veterinary neurology – Vets on the Balkans - an online journal for veterinarians from the Balkans

Glioblastoma in cerebellum of the dog

August 5, 2020

Dr Dimitar Ivanov

Veterinary Clinics Dobro Hrumvane

Sofia, Bulgaria

Glioblastoma is a malignant tumor of the nervous tissue. This is the fourth degree of astrocytoma. It is more common in the frontal and temporal lobes. Good contrast enhancement in magnetic resonance imaging, edema of the surrounding tissue is often observed. Macroscopically, it has well-defined borders.

Male dog, named Jazz, 9 years old, husky, brought to the clinic on 01.07.2020

There is worsening of the condition since the day before, the animal was no longer interested in food or water, there was lack of coordination. The clinical examination reveals that the animal was obtunded, but still responsive and it was responding to commands, given by the owners, it was also consciously resisting some tests, during the examination, which it doesn’t seem to like. No evidence of seizures. Posture – head turn to the left and tilt to the right. Gait – vestibular ataxia. Cranial nerves – absent menace reaction on the left. Postural reactions – decreased proprioception of the left pelvic limb, decreased hopping reaction of the right thoracic limb. Spinal reflexes – normal. Localization – the decreased proprioception only on the left pelvic limbs cannot definitively determine the localization. Due to the left head turn, the localization is determined in the left forebrain or peripheral vestibular syndrome. Differential diagnoses: ischemia, metabolic disease, neoplasia. MRI is recommended.

On 02.07.2020 blood was taken for CBC – nothing remarkable, Biochemistry – a slight increase in glucose and AST, ALP – 455.99 (10.6-109 U / L). FT4 and TSH are normal.

On 03.07.2020, an MRI was performed. The imagining showed a mass in the left cerebellum, with mass effect on the brainstem and cerebellum, obstruction of the normal outflow of cerebrospinal fluid and for that causing hydrocephalus. Also edema in the surrounding tissue.

Preoperative preparation was started with Mannitol 1.5 g/kg/12h i.v., Methylprednisolon 15.78 mg/12h i.v. Antibiotic therapy – Ceftriaxone – 1 g/12h i.v.

On July 4, 2020, a left suboccipital craniectomy was performed for removing the mass, part of which was sent for histopathology to Laboklin, Germany. Part of the capsule of the tumor has not been removed due to adhesions with the brainstem and the risk of injury during the process of removing it. An artificial dura was placed on the defect to prevent the leakage of cerebrospinal fluid.

After the surgery Jazz was recovering very well. There was a manifestation of vertical nystagmus, which disappeared quickly by itself. Antibiotic therapy was continued, as well as mannitol and methylprednisolone therapy 24 hours after the surgery. Meloxicam was included for pain management 12 hours after the steroids were stopped

The first day after the surgery Jazz was still slightly uncoordinated and his head was still with negligible turn, but he was able to get up and walk on his own.

On July 6, 2020, 48 hours after the surgery, Jazz was more stable, progressively getting better and eating and drinking water.

On July 9, 2020, in the middle of the day Jazz’s condition got worse. He started to turn his head to the left again. On the same day, the histology result was received:

Glioblastoma with high degree of malignancy.

On 10.07.2020, steroid therapy was started, which led to a fast improvement. On the next day Jazz was sent home with home therapy of prednisolone 0.5mg/kg/12h.

Consultation with oncology department for chemotherapy was recommended

On 17.07.20 the sutures were removed from the skin incision, Jazz’s therapy with prednisolone (0.5 mg/kg /12h) was continued. There was a slight incoordination and tilt of the head.

Hypothyroidism- 2 case reports with different approach

July 29, 2019

Dr Dimitar Ivanov,
Veterinary surgeon, Neurology specialist. ESAVS Neurology courses
Dobro hrumvane veterinary clinics
Sofia, Bulgaria

Dr.d.ivanov.vet@gmail.com

Hypothyroidism endocrine disease that can be reason for very different neurological signs, varying from signs of polyradiculoneuritis to neurological signs from the brain and vestibular disorder.

The good news are that all of this neurological problems and deficits can be reverse with adequate treatment, good nursing and physiotherapy.

I will present 2 cases of hypothyroidism in dogs with very different neurological signs. In first case I did not believe that this disease can manifest so heavy clinical signs. In second case, I took blood sample for fT4 just to be sure that this is not hypothyroidism.

Scarlett

Signalment: Dog, F, 9 y.o., Samoyed

History: Two days ago while the dog is on a walk, the owner noticed small paresis with front legs but it was for few minutes and they went back home. The dog came in the clinic on 1^stof December in lateral recumbency, not able to stand up and not able to stay on her legs, even with help. The dog could not eat without help and holding the head and the body.

General examination: no abnormalities, the dog was not vaccinated the last year. Orthopedic examination: no abnormalities.

Neurological examination:

-Hands off exam:

Consciousness – normal
Behavior – can’t find any abnormalities in this position
Seizers – no seizers
Body posture – lateral recumbency but the dog can move head and neck
Gait – symmetrical tetraplegia

-Hands on exam:

Cranial nerves – no neurological deficits
Postural reaction – can’t be checked in this position
Spinal reflexes – absent withdrawal reflex on both front legs, reduced extensor carpi radialis on the right front leg, there are no abnormalities in hind limbs spinal reflexes. Normal tail movement, there is a perineal reflex and normal deep pain sensation.

Localization: C₆ – Th₂

Differential diagnosis: Degenerative/Neoplastic/Vascular

At this point we were unable to make CT or MRI and the decision was to use steroids in dose 2 mg/kg, famotidine 0,5 mg/kg/12 h p.o., Omeprazole 1 mg/kg/24 h p.o. and to see what will happen on the next day. On the next day the dog was in the same condition and I repeat the steroid. After second injection the dog has profuse diarrhea so we stopped the steroid and treated the GI signs.

Two days later we made CT and there are no abnormalities.

On the next day was taken blood sample for biochemistry and fT4. The biochemistry showed no specific abnormalities, but fT4 was very low.

fT4 – 0,1 pmol/L (7,7 – 47,60 pmol/L)

Creatinin – 39 mmol/L (44,3 – 138,4 mmol/L)

Glucose – 6,2 mmol/L (3,4 – 6,00 mmol/L)

Creatin kinase – 298,1 U/L (13,7 – 119,7 U/L)

LDH – 576,9 U/L (24,1 – 219,2 U/L)

Magnesium – 2,00 mmol/L (0,7 – 1,1 mmol/L)

The algorithm was to start levothyroxine and if we don’t have any results may be the reason for this condition is polyradiculoneurtis.

I didn’t believe that the reason for so hard clinical signs is only hypothyroidism.

Eight days later the dog was with total areflexion of all four limbs.

The decision was to take CSF, muscle biopsy (from M. gastrocnemius, M. triceps brachii) and nerve biopsy (from n. peroneus). The samples (the biopsies and the CSF smear) were send to Laboklin Germany. The cells count, protein, glucose and microbiology of CSF were made in laboratory department of “Dobro hrumvane!” veterinary clinics.

The results were:

Number of cells – normal (<5)

Protein total – 2.4 (<25)

Glucose – 4.6 (80% of normal blood values)

Microbiology – negative

“The smears were cell free. Only few keratin flakes were present.
Diagnosis:
1:
– striated muscle with multifocal mild degenerative and regeneative
changes
– mild multifocal purulent perivasculitis (M. gastrocnemius)

2:
– histologically normal nervous tissue

Critical report:
Mild multifocal degenerative and regenerative changes of the striated muscle was found. A specific cause was not detected. It should be kept in mind, that in muscle pathology there may not be a strong correlation between histological changes and severity of the clinical symptoms.
Considering the purulent perivasculitis in the sample of the M.
gastrocnemius an inflammatory (possibly infectious) process in other
locations should be excluded clinically.
Signs for a polyneuritis have not been observed within the examined
locations.”

I had to resign that the most likely cause of Scarlett’s condition was hypothyroidism and we started physiotherapy procedures.

Meanwhile, the patient’s condition has begun to improve. First Scarlett started to move her head better, started to lay on her chest and started eating by herself. The muscle tone start to improve.

40 days later

The day that Scarlett left the clinic.

Chata

Signalment: Dog, F, 5 y.o., German shepherd dog

History: Everything started with variable appetite. The dog came in the clinic for second opinion on 06.06.2019.

Colleague already took blood samples and there were no specific abnormalities.

Neurological examination:

-Hands off exam:

Consciousness – abnormal
Behavior – abnormal
Seizers – no seizers
Body posture – abnormal, head tilt, from time to time head turn, opisthotonus
Gait – abnormal, symmetrical, general proprioceptive ataxia

-Hands on exam:

Cranial nerves – vision, oculovestibular and menace is absent, contraction of the pupils is normal but dilatation is reduced, increased jaw tone, reduced gag reflex and reaction of the tongue.
Postural reaction – proprioception and hopping are absent
Spinal reflexes – absent withdrawal reflex on the left front legs, reduced on the right front leg.

Localization: Central vestibular

Differential diagnosis: Metabolic/Inflammatory/Neoplastic

I took blood samples to examine fT4 just to be sure that this is not hypothyroidism.

We discussed with the owner that if there is no abnormalities in thyroid hormones we will take and make some tests with CSF.

The level of fT4 was 1,60 pmol/ L (7,7 – 47,60 pmol/L)L

I started levothyroxine and after two intakes of the medication the result was:

The next few weeks the dog was not still in perfect condition, but there was improvement.

Conclusion: Hypothyroidism is often over diagnosed condition, but is also misdiagnosed metabolic disease with lots of different signs and different manifestation in every part in veterinary medicine.

C2 FRACTURE AND CENTRAL CORD SYNDROME

June 9, 2018

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Dr Svetoslav Penchev

United Veterinary Clinic

Varna, Bulgaria

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.

Tibial nerve peripheral nerve sheath tumor in dog

January 26, 2017

Loncar, DVM1
Dr Zoran Loncar
Hadzic, DVM2

M.Dragomirov, DVM2

1,2 Department of Orthopedic Surgery and Neurology, Veterinary Clinic Novak, Belgrade, Serbia

INTRODUCTION

An 8,5 years old miniature schnauzer dog was presented at the clinic with finding of right hind limb monoparesis and grade 1 lameness. CT diagnostic study was done but it was suggested that there was no visible lesions. MRI study shoved a lesion consistent with PNST. The dog was treated surgically and the tumor was excised completely with large margins. The dog recovered completely. The purpose of the article is to suggest that a lesion consisted with PNST distal to the stifle an elbow can be treated with large margins and very good motility of the limb afterwards. This type of pathology can be often missed with orthopedic conditions.

CASE HISTORY

A 10 kg BW, 8,5 years old miniature schnauzer was presented at the clinic with owners complain of lameness on right hind limb for last five months.

At previous vet the dog was submitted to complete orthopedic, radiography and CT study with no diagnosis after the diagnostic workout. The dog was treated with 20 days of NSAID therapy (carprofen 2mg/kg BID 10 days and the dosage was reduced by half for the next 10 days). There was no improvement so the dog was treated with prednisolone for 20 days SID with again very little improvement.

The dog doesn’t have any important data in medical history.

At the presentation in our clinic:

During the walk dog showed grade one lameness.

CT STUDY , Fig 1 and 2

At the clinical examination the dog showed normal proprioception but reduced withdraw reflex on right hind limb. During palpation region of gastrocnemius muscle was markedly painful. The rest of nurology and orthopedic examination was in within normal limits.

CT Study

Figure 1. and 2.

MRI SYUDY Fig 3

MRY STUDY- Fig 4

There is a focal dilation of a vascular structure, presumably a vein, caudal to the medial aspect of the right stifle. The vascular dilation/aneurism has a maximal diameter of 7.7 mm and extends over a distance of approximately 4 cm. Contrast filling of the dilated area is heterogeneous with some areas lacking contrast filling. The affected vessel is an anastomosis/branch between the caudal branches of the saphenous vein and the caudal proximal femoral vein.

MRI study:

Figure 3. T1+contrast: On the right limb at the level of tibial nerve there is a lesion with heterogeneous contrast intake in long contact with blood vessel. The lesion is 3 cm long in diameter.

Figure 4. T1+contrast: Lesion at the level of tibial nerve in close contact with saphenous vein and the caudal proximal femoral vein. Heterogeneous contrast intake.

Figure 5. Surgical field

The surgical approach was made from medial side at the level of proximal part of gastrocnemius muscle. The careful identification of blood supplies and nerve structure was needed. The healthy proximal and distal part of the nerve was identified and the excision with 3 cm margins has been done.

The dog was treated post operatively with antibiotics for 7 days (cephalexin 15mg/kg BID), fentanyl patch for 3 days, carprofen 2 mg/kg BID for 7 days, gabapentin since 3th day 20 days 10mg/kg TID.

Neurological exam has been done after 1,3,6 and 12 months. The only abnormal finding 6 and 12 months post op was longer ground phase during walk and reduced withdraw reflex.

DISCUSSION:

Tibial nerve is in charged for the motor function of caudal aspect of tibia and fibula. Deficit in function shows clinical signs that look similar to orthopedic conditions. Ground phase is longer, calcaneus drops distally more than in contralateral limb. Sometimes we can see plantigrade stance. Orthopedic conditions similar to these in term of signs are pathology of Achill’s tendon and tarsus and metatarsus.

PNST if at the distal part of peripheral nerves can be treated with good outcome. The reasons are fewer functions that lead in less of dysfunction of the limb, and good surgical margins. If PNST is localized at plexus or nerve root, 78% of dogs are going to be euthanized. The prognosis depends on localization and histopathology grading.

CONCLUSION

This article shows how close sometimes can be neurology and orthopedic clinical findings. Even if advanced imaging is available the cruciate information is localization of the lesion during the clinical examination. Further a right interpretation of images is necessary to define the lesion. PNST is an important differential diagnosis in investigation of distal extremities dysfunctions.

CHIARI-LIKE MALFORMATION AND SYRINGOMYELIA

January 22, 2016 Leave a Comment

Dr Ates Barut, DVM, PhD

Owner of Small Animal Veterinary Clinic PETCODE

Introduction

We can describe Chiari-like Malformation as an overcrowded and narrow caudal occipital fossa and cervicomedullar junction due to a congenital developmental malformation of caudal occipital bone. Disease is similar to Chiari Type I disease in humans and therefore named as «chiari like malformation» in dogs.

Chiari-like malformation is a hereditary condition and first described in king charles cavalier spaniels and altough several other small breeds can become effected king charles cavaliers are the most common breed effected by the disease.
The other reported breeds are; Griffon, Miniature poodle, Yorkshire terrier, Maltese, Chihuahua, Bichon frise, Staffordshire terrier, Pug, Shih Tzu, Dachsund, Pincher, French bulldog, Jack Russel Terrier, Pekingese and Boston terriers.
Affected patients has a kind of cerebellar compression and narrowing around foramen magnum and cervicomeduller junction.

Patho-physiology

Bony compression, progresive meningeal hypertrophy and dural fibrosis cause; several different neurological dysfunction like cerebellovestibuler disfunction, cervical myelopathy, seizure activity, syringomyelia, ventricle dilatation and hydrocephalus

Although in humans almost all chiari malformation patients has some degree of cerebellar herniation , in dogs cerebellar herniation is not that common and this is the main difference between these 2 species. Caudal occipital malformation syndrome is a genetic deformation of the mesoderm of caudal occipital bone causing cerebellar compression and herniation.
In normal dogs CSF move from cerebral subarachnoid space to cervical spinal subarachnoid space through foramen magnum in every sistom and diastol in a pulsative manner.

Compression and partial obstruction caused by Chiari malformation disturb CSF flow in both ways but because of high systolic pressure push CSF to central canal of cervical spinal cord and produce a cavity with this hammer effect. Valsa maneuras like barking and coughing, make sudden changes in intrathorasic and intraabdominal pressure which cause epidural venous distention and fast fluid acumulation to the cavity. Because of spinal epidural vein distention and compression in cervicomedullar junction syringomyelia cavity continue to enlarge gradually.

Herniated cerebellum increase the amount of obstruction , CSF flow and fluid accumulation. CSF will flow from intrcranial cavities to cervical region easier but can not come back again.

Symptoms and clinical presentation

Presentetion of the disease is different from patient to the other. The first signs can be seen from 5-6 months to 9-10 years.
The disease can cause several different neurological signs.

We can list the possible symptoms as; cervical hyperaesthesia, scratching( air scratchig or phantom scratching)

, facial rubbing, air licking, fly catching, tail chasing, vocalization, pain reaction during atlantoxipital palpation., cervical myelopathy, fore leg paresis characterized by lower motor neurons, multifocal CNS dysfunction, torticollis, scoliosis, seizure activity.
Pain due to or seconder to syringomyelia is a very important symptom and it happens because of the damage on the dorsal horn of spinal cord.

It usually happens Because of the hypersensitivity due to the damage on spinothalamic pathways and/or dorsal horn neurons
Abnormal sensitivity in head, shoulder, neck, axillar and sternal regions is prominent in several patients with syringomyelia but pain severity is not directly correlated with the amount of the fluid inside the spinal cord. Pain is most common in king charles cavaliers and usually more dominant in one side.
Scratching is another very common sign in king charles cavaliers and stress, excitement or a touch to the neck stimulate or increase sctraching. Some dogs has a scratch point and react to a simple touch to this point. The scratching style usually without touching the body is also unique and that is why named as air scratching or phantom scratching.

In some severe cases the patients can have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. In these cases severe neck pain, strabismus, head tremor and nystagmus can be observed. Loss of muscle tone due to asimetric innervation of paraspinal muscles can cause opusthotonus.

Some patients with chiari-like malformation can have seizures but pathogenesis is not so clear. This rare condition can be related with impaired cerebellar functions because cerebellum has an inhibitoric effect on seizure activity.

The most common neurological and physical examination finding is atlanto-occipital pain and increased sensitivity on pin point palpation on atlanto-occipital joint.

Magnetic resonans imaging is the only way for exact and definitive diagnosis of chiari-like malformation and syringomyelia. T2 and T1 weightened midsagital and transversal images of
the foramen magnum, caudal occipital fossa and cervical spinal cord will show syringomyelia.

We can describe magnetic resonans imaging findings as a narrow subarachnoid space in cervicomedullar junction, occipital bone compression on caudal cerebellum, rostral movement of caudal cerebellum, syringomyelia, cerebellar herniation from foramen magnum and kinked appearance of caudal medulla.

Lateral vetricle dilatation is a very common sign but hydrocephalus is a possible but rare condition.

Treatment

Most of the patients with syringomyelia can spend their whole lives with mild neurological symptoms without any need for medical or surgical treatment. Life quality is the main concern for treatment decision. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Patients with mild symptoms and pain or non-responsive to pain medication are candidates for medical treatment.

Non-steroidal antinflamatoric medications are not effective against neurologic pain. In severe cases pain can be manage just by some anticonvulsants like gabapentin( 10mg/kg tid) or pregabalin (2-4 mg/kg bid). Last researches showed that omeprazol decrease cerebrospinal fluid production and can be used in some patients but some studies done in rats showed that long term use can cause hypergastrinemia and increase the risk of stomach cancer.

The other medicatios can be used to depress the clinical signs of syringomyelia are; acetozalamide, furosemide, corticosteroids, and phenobarbital. Another promising medication for neurologic pain is palmitoylethanolamide (pea) nad can be effective in several syringomyelia patients.

Surgical treatment is indicated in patients with worsening neurological signs and unresponsive pain. Aim of the surgery is to reorganize cerebrospinal fluid flow pathways and decrease the abnormal CSF in side the central nervous system by decompressing cerebellum. For this aim “Foramen magnum decompression” is indicated by a suboccipital craniectomy and partial dorsal laminectomy of first cervical vertebra that enlarge foramen magnum .

Foramen magnum decompression window limits and borders are so important. A small window will be effectless and a large window can cause atlanto-occipital instability or excessive bleeding in a very sensitive area which can cause life treating situations. Lateral borders of the window are atlantooccipital joints and lateral vertebral foramens of atlas , rostral borders are midpoint of the distance between protuberentia occipitalis and dorsal border of foramen magnum, caudal border is ¾ of atlas. Durotomy and marsupilization of dura to the muscular structures around the foramen magnum window is the common procedure but cerebrospinal fluid leakage can cause an inflamation and this inflamation can lead severe soft tissue thickening which can cause compression in the area. Altough durameter is firmly attached to the bony structures in atlantoaccipital region carefull dissection can be done without duratomy to prevent csf leakage.

Foramen magnum decompression will reorganize cerebrospinal fluid flow but the present fluid and the syringomyelia cavity will remain which means the present symptoms will continue most of the time. Foramen magnum decompression is most effective against pain which is the most common indication of surgical treatment.

To drain the present syrinx in syringomyelia cavity “syringosubarachnoid shunt application” is the most effective and popular method. Approach to spinal cord with a dorsal laminectomy where the syrinx cavity is most prominent has to be done first. After a “T” shaped duratomy placement of a shunt in 1-1.2mm thickness from syrinx cavity to subarachnoid space has to be performed to complete the procedure.

Discussion

As a result chiari-like malformation and syringomyelia is one of the most important breed predispositions of veterinary medicine and although the disease is reported in several other breeds it creates a very important clinical problem among king charles cavalier population. Most of the patients with syringomyelia can live whole their lives with very mild symptoms within a normal life expectancies but some patients will have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. Pain and life quality is the main concern and criteria for treatment. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Foramen magnum decompression and syringo-subarachnoid shunt application are the two surgical procedures described to reorganize normal cerebrospinal fluid flow and drain syrinx from its cavity.