymal) and/or diffuse parenchymal calcifications (Fig. 4.23). These can be noted either at the time of diagnosis or can develop rapidly between the initial consultation and the actual admission of the child for treatment.This was the case in 7% of patients with supratentorial CAVFs (Weon et al. 2005).