Pneumoperitoneum refers to accumulation of gas within abdominal cavity, resulting from a perforated hollow viscus, penetrating wounds or bacterial peritonitis. Emergency condition of massive pneumoperitoneum compromise cardiorespiratory function, known as pneumoperitoneum, has been reported in humans. In veterinary medicine, there are also a few similar cases.
This study reports a case of a cat that developed tension pneumoperitoneum secondary to gastric perforation. The cat was treated with emergency abdominocentesis, followed by laparotomy.
A 10 years old British shorthair spayed female cat Tara (2.8 kg) was presented with a remarkable abdominal distention. Three months ago, the cat was operated because of suspected alimentary lymphoma. A part of small intestine and caecum was removed. Histology confirmed large cell lymphoma. Tara was started on chlorambucil and prednisolone protocol. Regular control examinations showed only decreased appetite and one or two times weekly vomiting. The last examination was two days before pneumoperitoneum, and ultrasonography was unremarkable.
At the time of admission, the cat was in good condition except respiratory distress, with huge ballooned, tympanic abdomen. Abdominal US showed only gas. Emergency needle abdominocentesis was performed, and about 300 ml air was aspirated. Than was performed X-ray. The abdominal radiograph showed distended by air abdominal wall, compressed viscus, displaced to thoracic cavity diaphragm. There was no evidence for free fluid in abdominal cavity. Subcutaneously was small amount of air, leaked after the needle aspiration. Second abdominocentesis was performed, and about 400 ml air was aspirated. The aspirated gas had no odor or admixtures.
On the next day, the cat was rehydrated, and a laparotomy was performed. Mild peritonitis was found with a small almond of yellowish ascites. The small intestines were empty, in the large intestines there were some faeces. The site of previously enter anastomosis was perfect. There was no evidence of leaking from the gut or any visible evidence of recurrence of lymphoma. A 6-8 mm perforation was found at the gastric fundus. The stomach, liver margin and omentum were mildly adhered. Other portions of stomach wall looked visually and palpably normal. After blunt dissection of the adhered liver and omentum, the gastric perforation was closed with interrupted sutures. Materials from stomach wall for cytology and from free fluid for microbiology were taken. Abdominal cavity was flushed with 0.9% warm saline and closed in a routine manner. Cytology did not show atypical cells, or any suspect for alimentary lymphoma. Microbiology was unremarkable.
Reported common causes for pneumoperitoneum in small animals include abdominal surgery, gastrointestinal perforation and bacterial peritonitis. In cats pneumoperitoneum also has been reported as complication after endoscopic biopsy or gastrostomy tube replacement. Most of these cases have not shown severe abdominal distention, necessitating emergency decompression.
The exact cause of gastric perforation in this cat is unknown. We suspect local weakness of gastric wall due to iatrogenic factors. Chlorambucil or prednisolone, or combination of these two medicaments may cause damage of mucosa and weakness in the walls of GI tract.
Necessity of therapeutic emergency abdominocentesis due to spontaneous pneumoperitoneum in cats has been emphasized only in few previous reports.
Paradoxical Vestibular Syndrome is a condition that affects flocculonodular lobe or the caudal cerebellar peduncle of the cerebellum and causes vestibular signs. These parts of the cerebellum participate in central components of vestibular apparatus and are responsible for the maintenance of equilibrium and coordination of head and eye movements;
This syndrome is called paradoxical vestibular disease because the head tilt and circling occur contralateral to the lesion. There is usually some evidence of cerebellar disease on neurological examination, such as ipsilateral dysmetria and head tremor.
Signalment: 8 years old, male, not castrated French bulldog
History: The owner noticed that the head of his dog is not in normal position and is tilt to the left. The dog was carried to its personal doctor, and the doctor had doubts that the dog was having problem with the inner ear . The doctor refer the dog to me for computer tomography, and for approval of the diagnosis.
Case presenting signs: Left head tilt, progressive vestibular signs
Clinical examination: Internal body temperature 38,1 ; Respiratory rate: 36 breaths per minute ; Color of mucous membranes – pink; CRT – 1,5 sec.
Puls 110 bpm ; The overall condition of the dog was normal and there was no no signs of pain.
Neurological examination:
Mentation and behavior-normal; Posture – Left head tilt; Gait – Vestibular ataxia, increase muscle tone and dysmetria of right fore and hind limbs The dog react with cranial and spinal normoreflexia. Menace response reaction of right eye was a little bit reduced. There was no change in conscious proprioception and bladder function was normal. The owners report for intention tremor of the head when the dog is waiting to be fed.
Neuroanatomic localisation: Central Vestibular ; Right Cerebellar Flocculonodular lobe; Paradoxical Vestibular Syndrome
Differential diagnosis:
Neoplastic/Degenerative
Case work-up:
CBC and Biochemistry were normal. Magnetic resonance of the head was performed with GE MRI 1.5 Tesla.
MRI findings :
A single oval T1-hypo and T2, T2 FLAIR-hyperintensive intra-axial mass is observed, leading out of the cerebellar vermis and affecting the both cerebellar hemispheres. The mass is well circumscribed by the surrounding tissues, with extracapsular expansion and diffuse infiltration into the the gray matter. There is a significant mass effect that reveals compression of the flocculonodular lobe and reveals obstruction to the flow of cerebrospinal fluid with secondary dilatation of the quarter ventricle and central canal with subsequent syringohydromyelia.
Diagnosis: Cerebellar neoplasia
Treatment:
The clinical condition of the dog did improved after i.v
infusion with Mannitol (0.25g/kg bolus 3 times over 20 minutes) , Harmann`s solution 20ml/kg and Prednisolone p.o 0.5mg/kg – 2 times daily – for 3 days . Next 10 days the dog take Prednisolone 0.5 mg/kg 2 times daily at home.
Control visiting on the 14th day -https://www.youtube.com/watch?v=XRyp9sgqCjE
All of previous clinical signs were more severe present. There was no more improvement with this therapy and the owners chose to euthanize the dog.
With both central and peripheral Vestibular syndorme, the head tilt, circling and nystagmus typically occur ipsilateral to the side of the lesion. Less frequently, lesions affecting the caudal cerebellar peduncle, the fastigial nucleus, or the flocculonodular lobes of the cerebellum can cause central Vestibular disease with a resulting paradoxical head tilt. Bilateral Vestibular disease is characterized by head sway from side to side, loss of balance on both sides and symmetrical ataxia with a wide-based stance. A physiological nystagmus usually cannot be elicited and a head tilt is not observed.
The gastrointestinal tract is inhabited by communities of microorganisms essential to host health. These microorganisms, including desirable and undesirable bacteria, are referred to as the micriobiome and the exact population of micoorganisms is unique to each host.
Bacteria in the microbiome are functionally and compositionally diverse, allowing contribution to energy homeostasis, metabolism, gut epithelial cell health, and immunologic activity. This population is not static and can change to due to medications, such as antibiotics, environmental factors, disease states and dietary influences. Additionally, it is common to see dysbiosis (imbalance in the gastrointestinal microbiome) in chronic GI disease in cats and dogs.
Over the past several years, Hill’s has focused heavily on studying the microbiome, characterising bacterial populations of the gastrointestinal tract of cats and dogs. Most critically, Hill’s has performed analyses to understand the functions of those bacteria in the gastrointestinal tract.
Hill’s has found that a pet’s gastrointestinal health can be impacted by ActivBiome+ Technology, a blend of synergistic prebiotic fibres that works with with each pet’s unique gastrointestinal microbiome.
WHAT IS ACTIVBIOME+ TECHNOLOGY?
Hill’s Prescription Diet Gastrointestinal Biome contains ActivBiome+ Technology. This is a proprietary blend of synergistic prebiotic fibres that works with, and is utilised by, each pet’s unique bacteria in the large intestine allowing the beneficial bacteria to flourish and produce postbiotics (metabolic products of microbial metabolism) to help the host. By promoting the growth of desirable bacteria, it also helps to reduce the growth of potentially undesirable bacteria and their metabolites. The fibre sources in ActivBiome+ Technology were selected because they have multiple functions and have fibre bound polyphenols. The bacteria ferment the fibres and produce gut-nourishing compounds, as well as release and activate antioxidant and anti-inflammatory polyphenols. These postbiotics benefit the gut, as well as other organs and tissues.
How does ActivBiome+ Technology improve Gastrointestinal Health?
A series of studies at Hill’s Pet Nutrition Center (PNC) were conducted demonstrating how ActivBiome+ Technology works and clinically showed improvements when this synergistic blend of prebiotic fibres was added to certain foods. Both dogs and cats showed improvements in markers of gastrointestinal microbiome health. Dogs also showed improvements in stool quality.1,2
One canine feeding study evaluated the benefits of the ActivBiome+ Technology in healthy dogs (n=16) and in dogs with chronic, recurrent enteritis or gastroenteritis (n=16) in a randomised, cross-over design study. ActivBiome+ Technology was added to either a hydrolysed meat food (Food A, Fig 1) or grain-rich food (Food B, Fig 2) and fed over a 56 day period. All dogs had significant improvements in stool quality, including those with chronic enteritis/gastroenteritis, when given food that included the ActivBiome+ Technology fibre blend.2 ™
Active Biome+ Technology Improved Stool Quality in All Dogs
Figures 1 and 2 illustrate the changes in stool quality among all dogs consuming this fibre blend. By the end of 4 weeks, the stool quality score of the dogs with chronic enteritis/ gastroenteritis had improved to the point that they were no longer significantly different from the healthy dogs.
Additionally, a significant increase in beneficial bacteria taxa (e.g. Lachnospira sp, Fig 3) and a decrease in harmful bacteria taxa (e.g. Desulfovibrio sp.) was observed. This positive change in the microbiome also leads to an increase in the production of helpful postbiotics. ActivBiome+ Technology significantly increased faecal levels of certain polyphenols and short-chain fatty acids (SCFA’s, Fig 4). The SCFA’s help reduce faecal pH, creating an environment that favours the growth of beneficial bacteria in the host. Potentially harmful postbiotics (faecal polyamines such as putrescine, spermidine) were also measured and were reduced by the addition of ActivBiome+ Technology2.
Similar to studies performed with dogs, the feline research done at the PNC on 28 healthy cats showed that ActivBiome+ Technology helped create a more positive gastrointestinal microbiome environment. There was a significant increase in beneficial bacteria. There was also a significant increase in key postbiotics, such as SCFA’s (acetic & propionic acids) from fibre fermentation and a decrease in fatty acids (isobutyric, 2-methylbutyric, & isovaleric acids) from protein breakdown. Increased stool moisture and decreased pH were also achieved whilst maintaining acceptable stool scores1.
NEW ActivBiome+ Technology has been proven to provide
numerous benefits in cats and dogs.
Nourishes the pet’s individual gut microbiome and promotes beneficial bacteria
Activates the microbiome to release and convert fibre bound polyphenols into more potent anti-inflammatory and antioxidant postbiotics
Increases short-chain fatty acid production to nourish colon cells
Promotes healthy stool quality in healthy dogs and dogs with enteritis2
Cat, M, approx 3 years old, Otelo. The cat has survived after severe trauma which forced colleagues to amputate one frontlimb and to try saving the other one using standard surgical procedure. Weeks later the cat came to us for euthanasia: lethargic, anorhexic, with decubital wounds and with very deep and extremely inflammated and painful exhoriation at the chest area due to body dragging on the floors. The not amputated leg wasn’t functional. It was swallowed, with severe purulent inflammation and permanent fistula, with evaluating maluinon (high degree rotation and mild varus) and with radial nerve paralysis, the antebrachial bones showed all radiographic signes of osteomyelitis. The patient showed all clinical and paraclinical signs of evaluating sepsis. Additionally Otelo had also severe lungs problem. We took the risk to prepare the cat for the DH arthrodesis surgery and to test our technique in these extremest possible conditions.
Otelo’s condition 1st day in clinic:
It took almost 3 weeks to prepare Otelo fur surgery, lungs multimodal treatment including Opti-Airwei, treatment against the systemic and local infections and lesions, chronic pain and exhaustion.
We used the technique on its standard way, we just decreased the rerotation angle from 90-95 degrees to 80-82 degrees, because cats with only one front limb move the existing one to the median body line which leads to natural 10-12 degrees carpal rerotation.
Otelo 5 min post-op X-ray:
Pre- and intra-operatively we took material for bacterial identification and antibiogram. Of course we counted as usual on VetDiaLab with their unique system for automathic identification even to subtype and for authomatic machine antibiograms. The VetDiaLab fantastic work was the key for complete solving of the chronic multi-infection.
Thanks to the precise lab results, the reliable technique and the amazing post-op care of our team (even including adoption of the patient by “fallen in love” with him team member) Otelo overcame the victim pose, the decubital wounds, the chest deep exhoriation and uses its leg with full geometrical functionality. The deep antebrachial bone infection was 100 % overcome only after removing one of the screws which kept infection – after this manipulation the operative suture finally healed 100 % and we removed the collar on Christmas!
The European Advisory Board on Cat Diseases (ABCD) invites applications for the 2020 ABCD & Boehringer Ingelheim Award, which aims to reward innovative and outstanding work by promising young professionals in the field of feline infectious diseases and/or applied immunology.
Candidates should have made an original contribution to the field of feline infectious diseases and/or immunology, which has been published or accepted for publication in a referenced journal or accepted by another assessing body in 2018 or later.
Candidates should be based in Europe, have completed a veterinary or biomedical curriculum, and ideally be under 35 years of age at the time of application.
Applications should be made in English in an electronic format and include a short abstract (max. 500 words) of the work the applicant wishes to submit, as well as a short curriculum vitae and two personal references. Any relevant publications and/or dissertation on the topic should be included. The deadline for submission is 15 April 2020.
The 2020 award (1000€) is funded by Boehringer Ingelheim and will be presented by the ABCD at the congress of the International Society of Feline Medicine, to be held from 10 to 14 June 2020 in Rhodes, Greece. The award winner will receive a complimentary registration to this congress. Return travel expenses and accommodation will also be covered to allow the laureate to attend the event. The winner is expected to give a short presentation or present a poster of his/her findings at this event.
The Young Scientist Award was created in 2008 jointly by Boehringer Ingelheim (then Merial) and the ABCD.
The 2019 recipient of the Award was Rosina Ehmann (Germany).
Defects located on the tail are challenging due to lack of skin. Second intention healing, skin grafts or random local flaps can be used as a treatment in this particular area. Primary closure can be used when small defects are present but risk of dehiscence and vascular compromise is very increased due to tension and tourniquet effect. In cats was described a perineal axial pattern flap used for covering a defect located on the proximal third of the tail. Also a “spiral closure technique” can be used to close small to medium size defects on the tail. The use of the advancement flap is usually the first choice in approaching the closure of defects if they can not be closed by undermining and suturing. This article illustrates the usage of advancement flap from the base of the tail for closing the surgical defect left after excision of a tumor located on the dorsal proximal third of the tail in a dog. No complications were noted after surgery and the tail maintained the normal function.
Case report
A 5 years old female neutered cross breed dog was admitted for assessment of a lump located on the tail. The owner was not sure for how long time the lump was in that place and how fast developed, was just recently observed on the tail.
On general examination no abnormalities were detected. A 4 cm mass was identified on the dorsal aspect of the mid proximal third of the tail. The mass had round shape, located under the skin and well attached to the coccygeus muscle. On palpation, local temperature was normal, elastic-firm consistency, without local pain. No other abnormalities were detected. Fine needle aspirate was recommended and performed before surgery.
Cytologic interpretation: marked pyogranulomatous inflammation, epithelial proliferation, neoplasia probable and evidence of mineralization.
Surgical approach and suture technique
Surgical site was aseptically prepared and the patient was placed on the table in ventral recumbency. Before starting the procedure, another evaluation of the mass in relation to the skin located on sacro-coccygeal area but also with the skin which surrounds the mass was done. Before incision, the skin mobility was checked. In physiological position a small skin fold was observed cranially to the lump (Fig.1).
Figure 1. Preoperative appearance of the sacrococcygeal area after surgical site preparation. The tumor have a spheric shape, is located in the proximal third area of the tail-dorsal aspect and have a wide base of implantation. At the base of the tail a small fold can be observed
A circular incision was performed 3mm distance from the mass. No.10 scalpel blade was used to create the skin incision and the dissection until the muscle was done with Metzenbaum scissors.
A thin capsule that surrounds the mass was discovered at the junction between it and the coccygeal muscle. At that point the dissection was performed with the scalpel blade until the end. Care was taken to avoid the major vassels of the tail( Fig 2, Aand B)
Figure 2. Intraoperative view of the tail. (A) Right lateral side before tumor excision and (B) left lateral side after full excision hightlights the intact lateral coccygeal veins (yellow and black arrows).
Fig 2
Fig 2
Figure 3. Transverse section at the level of caudal vertebrae illustrates distribution of the muscles
The tail movements are coordinated by 6 pairs of muscles (12 muscles in total) that are distributed concentrically over the coccygeal vertebrae (Fig.3).
The vascular supply of the tail is composed by 2 lateral caudal veins and arteries located
on lateral sides and the median caudal artery and vein. In this case both caudal lateral veins were preserved. Minimal bleeding was present and the small blood vassels were ligated with 3/0 PGA. Two parallel lines extended from the proximal border of
the defect to the base of the tail were made in the skin deep to the muscle. Meticulous dissection of the skin was performed with Metzenbaum scissors until the fold located at the base of the tail. The flap was elevated and advanced distally to cover the defect
(Fig.4 A). The flap managed to cover ¾ of the defect without tension. Undermining of the skin located on the distal border was attempted to obtain the mobility that can help to cover the ¼ of the defect but faild. To obtain the maximum coverage, walking sutures were used to further advance the flap. The first bite went deep into the dermis and the second bite in the tendinous portion of the m.sacrocaudalis dorsalis lateralis (sacrococcygeus dorsalis lateralis).Few walking sutures were placed so that the tension is equally distributed (Fig. 4B).
Figure 4. Undermining and elevation of the skin flap. (A) Stay sutured were placed on the flap corners (yellow arrows) to manipulate the skin; (B) Closer wiev of the first walking suture. First bite (blue arrow) is inserted deep in the dermis and the second bite is inserted in the tendons of m.sacrocaudalis dorsalis lateralis (black arrow).
Fig 4
Fig 4
Nor following this procedure the primary defect has not been fully covered. In the end, horizontal mattres pattern (“U” shape) was used on the edge of the flap and full coverage was achieved under moderate tension (Fig.5).
Figure 5. Dorsal aspect of the tail after final closure
Usually after advancing a flap “dog ears” will result at the base. In this particular case minimal “dog ears” were present. For a cosmetic appearance and to preserve the soft tissue, central suture technique was performed on the lateral sides of the skin flap due to crescent shaped defect. There are many ways to close up a crescent shaped defect but in this particular case central suture technique was chosen to avoid “dog ears” removal. First simple interrupted suture was placed in the middle of the defect and after, another sutures in the middle of the two defects obtained and so on until complete closure.
The central closure technique distributes the “dog ears” all along the sutures line in small increments (Fig.6a, 6b). In the end, the final aspect of the tail in relaxing position was changed due to advancement flap. The tail gain a curved up position (Fig.6).
Figure 6. Central suture technique. (a) Left lateral view of the tail illustrates no “dog ear” present at the base of the flap due to suture technique. The black line show the curved shape of the tail after the final closure. (b) Illustration of closure of crescent shape defect1.
Fig 6
Fig 6
Postoperative care
Figure 7. Postoperative view after bandage application
For protection, a soft padded bandage was used to cover the surgical site, this being made up of square gauze applied on top, fixed in place with an elastic band; Stirrups were applied over the gauze and extended proximally to the base of the tail and Vetrap was used as a last layer (Fig.7).
The patient was sent home with booster collar to prevent self trauma and 3 days of robenacoxib, also in the surgery day a NSAID injection was administered with the same nonsteroidal anti-inflammatory drug. Until the first recheck (3 days post surgery) the bandage has fallen due to excessive tail movement in 24 hours but the owner apply another one at home; Four days after surgery the patient present for the first recheck, on inspection the tail was less curved in compare with the day the surgery was performed and no complications were present. The owner reports the patient was comfortable at home after surgery, and did not show any changes in behavior. The same bandage was applied in the same manner and this time did not slip until the second visit. The patient has presented for sutures removal in day 10 aftert surgery . No postoperative complications were present and the tail was less curved upwords. One last visit was 34 days after surgery. Due to the weight of the tail, continous tension was applied on the skin over time and the natural position was regain (the processes of mechanical creep and stress relaxation) (Fig.8). The owner reptorts the patient was comfortable in all this period and does not seem to be disturbed by surgery.
Figure 8. Ventral (A) and right lateral (B) aspect of the tail after sutures removal – 10 days post surgery; (C) Dorsal view of the tail 34 days after surgery.
Fig 8
Fig 8
Fig 8
Histopthologic result and prognosis
The mass (Fig. 9) was put into a containter with formol and sent to the lab for histopathologic examination. Pilomatricoma partially ruptured and mineralized, associated with moderate granulomatous inflammation. This is a benign tumour of the hair follicle, slow growing, non-invasive, and generally rarely metastasizes (malignant variant exists but is rare). was the diagnosis and clear margins were achieved and the prognosis is was good. Poodles, Schnauzers and Kerry Blue and Bedlington terriers may be predisposed.
Pamas Trading is one of the best veterinary distribution company in Romania. Their portofolio for small animal consists in pet food , diets and medecines very usefull for clinicians. We have a very good cooperation and every year new products are offered on vet market. I believe in this partnership and hope that our relation will be better every year.
Dr Raluca Zvorasteanu
We have been working with Pamas for many years. The portfolio of products offered by them meets our standards and that of our clients. As professionals we want to offer only what is best to increase the quality of animal life. Together with Pamas we managed to raise the standards, offering treatments with the latest generation products. Collaboration with them is a flexible one, being prompt and attentive to our requirements as veterinarians
Clinica Veterinara Ortovet
During our collaboration, Pamas provided us with a wide range of products, which we have used with good results in the treatment and care of our patients. We enjoy an efficient communication, the Pamas team giving us prompt and appropriate answers to our needs.
Thank you, Pamas!
The Ortovet team
Dr Simon Corneliu, Tazyvet Clinic
I like the collaboration with the company Pamas because it is a company with good management.
It has good products which then become a brand under their distribution.
Always looking to distribute good and niche products.
They have flexible payment terms and are prompt in delivery.
It encourages and facilitates young doctors in the exchange of experience with other clinics.
I wish them success in what they do and keep it that way.
Dr Ina Dragomir
In the more than 4 years of collaboration, Pamas has shown me that it is a company I can rely on, with a wide portfolio of products and seriousness in the delivery of orders. Also, the team from which it is formed and that broke my threshold in the cabinet is cooperative, united and very serious. At the same time, all its members proved to be jumping, understanding and always funny. I hug you PAMAS!
Dr Matei Alexandru
We have been collaborating with Pamas company for over 7 years. During this time we managed to create a strong connection based on professionalism and mutual trust. All the problems that have appeared over the years have been solved in a professional and equitable manner for both parties. I have recommended and I will continue to recommend my colleagues to collaborate with Pamas Trading for the quality of the products and for the short delivery time.
Dr Sonia Pintece
The Pamas Trading Company is very professional, they pay attention to our needs, the delivery is fast and they have good prices. Pamas Trading and Dr. Luba Ganceva by ”Learn and Travel” program made possible my externship to Central Vet Clinic – Sofia, Bulgaria and for that I would like to say : ” Thank you!”.
Dr Mirel Marafet
I have been working with Pamas for over 5 years, during which time it has proved to me that it is a company I can rely on. I hug you and wish you Happy Holidays PAMAS
Dr Plamena Boycheva from Bulgaria attended our program Learn and Trave with Vets on The Balkans in December 2019 with the support of Blue Sky Commerce and Clinica Veterinara Laggo Magiore.
Let her tell us more about her adventure:
“We all know that to be good vets and to provide the best possible care for our patients we need to be up to date with the newest, the most modern and well-used techniques in our everyday practice. Is there a better way to achieve that than being part of a Vet on the Balkans. Talking about pursuing that goal, I want to thank the whole team of Blue sky commerce and Vet on the Balkans.
I am thrilled to have had the opportunity to be part of the Lago Maggiore Clinic team, even for a week. After a few emails exchanged, I knew that I was going to the right place. I had no doubts regarding my safe journey and the organization of the trip. Let me tell you how I spent my time there:
In a late and rainy afternoon, I arrived at the airport in Italy, where I was greeted by Dr Sara Manfredini – an incredible person and anesthesiologist, who showed me handy tips in anaesthesia. Furthermore, I find out what a great spirit she has. I can easily say that she is the heart of the clinic; she has never stopped giving her passion for everything she has done. She was very supportive, and on the very same day, she arranged a tour around the clinic. I was impressed with the scale of the clinic. There are digital X-ray, CT, well-equipped laboratory room, endoscapy, ultrasound very well organized stationary. Of course, Dr Sara Manfredini was so kind as to order an Italian pizza for my first dinner there. Immediately I felt a friendly and warm atmosphere. Then I met Dr Jessica; rigorous and dedicated doctor. She was the person who showed the apartment where I would be staying and made my time there very easy; thank you, Jessica, for being so lovely and kind.
My colleagues had thought of everything, and the organization was incredible, like everything else that the team do. I can assure you that the atmosphere of this place is terrific.
The chief doctor at the time that I was there was Dr Mariangela De Franco, who has inspired my work. Also, she gave me essential pieces of advice on the field of echocardiography, in which I am very interested. She is not only a fantastic specialist but also a wonderful person. She has led her team with great love and warmth, which reflected on their overall work and attitude towards patients. A few days later, I had the honour to meet Dr Luigi Venko and Dr Luca Formaggini; Two exceptional people and doctors. With professionalism and humanity Dr Formagini, the head of the clinic is the inspiration of each member of the team. Everyone at the clinic has been dedicated and has taught many tricks in my day-to-day work. Besides the professional experience I had given, I also learned to cook some Italian dishes according to original recipes.
Although, I might not mention everyone: thank you, people, for your hospitality, your attitude and your guidance. Thank you for the spirit you carry. I wish I would have the opportunity to meet you again soon.”
This is case series of two dogs with similar advanced brain compression. The aetiology was different, but in both cases there was gradual epidural compression, indeed allowing survival of the patients. The final size of the brain compression lesions in both dogs was impressive and was related to the delayed diagnostic process. Both dogs were successfully treated and followed in next few months post op. Different surgical approaches and techniques were applied, according to the specific needs.
These cases present interest because such large lesions are rarely met in practice, and may be considered untreatable by some veterinary clinicians.
Case 1
Referring Vet: Dr. Evgeni Evtimov
Corresponding authors Dr. Aglika Jordanova (Clinical pathology), Dr. Vladislav Zlatinov (Surgery),Dr Nikola Penchev( Anesthesia)
Felix, a 7 months old Collie dog was presented for treatment of progressively deteriorating central nervous system dysfunction.
The male puppy lives in an apartment; vaccinations and deworming are current, fed on regular dry food diet. Had been with his owner for a month, came from a breeder.
The clinical signs had started 3 weeks ago, with unclear manifestation- decreased appetite, lethargy, intermittent fever, unstable walk. The overall body condition of the patient had been appreciated as underdeveloped, and the owner reported the dog is not growing.
Felix had been initially consulted by the referring vet, who had started primary diagnostic and treatment steps. Biochemistry profile, CBC and vector diseases fast serology tests had been done- being normal/ negative, not revealing the specific cause of the condition. Symptomatic antibiotic treatment had been started, without significant improvement. NSAIDs resulted in temporary alleviation of the symptoms – body temperature back to normal, the dog was brighter.
At this point the dog was referred to us to investigate the possible cause of the condition, suspected to be endocrinological.
The dog was found to be lethargic, walking with head positioned low, no pain during head lifting, does not resist opening the jaws, wobbly gait, with normal proprioception of all 4 limbs. body temp.39.0C. The CBC was WNL. Total T4 was normal (16nmol/l). Radiography of limbs and vertebrae showed normal physeal growth for the dog’s age; thus excluding congenital hypothyroidism.
Cerebrospinal fluid collection and computer tomography study of the head were suggested, as the symptoms were assessed as central neurological. During the period of owner contemplation, trial course with corticosteroids had been applied. Short-term clinical improvement had been noticed, followed by further decline in the dog’s condition. A bulge on the left side of the head became visible. After gradual progression of neurological symptoms- dull behaviour, mild head tilt, inactivity, the dog deteriorated profoundly to the status of stupor- severely depressed mental status, barely reacting to stimuli.
CT study of the head was performed 14 days after the initial examination at Central Veterinary Clinic (with no anaesthesia needed), revealing dramatic findings. Extensively grown soft tissue “mass” (vs thick fluid accumulation) was found over and under (extra and intracranially) the left parietal and occipital skull calvaria. The outside lesion was more heterogeneous, lobular like, under the temporal fascia. The internal part was homogenous, with clear fluid density, well encapsulated, caudally extending over cerebellar tentorium. It was causing a significant mass effect with compression of the left parietal and occipital cerebellar brain lobes. Dramatic lateral ventricular compression and a falx shift to the right was present.The skull bone in the area was hypertrophied, with aggressive periosteal reaction, mostly extra- cranially. In the cranial left parietal bone, a small concave defect was noticed on 3d reconstruction images.
Fine needle aspiration was done puncturing the extra cranial lesion area. Pus-like fluid was obtained, cytologically tested, confirming suppurative process.
All these findings suggested the main differential diagnosis- massive epidural empyema (abscess), compressing the brain parenchyma and causing profound neurological deficit. The probable cause was bite wound on the head (<=concave defect on the parietal bone).
Surgical decompression was suggested and accomplished as an urgent procedure because of the fast deterioration of the patient.
Lateral approach to the skull was applied. An abscess cavity with intensively neo-vascularised capsule was found, just under the temporal fascia, Topographically it was within the temporal muscle tissue. After partial capsule resection and copious lavage, the soft tissues were undermined and reflected to expose the lateral (parietal) skull area. Next, rectangular rostrotentorial craniectomy was accomplished using maxilo-facial mini oscillating saw. Skull sutures and the concave defect (bite area?) were used as reference landmarks to orientate the cuts. The skull bone in the area had reached 1 cm thickness. A fluid filled epidural (over dura mater) cavity was found. It was filled by thick bright yellow purulent fluid. After microbiology and pathohistology sampling, the pus was aspirated and the residual cavity copiously lavaged. Prompt haemostasis was applied, with minimum haemostatic materials left in place.
A fenestrated drain tube was inserted into the empyema cavity and under the soft tissues. The temporal fascia and the skin were closed routinely over the defect. The drain tube was connected to active vacuum suction system.
Intense post op care was applied in the next 12 hours- blood pressure monitoring and correction with vasopressors, fluid infusion, pain control, i.v. antibiotic therapy. The patient started to improve slowly but steadily- the mental status improved within 24 hours, and the dog was able to stand up on the second day after the surgery. On the fourth day it was stable enough to be discharged from the clinic (still with the active vacuum drainage). The last was removed on the 7th day. Ultrasound examination rechecks was done on the 10th and 14th days, excluding new fluid accumulation.
The microbiology culture test result was negative, but no anaerobic isolation media was available. Just in case of not detected anaerobic infection- 3 weeks course with Clindamycin was prescribed.
The pathology report confirmed the the diagnosis of pyo-granulomatous inflammation with no neoplastic tissue present.
Eventually, Felix did full recovery with no infection relapses within the follow up period of 4 months.
Case 2
Referring Vet: Dr. Milena Pancheva
Dr. Vladislav Zlatinov (Surgery), Dr. Antoan Georgiev (Anaesthesia).
Beki, 4 years old female Dalmatian was referred for consultation, regarding the possible treatment of a huge intra-cranial mass.
The dog had a long history of slowly progressing vestibular signs and eventually obvious ataxic walking Unfortunately the owners had ignored the problem for several months (> 7 m), because of the mild clinical presentation in the beginning and the good overall condition of the patient. Recently the dog deteriorated- difficult to keep balance during walking and eating. Two seizures and nocturnal hyper excitement activities were also demonstrated.The dog had already computer tomography study of the head, revealing huge cranial mass. An opinion about euthanasia was already suggested to the owners. Empirical therapy with steroids and antibiotics was already applied before the achievement of the correct diagnosis.
During our neurological examination we found: normal mental status and vision, normal cranial and limb segmental reflexes; the menace response reflexes were decreased; body posture revealed broad-based stance. The patient demonstrated obvious ataxia. It was defined as cerebellar one, presented by hypermetria and swaying, mild intentional head tremors.
We analysed the CT study and found: large hyper-dense oval mass, starting from the region of the occipital bone and engaging the cerebellar tentorium. The mass was protruding extensively into the brain cavity, eccentrically to the right side. Bone lysis and infiltration was evident in the right occipital nuchal area and also cranial to the right nuchal crest. Severe cerebellar compression in cranio-ventral direction was evident. Less severe compression of the occipital cerebral lobes (without lateral vetntricular displacement) was also found.
Despite the large size of the mass, we suggested moderate malignancy of the lesion- smooth, encapsulated margins, homogenous density. Bone neoplasia (osteosarcoma and multilobular osteochondrosarcoma) or meningioma were the most probable diagnosis. Slow progression of mass, made the osteosarcoma less probable. The bone involvement is not typical for meningiomas. Multilobular tumors usually has similar imaging features as presented in the case. Their excision offer good opportunity for long-term tumor control, so a surgical decompression and mass removal was suggested and accomplished in Beki’s case.
We approached the skull caudo- laterally, undermining and retracting the overlaying temporal fascia and neck muscles. The tumor mass was found protruding from the bone through osteolysed right occipital and parietal bones. Using speed burr we created large combined occipital and caudal-lateral craniotomy. Excessive bleeding from the right transverse sinus was anticipated but fortunately not found, because of possible gradual vein obliteration. Despite this, during gradual enlargement of the craniotomy, special precautions was taken not damage the ipsilateral left one.
After exposure the cranium, we attempted to determine the mass borders. The tumor was originating from the cranium bone not invading (just compressing) the nervous tissue. Because of the huge size, en block resection was far from possible, so slow “debulking” mass removal was started. The brain meninga (dura mater) was not affected by the neoplasia, so tissue direction was amenable.
Diffuse, moderate but constant bleeding was met through the whole process of removal small partial tumour masses. Haemostatisis was achieved using Cellulose blood clot inducing products (Surgicel mesh) and intermittent gentle compression. Copious lavage was applied during the whole surgery.
To complete the mass removal was a laborious procedure, taking itself about an hour. Finally, immediately after the decompression a visible brain tissue re-expansion was noticed. After prompt haemostatis (using bone wax and Surgicel materials), the residual craniotomy defect was covered with apposition of the soft tissues over it.
In the next 24 h post op period, the dog was was given opioid analgesia, anti-inflammatory doses of steroids and anti oedematous osmotic agent (Manitol).
Indeed, Beki started to recover surprisingly fast- eating on the 12 h post op (on the video). For about 48 h she showed exaggerated ataxia, with difficulties in walking, but the coordination started to improve fast. The patient was discharged from the clinic on the third day pos op, walking reasonably well. Harness supported leash walks were recommended.
No physiotherapy was applied in the recovery time, because the patient coordination improved to normal on the 10th days pos surgery.
Patohystology evaluation of the tumor was done. The results was Multi lobular bone tumor. This is a low malignant, well differentiated neoplasia. In short term it can be controlled successfully by surgical resection. Slow reoccurrence could be expected, also long term metaplasia to more aggressive osteosarcoma.
Recheck of the patient revealed condition undistinguishable from normal. The follow up period till now is 3 months.
Vets on The Balkans express their gratitude to Dr Murat Saroglu for the opportunity and being part of our team! Thank you Pamas Trading for supporting the program for Romania.
Dr Dana Stoian has done her externship together with Dr Murat Saroglu in Istanbul, Turkey.
Let her tell us about this amazing experience!
After living in the last 2years only 2seasons (summer and super summer), thanks to Luba Gancheva and Vet On Balkans I had the perfect motive to enjoy a few days of normal climate and learn a little more about ophtalmology. And what a great place for all of this as well, Istanbul, Turkey!
I started my day walking thrilled towards the clinic and enjoyed every leaf fallen on the sideway, every cat that stopped me for a pet on the head and when I eventually arrived at the clinic, boom! Huge waiting line up untill the frontyard’s door.
I did my externship at Prof. Dr. Murat Șaroglu’s Eye Center, a small but well equiped practice on the Asian part of Istanbul. The first thing that surprised me was the waiting line. Wow, lots of cases! The clinic was opened 3 or 4 days a week, but those are some days!
I had soon to discover that the patients influx would maintain at least the same if not even it got more crowded during the examination day.
At the end of day1 I have counted 90cases, out of wich 5 were surgeries. Starting the next day I didn’t even had time to count anymore!
The clinic had 1 floor, with a spacious reception that would lead straight into the examination room at the ground floor and at the 1st floor an office and the surgery room.
The surgery room was equiped with a hemogram and biochemistry analizer, 2 different phacoemulsification devices, laser device, an ophtalmic surgical microscope and an inhalant anesthesia machine, altough all of the surgical cases received general anesthesia and not gas.
An eye examination usually consisted of a direct inspection, exam with the opthalmoscope, slit light, fluoresceine or Schirmer test were would be the case, almost always eye ultrasonography and fundoscopy.
80% of the patients I had the chance to see during my visit there were cats.
Turkey loves all animals but they surely have a thing for cats. Never anywhere had I seen cats as sociable and respected like in Istanbul.Actually, never had I seen stray animals so well taken care of and loved as in Istanbul. And big, chubby dogs sleeping in coffee shops, cats sleeping behind the doors in clothing stores or on a seat on the terrace of a restaurant.
On another note, back to my learning experience, I am happy I had the chance to observe and learn about surgical procedures from the most common, like a simple tarsoraphy to delicate procedures such as:
-cataract phacoemulsification surgery,
– pupilary reconstruction,
– surgical lens removal or intrascleral prosthesis placement,
– Sinblefaron reconstruction,
-keratectomies,
– eyelid surgeries,
-post-traumatic enucleations.
One very important note I took back home with me is that ultrasound should always be part of my examination.
The profesor and his team were nice to explain to me all of the history of each patient who came for a follow up consultation, altough time was short and appointments were waiting (80-100 cases per day). I learned here that with perseverance and patience even a disaster can be fixed. I saw kittens with minor corneal scars or no scarr at all instead of the mess they used to have for an eye 8weeks prior to the follow up.
I think it’s very important to relate to your patient and his caregiver with patience and in the same time use all of your weapons, have them come back for follow up as much as they need to, make sure your patient is confortable and DO THE ULTRASOUND.
I am definitely grateful for this experience, it’s quite important to travel and learn from your colleagues abroad, to learn how to work under different circumstances with different resources that you may or may not have acces to, with pathologies you may or may not see again.
Indeed such a great ideea Vet on the Balkans!
The city was also amazing, I strongly recommend to anyone to walk it’s streets up and downhills, enjoy a turkish breakfast on the Bosphorus Shore or try the old ottoman cuisine and terribly sweet and tasty baclava.
Many thanks to Luba Gancheva, prof. Dr. Murat Șaroglu and his lovely team at Veterinary Eye Center. I hope to see you all again!
Borislav Metodiev, DVM Yavor Stoyanov, DVM
