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  • Author or Editor: Alan S. Boulos x
  • By Author: Waldman, John B. x
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John C. Dalfino, Matthew A. Adamo, Ravi H. Gandhi, Alan S. Boulos and John B. Waldman

Object

The optimal management of a ventriculoperitoneal shunt in the setting of acute, non–shunt related abdominal and pelvic infections is unknown. In the literature, distal shunt catheter reimplantation with or without a variable period of externalization has been recommended to prevent ascending ventriculitis. While this strategy is effective, there is little to almost no published data suggesting that it is necessary in all cases. Furthermore, it is not clear that shunt externalization to an external drainage bag during the treatment of non–shunt related peritonitis is any less likely to lead to ventriculitis than leaving the catheter in place. In the authors' experience, shunt externalization or revision during an episode of acute, non–shunt related peritonitis is unnecessary to prevent ventriculitis or chronic peritonitis.

Methods

In the present case series, the authors report on 7 patients whose shunts were left in the abdomen while they were treated for acute peritonitis. The patients were followed clinically for up to 21 months after the diagnosis to assess for evidence of recurrent abdominal infections, shunt infections, or shunt failure.

Results

In a follow-up period ranging from 13 to 22 months, no patient developed ventriculitis, required a shunt revision, or was unable to clear the peritoneal infection.

Conclusions

The results of this small series suggest that leaving the distal end of a shunt catheter in place in a patient with acute peritonitis is a reasonably safe choice in specific patients, provided the source of infection is aggressively treated with systemic antibiotics and local debridement when necessary.

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Tyler J. Kenning, Eric M. Deshaies, Matthew A. Adamo, John B. Waldman and Alan S. Boulos

Identifying a source of spontaneous subarachnoid hemorrhage (SAH) or intraventricular hemorrhage (IVH) in patients with negative results on cranial angiographic imaging can be a diagnostic challenge. The authors present the case of a 14-month-old girl who presented with lethargy and spontaneous SAH and IVH, and later became acutely paraplegic. Except for the SAH and IVH, findings on neuroimages of the brain were normal. Magnetic resonance imaging revealed an intramedullary thoracolumbar spinal cord hemorrhage that was found to be associated with arterialized veins intraoperatively. Catheter-based diagnostic angiography identified a spinal perimedullary macroarteriovenous fistula (macro-AVF) that was completely embolized with Onyx, negating the need for further surgical intervention. The authors believe this to be the first reported case of a thoracolumbar perimedullary macro-AVF presenting with SAH and IVH. In addition, descriptions of Onyx embolization of a spinal AVF in the literature are rare, especially in pediatric patients.