Portosystemic shunts are anomalies that allow blood returning from the gastrointestinal systems to bypass the liver and pass directly into the systemic circulation. When this occurs, toxins from gastrointestinal tract that are normally cleared by the liver are shunted directly into the systemic circulation. This build-up of these toxins in the bloodstream leads to the clinical signs commonly seen in animals with these shunts. Three categories of clinical signs commonly are associated with the presence of these shunts: neurological, gastrointestinal and urinary. Neurological signs include seizures, head pressing, circling, lethargy and blindness among others- hepatic encephalopathy. Gastrointestinal signs include vomiting, anorexia, weight loss and a reduced rate of growth. Urinary tract signs, including stranguria, pollakiuria and hematuria are generally related to the development of urate cystoliths secondary to the presence of ammonium biurate crystals in the urine.
Contrast CT study with 64 slice scanner was performed with i.v administration of iopamidol solution 370g/ml (contrast agent) in dosage 1ml/kg.
CT findings: There is a abnormal communication between the portal vein and the caudal vena cava using the splenic vein. The portal vein decreases in diameter cranial to the shunt exit and splienic vein is enlarged. The both kidneys are too big and liver is too small.
Congenital extrahepatic splienocaval-caval shunt
The treatment consisted of medical and surgical approach. Ten days before the surgery the condition was managed with amoxicillin 12,5 mg/kg p.o q12h for 15, Lactose oral solution 67g/ 100ml in dosage 1ml/kg p.o q12h and hydrolyzed protein food.
The surgery was planned in great teamwork with d-r Kaloyan Voichev in Multidisciplinary Veterinary Clinic Bulgaria. The operation was performed with the kind assistance of the whole team. The operational approach consisted of midline celiotomy and isolation of the shunt from surrounding structures and placement of thin cellophane band surround the vessel.
Max recovered well from the anesthesia and was discharged after 48 hours with amoxicillin 12,5 mg/kg p.o q12h for 10days, Lactose oral solution 67g/100ml in dosage 1ml/kg p.o q12h for 15 days and hydrolyzed protein food. In postoperative period Max was vomiting sporadic within one week, but with good appetite. The vomiting was stopped with maropitant 1mg/kg s.c q 24h for 3 days.
One month after the surgery Max doesn’t show any clinical signs.
United Veterinary Clinic, 34 Tzarevetz street, Varna, Bulgaria
The aim of this case report is to describe the technique and clinical outcome of limb salvage procedure in a cat with а distal segmental femoral bone deficit due to bone nonunion using customised expandable stifle arthrodesis plate.
3.5 years old female cat was presented to us after unsuccessful repair of multiple fractures of the right femur. The current condition of the cat was as follow: Gustilo-Anderson type 3b open intercondylar and distal diaphyseal femoral fracture, fracture of the femoral head, fracture of the greater trochanter, patella ligament rupture and extensive skin and soft tissue loss in the right stifle region (1). The aim of the treatment was anatomical reconstruction of the femoral fractures, temporary transarticular fixation and soft tissue reconstruction using ipsilateral mammary chain (caudal superficial epigastric axial pattern flap) with a future plan of performing stifle arthrodesis due to a non repairable patella tendon rupture (2). Surgical goal was achieved, but sequestration of the whole distal femoral segment was confirmed radiographically two and a half months after the revision surgery. As the owner declined amputation and insisted for limb salvage procedure, personalised 3D expandable arthrodesis plate was designed, fabricated and used for achieving stifle arthrodesis.
Picture 1-Gustilo-Anderson Grade 3b open distal femur fracture
Picture 2-Shirley, soon after the first surgery when reconstruction of the femur and closure of the soft tissues were performed using caudal superficial epigastric axial pattern flap
Two radiographic examinations immediately postoperatively and five months after surgery were performed. Four months follow up x-rays showed no signs of periprosthetic bone resorption which seems to be in the main concern in this clinical case and whether the porous spacer will be integrated to both the femur and the tibia.
Designing and fabrication of the customised implant is a complex, time consuming and cost depending process, but 3D printed expandable stifle arthrodesis plate could be a realistic option for hind limb preservation in cats. Further cases and long term follow up are required to determine the success and complication risk of the procedure.
The femur is the most commonly fractured bone in cats, accounting for more than 30% of feline fractures (3). Those involving the shaft and the distal femur are most commonly seen. Inadequate fracture fixation leads to poor mechanical stability and further compromise of the biological environment, especially if there are migrating implants. The basic tenets for treatment of joint fractures are reestablishment of articular congruity, joint stability, axial alignment and preservation of joint mobility (4). Patella tendon rupture is unusual condition and it is most commonly due to a sharp trauma (5). In our case, an iatrogenic rupture of the patella tendon was suspected due to migrating implants following surgical stabilisation of the distal femur fracture. Arthrodesis of the stifle joint is a salvage treatment option if joint function cannot be preserved with another methods. Arthrodesis will leave the cat with significant gait alterations, and careful consideration should be made before electing for this option. The angle of fusion is estimated from the standing angle of the contralateral limb, and is around 110°. Strict attention should be paid to surgical technique to avoid complications. These tend to occur because of the long lever arm created, which can result in fracture of the femur or tibia at the implant–bone junction. Implants should end in metaphyseal areas and not over the narrowest part of the diaphysis to avoid this complication (6).
3.5 years spayed female cat was presented to us after unsuccessful repair of multiple fractures of the right femur. After removal of the existing implants, reconstruction of the articular fracture was performed using 2.4mm lag screw and antirotational K-wire. 2.0 mm SOP plate was applied as medial transarticular stabilising implant and for fixation of the supracondylar fracture of the femur. Two K-wires and tension band wire were used for fixation of the greater trochanter. The femoral head seemed already stable and no attempt for surgical stabilisation was performed.
Bacterial culture was done during the first surgery and the results came back as Methicillin-resistant staphylococcus. Based on antibiotic susceptibility testing, Amikacin was used as an appropriate antibiotic for seven days. Unfortunately no signs of fracture healing were noticed in the next 8 weeks and small fistulous tract appeared at the lateral aspect of the stifle joint.
Picture 3-Femur fracture configuration with loosed implants before, and the Picture 3-femur anatomically reconstructed after the revision surgery. At the most right radiograph – signs of osteomyelitis and sequestration of the whole femoral condylar segmen
In a subsequent surgery all implants were removed together with the distal femoral fragment, a transarticular external skeletal fixator was applied and CT was performed immediately after that. Bacterial culture has been obtained and came back again positive for Methicillin-resistant staphilococcus. Chloramphenicol was initiated for 7 days p.o. based on bacterial sensitivity testing.
A further attempt was initiated for designing and producing of expandable stifle arthrodesis plate. The aim of the proposed implant was to provide stifle arthrodesis but at the same time to replace the distal femoral segment for overall limb length preservation. The implant was designed by CABIOMEDE Vet, Poland and consisted of two solid portions with locking screw holes and central porous portion for promoting bone ingrowth. The length of the porous part of the plate was 28mm and was intended to replace the missing distal femoral segment.
Picture 4-Shirley with an applied transarticular ESF, waiting for a stifle arthrodesis surgery
Two DCP holes were designed at both sides of the solid part of the plate in order to provide compression on the osteotomised bone segments against the porous part of the plate. The rest of the plate holes were locking ones and were arranged in such a way so they can engage each bones in a different angle providing some sort of orthogonal fixation and at the same time avoiding the holes form the existing ESF pins. The plate was designed to span almost the entire length of both the femur and the tibia, avoiding possible periprosthetic fracture. Limited contact under-plate surface was designed, reducing the implant footprint on the bone because of the concern of too much implant wrapping and possible implant-associated infection. The customised implant and dedicated cutting guides were printed from Polygon Medical Engineering, Russia.
Picture7-Renderings of the femur, tibia and lower extremity showing the position of the custom plate. The arrows are indicating the position of the two non-locking screws which are going to provide compression of the bone segments against the porous part of the plate.
Picture 8-A cutting guides designed for precise osteotomies of the bone ends and proper fit of the customised plate
Picture 9-The stifle arthrodesis expandable plate is printed from titanium alloy (Ti6Al4V ELI) which is the gold standard for orthopedic implants when osteointegration is required. Figure 9
During the surgery, the patient was positioned in a lateral recumbency with the affected limb upermost and cranial skin incision was performed starting from the most proximal aspect of the femur to the the most distal aspect of the tibia. A standard lateral approach to the femur was made which continued over the cranial aspect of the stifle area and on the craniomedial aspect of the tibia. The cutting guides were secured and the bone ends were osteotomised. The plate was then attached to the cranial aspect of the tibia and the femur using temporary K-wires through dedicated holes. The most distal tibial plate hole and the most proximal femoral one were designed for 2.0mm non locking cortical screw to be inserted in a neutral position and two gliding holes at both sides of the porous part of the plate for 2.4mm cortical screws in a compression mode. Autogenous cancellous bone graft was obtained from the proximal aspect of the contralateral humerus and applied at both sides of the porous part of the plate. All needed 2.4mm locking screws were predetermined and their length marked on the plate for faster and precise application.
Picture 10-Tibial cutting guide on place and secured with K-wires (on the left). The 3D printed arthrodesis plate fixed to its final position (on the right)
Picture 11-Medio-lateral radiographs immediately after removal of the transarticular ESF and the application of the printed arthrodesis plate
Picture12-Shirley a few days after performing the limb salvage surgery
This case report describes fracture complications in a feline femur multiple fracture and application of customised 3D printed expandable plate for stifle arthrodesis as a limb salvage procedure. The customised plate made of Titanium alloy has the features of the replacement of missing bone, providing initial fixation using screws (both non-locking and locking ones) and long-term bone fixation (bone ingrowth) (7). Our main concern was mainly the long-term bone ingrowth and the bending and shear strength of the plate at the porous/solid part of the implant. Five months after the surgery (at the time of this article has been published) there are positive radiographic signs for osteointegration (no signs of peri-implant bone osteolysis, lack of osteolysis around the screws and progressive bone bridging over the porous part of the plate). In a recent paper (8), porous implants without hydroxyapatite coating showed a consistent bone ingrowth in a canine transcortical model. Despite the concern of poor functional limb after limb sparing/fuse of the stifle joint (4) , our cat was performing extremely well and almost fully weight-bearing on the operated leg about ten days after surgery. Till today she improved her gait a lot and the limb use while she is running and playing with toys.
“Shirley is doing great. She really behaves as a kitten which never had an issue with that leg” – Shirley’s owner, 25.09.2020
Picture 13-Five months follow up radiograph. Close up views to the bone-implant interface
Picture 14-Abnormal sitting “on a side”. Shirley, about five months after stifle arthrodesis
2 weeks after the surgery:
Kim P.H, Leopold S.S. Gustilo-Anderson classification. Clinical Orthopaedics and Related Research 2012, 470:3270-3274
Moors, A. Axial pattern flaps. In: BSAVA Manual of Canine and Feline Wound Management and Reconstruction. BSAVA: 2009; 100 – 111
Hill, F.W.G. A survey of bone fractures in the cat. J.Small Animal Practice 1977, 18, 457-463
DeCamp C.E, Johnston A.Spencer et al. Principles of joint surgery. In: Handbook of small animal orthopedics and fracture repair. Elsevier, Inc. 2016; 211-229
Das S., Langley-Hobbs S., et al. Patellar ligament rupture in the cat: repair methods and patient outcomes in seven cases. Journal of Feline Medicine and Surgery 2015, Vol. 17(4) 348-352
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.
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
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
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.
Stroke or cerebrovascular accident (CVA) is the most common clinical manifestation of cerebrovascular disease, and can be broadly divided into ischemic stroke and hemorrhagic stroke. CVA are characterized clinically by a per acute or acute onset of focal, asymmetrical and non-progressive brain dysfunction. Next cases show the both type of CVA in dogs.
1st case is about 9 years old female boxer. The dog was referring to the clinic with acute onset of seizures. The results of CBC and Biochemistry were normal and MRI was performed.
MRI findings: Intra-axial right piriform lobe and hippocampus lesion with impression of moderate swelling of these portions is present. The cerebral falx is only mildly displaced to the left. There is corresponding low T1 signal intensity in these sections of the brain suggesting edema. There is no enhancement of the lesion after contrast administration. The findings suggest that there is a non-hemorrhagic cerebrovascular accident in right forebrain of the dog.
The 2nd case is about a 8 years old male Cane corso. The dog was present in the clinic with unilateral fore brain deficits and history of epileptic seizures. Biochemistry and CBC were normal and MRI was performed.
MRI findings : There is a well‐delineated T1 iso- to hypointense and T2 hypointense mass lesion with surrounding brain edema in right piriform lobe with a thin peripheral rim of contrast enhancement. There is a mass effect, displacement of the right lateral ventricle and midline shift to the left. This imaging feature is consistent with an acute to subacute intracranial hemorrhage.
MRI features of Hemorrhagic infarction in dogs may not be distinguishable from hematoma caused by vascular disruption. Imaging characteristics will vary depending on the size, location, and chronicity ofthe hematoma.
Acute 1-3 days T1 iso- to hypointense ; T2 hyperintense
Early subacute >3 days T1 hyperintense ; T2 hypointense
Late subacute >7 days T1 hyperintense ; T2 hyperintense
Chronic > 14 days T1 hypointense ; T2 hypointense
Secondary features : mass effect, surrounding edema, midline shift , ventricular displacement and compression .
MRI features of Nonhemorrhagic Infarction in dogs include mildly T1 hypointense and T2 hyperintense lesion with minimal mass effect involving both gray and white matter on unenhanced MR images. These changes seen in ischemic parenchyma rely on an increase in tissue water content. Gradually, during the acute stage, the T2-weighted image becomes more hyperintense in the ischemic region, particularly over the first 24 hours. These signal changes seen in the first 24-hours are best appreciated in grey matter and are well visualized in deep grey matter structures such as the thalamus or basal ganglia, in addition to cortical grey matter. Gadolinium enhances infarcts because of vascular rupture but does not enhance ischemia or edema.
3 years old male, not castrated British shorthair cat with history of tetraparesis was referred to the clinic for Computed Tomography. Mineral-attenuating endobronchial lesions were detected in Thorax as accidental finings in spinal CT. The finding is specific for broncholitiasis.
CT features: Multifocal mineral-attenuating endobronchial lesions in cranial and middle right and cranial left lung lobe are present. There is mild generalized thickening of the bronchial walls and consolidation of right middle lung lob with regional bronchiectasis
X-ray features: Multiple mineral opacity nodules with irregular margins are present within left and right cranial and right middle lung lobe. The largest of which lies within the right middle lung lobe and interstitial patter in this region is present.
Broncholithiasis is very rare condition in cats and is defined as the presence of calcified or ossified material within the bronchial lumen. Only four cases of broncholithiasis in cats have been reported in the veterinary literature. Normal this condition is associated with lower airway inflammation, but in this case the owner does not report for respiratory problems. Broncholithiasis is an uncommon condition, which should be considered as a differential diagnosis for cats with chronic respiratory disease. Affected cats may develop broncholithiasis secondary to a diffuse inflammatory lower airway disease with mineralisation of secretions in the airways.
8 mounts ,female dog with congenital meningocele and hydrocephalus . The dog is with normal behavior and without neurological deficits.
Meningocele and meningoencephalocele of the skull are congenital deformities. These deformities, which are observed as cyst-like swellings in the median part of the skull cap, occur very rarely. The intracranial material protrudes through a spontaneous cavity, such as the anterior fontanelle , and they are classified as encephalocele, meningocele, or meningoencephalocele according to the cranial bifida.
1Veterinary surgeon in United Veterinary Clinic Bulgaria Varna 9000,
Heartworm disease in dogs and cats is well known in many European countries including Bulgaria. There are furthermore studies confirming dirofilariosis in wild foxes and Canis aureus i reports about heartworm disease in domestic ferrets in our country.
A 5 year old male, entire, pet ferret (Mustela putorius furo), weight 0,9 Kg was presented with labored abdominal breathing. The owner reported reduced appetite, difficulty breathing and restlessness. The ferret was not able to sleep or lie down for more than few minutes. The ferret was used to live mainly indoor and allowed during the summer to be outside in the garden, for just few hours during the day, to be exposed to natural sunlight.
Clinical presentation and collateral exams
On presentation ferret was lethargic with abdominal breathing and breathing rate up to 90/minute. There was clear subcutaneous edema more prominent on the front and hind legs and ventral part of the abdomen. Mucous membranes were pale, while CRT was not possible to be assessed. Heart rate ranged in between 120-180 bpm. Pulses were weak even if assessing on the femoral artery was difficult due to the subcutaneous edema. Abdominal palpation was unremarkable, lymph nodes were normal in size. Thoracic radiograph showed loss of detail into thoracic cavity consistent with pleural effusion. Thoracic US was performed confirming pleural effusion and one hundred and twenty ml of modified transudate was drained. Brief screening echocardiography showed normal left atrium and left ventricle and severely dilated right atrium containing double line hyperechoic objects suggesting the presence of few adult Heartworms. (Fig 1). Right atrium was larger than left atrium. Doppler study and any further detailed investigation of the heart were not possible to be performed due the fact ferret became aggressive and owner declined any sedation or anesthesia. Snap® HTWM Antigen test (Idexx) on blood yielded negative result and at fresh blood smear examination no microfilariae were possible to be identified. Knott test was not possible to be performed due to limited amount of sampled blood.
On the basis of echocardiography findings diagnosis of HW disease was done. Negative HW antigen test was assumed to be due probably due to juvenile D.immitis worms and right atrium localization to the small size of pulmonary arteries as described in cats and ferrets.
Therapy and Follow up
The ferret was treated with Advocate® spot on >4kg (half tube), Furosemide 2mg/kg twice a day and Prednisolone 1mg/kg daily both of them orally. The ferret was stable on that therapy. He was eating and drinking well regain the normal body weight 1.5 kg. no breathing difficulties were reported. He was rechecked 35 days after initial presentation. Echocardiography showed right mildly dilated atrium but no presence of HW (Fig 2). Only 10 ml of fluid was drained from the thoracic cavity. From that time he was stable with no owners complain for 6 month. Suddenly he developed respiratory distress and on presentation was with cyanotic membrane. Pulmonary thromboembolism connects to HW disease was suspected Owner elected euthanasia and no more investigations. Necropsy was declined.
This case shows the in endemic area even indoor domestic ferrets may be infected by Dirofilaria immitis. and that the disease is difficult to be diagnosed and can lead to death. Suspicion about this problem and monthly chemoprophylaxis should be warranted in this situation as in dogs and cats.
Case is about a 6 months , male cocker spaniel named Michael.Michael was brought in the clinic from another city in very bad candition.The owners report for a trauma in cervical region.Radiography and neurological examinations were made. Results revealed –Tetraplegie and atalnto-axial instability.It was made a CBCT on cervical region.The image show C2-Fracture .
It was maked a surgary to stabilize cervical spine. Ten days after surgery Michael starts moving the pelvic limbs first and tries to stand on them. Twenty one days after surgary Micheal start to moving and thoracic limb , but have ataxia and destroys proprioception on his four leg. Michael`s recovery begin first with the hind limbs and then with the thoracic limbs .In human literature, the symptom in which the thoracic limb is in a dysfunctional state with minimal to no deficit in the pelvic limbs has been referred to as CCS (Central Cord Syndrome ). The spinal cords that travel to the pelvic limbs are minimally affected because the lesion is centralized in the cervical region, which only affects the thoracic limbs. In general, CCS has a good prognosis for functional recovery and its common etiology is traumatic disease in human medicine. CCS treatments with nonsurgical management include cervical spine restriction with a neck collar, rehabilitation followed by physical therapy and occupational therapy. Surgical management is provided for patients who cannot be treated by conservative management alone.
Fibrosarcoma in rabbits are malignancy rapidly grow soft tissues tumor. Can affect cats dogs and rabbits . The couse of fibrosarcoma in rabbit also can be a viral infection (polyomavirus, malignant rabbit fibroma virus)
Rabbit, female , entire , 5 years old was evaluated because of sings of anorexia and apathy . History
The owners reported that a week ago the rabbit progressively stops eating. The last two days it didn’t eat at all. Тhe rabbit has regularly deworming and vaccination.
The rabbit eats hay and rabbit granules only and lives in an apartment and never go outside, there are no others animals in the apartment.
Anorexia, cachexia, apathy, unilateral uveitis, normal temperature (38.5).
Clinical examination revealed all of the body (back, neck, abdomen and all the legs) nodules, which are not painful, mobile, not tempered and pigmented .The size of the nodules was variable from 1 to 5 centimeters.
Some nodules were ulcerated and bleeding, and still painless. Such formations are not observed in the nose and the ears, and the front part of the head.
We did not find any abnormalities on the X-ray examination of the chest and abdomen. A nodule was surgically removed by cutting.
Symptomatic therapy was appointed until the results of the histopathological examination:
Metoclopramide-0,5mg / kg
Ranitidine-4 mg / kg
Simethicone-65mg / rabbit
Meloxicam-1mg / kg
Enrofloxacin, 10 mg / kg
Intravenous infusion Hartman 4ml / kg / hour.
So designated therapy lasted about 10 days pending the results of pathological examination The condition of the animal slightly improved, which is expressed in phrases in appearance of appetite. The animal took small amounts of food.
The prognosis for this type of tumors is garded to poor. Because of poor condition of the patient and the prognosis owners decided to euthanased the rabbit.