PEOPLE

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PEOPLE

• The man who smiles in the face of trouble
• Has found someone to blame it on.

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Anatomy
Supratentorial better prognosis Infratentorial
forebrain is responsible for "thinking,"
behavior, and final integration of sensory
information
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Brain Neoplasia

• Enlarging mass in brain causes compression of
  healthy tissue or replacement with cancerous
  tissue
• Primary meningioma, glioma, choroid plexus
  papilloma, pituitary adenoma or adenocarcinoma
  (cushings), and others.
• Secondary (metastasis) hemangiosarcoma, mammary
  carcinoma and melanoma
• Dogs most common meningiomas and gliomas

• Sagittal MRI of the brain of an 8 year old female
  German Shepherd dog.
• Seizure
• Well encapsulated mass in the olfactory bulb and
  frontal cortex of the brain
• Meningioma (histopathology)
• TX surgical removal of the tumor followed by
  radiation
• PX Good not touching brain (unlike gliomas
  radiation therapy)

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Hemangiosarcoma
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Brain Neoplasia

• Forebrain
• Behavior
• Depression, loss of learned behavior
• Seizures acute onset, 5-6 yrs old
• Pacing and circling (Vestibular signs)
• Ipsilateral vision bump
• E.g. Gliomas and new treatments
• Brachycephalic breeds such as the Boxer, the
  Boston terrier, and the French and English bulldog

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Brain - Neoplasia

• The Brainstem
• motor function (the ability to walk, CV and resp
  function), consciousness and balance
• 1st signs loss of balance (vestibular signs) and
  paresis of one side of the body
• Dysphagia, change in voice and inability to move
  the eyes
• Progresses into paralysis, coma and death.

• Vestibular signs
• Head tilt
• Leaning and falling to the side of the head tilt
• Drunken gait with loss of balance (ataxia)
• Circling to the side of the head tilt
• nystagmus
• Anorexia and vomiting
• Strabismus

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• Kasey, a 10-year-old female Golden retriever
• trigeminal nerve root tumor
• sensation to the face and motor function to the
  muscles of mastication
• 15 months

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Brain - Neoplasia

• The Cerebellum - coordination of movements and
  interacts closely with the vestibular system to
  control balance and posture.
• Uncoordinated gait characterized by dramatic
  goosestepping (hypermetria)
• Intention tremors Head tremors that are worst
  when the animal is intent on something (i.e.,
  food) but disappear when the animal is relaxed
  Swaying of the trunk
• Wide based stance
• Sometimes there can be vestibular signs such as a
  head tilt
• The animal's strength remains normal

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Brain Neoplasia

• Dx
• Systematic screening for tumors in other organs
• CBC, chem panel
• Radiographs metastasis
• CSF tap to assess increased cerebral spinal
  pressure
• Ophthalmic exam may indicate optic nerve edema
• Computed tomography (CT) scanning or magnetic
  resonance imaging (MRI) to locate tumor

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CT or MRI

• MRI
• shows the brain in more detail than CT
• the test of choice when assessing for brain
  tumors
• more expensive test and less widely available
• CT images (more artifacts for brainstem/
  cerebellum) meningiomas, choroid plexus
  papillomas
• MRI gliomas, brainstem or cerebellar disease or
  Boston Terrier.

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Brain Neoplasia

• Rx surgical removal, radiation therapy,
• chemotherapy, and palliative treatment of the
  symptoms
• Surgical removal of superficial single lesions
• Tumors of the brainstem pose problems
• Forebrain you can resect certain parts of the
  forebrain without long-term effects.
• Meningiomas tend to be located on the surface of
  the brain and are therefore the best candidates
  for surgical removal.
• Gliomas are more difficult to remove because they
  lie deep within the substance of the brain.

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MRI of a 6 year female old Boxer oligodendroglioma
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Brain Neoplasia

• Radiation therapy
• Chemotherapy efficacy varies with tumor
• type (lymphomas respond well other less so)
• Palliative Anti-seizure medication
  (Phenobarbital PO 2-3 times/day),
  Corticosteroidsprednisone
• Client info
• The more severe the signs, the worse the outcome
• The larger the tumor, the worse the outcome
• Supratentorial tumors (tumors of the forebrain)
  have a better prognosis than infratentorial
  tumors (tumors of the brainstem and cerebellum)
• Radiation therapy does prolong lifespan in most
  cases
• Meningiomas have a better outcome than tumors
  that lie within the brain (e.g. gliomas)

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Epilepsy

• MOA balance within
• the brain shifts too far
• toward excitation,
• too many cells may
• become too excited and a seizure can result

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Epilepsy

• Generalized/ tonic (stiff muscle) - clonic
  (rhythmic movements grand mal)
• Grand mal (motor)
• Prodrome
• Ictus the seizure itself
• post-ictal (post-seizure)
• Petit mal (absence seizure) little movement,
  animals?

• Focal/ Partial
• focal seizure may stay localized
• may spread and affect the whole brain causing a
  classic, generalized, tonic-clonic seizure
• brain tumor or infection
• Simple motor, twitching or blinking to one side
  of the face
• Complex sensory. Senseless repetitive behavior
  imaginary fly biting,

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Minimum work-up for an epileptic Minimum work-up for an epileptic Minimum work-up for an epileptic
History Your description of the character and timing of the episodes, relation to exercise, feeding, etc. Helps your veterinarian determine if this is indeed a seizure and what type. May provide clues to the cause
Physicalexamination Evaluation of the heart, lungs, abdomen, gum color, etc. Provide clues to diseases which could cause seizures or complicate treatment
Neurologicexamination Evaluation of behavior, coordination, reflexes and nerve functions Provide clues to disease of the nervous system which may be causing the seizures
Complete blood count (CBC), routine serum chemistry profile, and urine analysis (UA) Blood and urine samples are taken and analyzed Rules out metabolic causes of seizures and provides baseline data to monitor effects of medication
Bile acids assay or ammonia tolerance test Usually, the pet is fasted and two blood samples are taken Rules out liver problems and provides baseline data to monitor effects of medication
Thyroid function tests Blood samples analyzed for T4 and TSH levels Optional, but would rule out thyroid disease as a cause
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Seizures
When the seizure begins, the dog stiffensand
falls They then begin jerking movementsThey are
not in pain during the seizureand cannot control
their bladder or bowels.
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Epilepsy

• Signs of seizure
• short aura (stare into distance,
• seek comfort/protection from
• someone, vocalize)
• seizure lasts 1-2 min may consist of total body
  muscle twitching with extended arms and legs and
  arching of neck dorsally (opisthotonus)
• dog will be disoriented/blind for a few minutes

Click for video
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• http//www.thepetcenter.com/gen/epilepsy.html
• may be incited by certain events
• normal at other times

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Epilepsy

• Dx
• CBC, chem panelr/o metabolic diseases causing
  seizures
• hypoglycemia
• hypocalcemia
• hepatic encephalopathy (failure to detox blood)
• Shunt
• Cirrhosis
• Pb poisoning
• Radiographsr/o head trauma or hydrocephalus
• CT scan or MRIr/o space-occupying lesion in
  brain
• Rxdirected at cause if one can be found
• treat if gt1 every mo or two (Rx will not
  completely stop seizures)
• Phenobarbital is TOC

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Other tests that may be recommended(may require referral to a neurologist) Other tests that may be recommended(may require referral to a neurologist) Other tests that may be recommended(may require referral to a neurologist)
MRI or CT brain scan Evaluate the structure of the brain requires anesthesia Rules out diseases such as brain tumors which would need to be treated directly
Spinal tap Spinal fluid is collected and analyzed requires anesthesia Looks for infectious diseases and provides clues to other brain diseases
Antibody titers Blood and/or spinal fluid is analyzed for antibodies Identifies specific cause of an infection
Toxin tests Blood or other sample is tested for the presence of a toxin Tells if a specific toxin is present, but usually need a clue to what toxin to look for from the history or other test
Other laboratory tests Advanced tests on blood, urine, or spinal fluid Follows clues suggested by routine tests
Electroencephalogram (EEG) Recording of brain wave to look for the electrical storm Allows definitive diagnosis, but can be non-diagnostic
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Status Epilepticus

• Signsprolonged, uninterrupted seizures (gt5-10
  minutes) or cluster of seizures
• Rx
• Diazepam (2-10 mg to effect) can be repeated
  over several minutes
• Phenobarbital -
• Time to steady state blood levels 10-14 days
• Side effects sedation, ataxia, PU/PD/PP,
  hepatotoxicity, blood dyscrasias (Rare)
• Establish an open airway
• IV cath with IV fluids to keep an open vein
• Monitor blood Ca and glucose treat is needed
• Monitor body temp if elevated, treat
  appropriately
• If cerebral edema is suspected, treat with
  mannitol (IV)
• PhenobarbitalIV or IM

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Status Epilepticus

• Client info
• Epilepsy is an incurable disease
• Even with treatment, animal may still seize
• goal is to reduce frequency and intensity of
  seizures
• Spaying/neutering will remove any hormonal
  influence on seizures
• Medications will probably be required for life
• Most animals that seize can live a normal life
• If seizure free for 6-9 mo, may reduced or
  discontinued Rx

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LIFE

• Life is the art of drawing without an eraser.
• -John w. Gardner

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Spinal Cord

• Function
• Nerve fibers carry signals between brain - rest
  of body
• Anatomy
• Like brain, protected by hard covering dura
• Intervertebral disk (cushion)
• between vertebral body
• increases range of motion
• prevents vertebrae rubbing

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Spinal Cord Anatomy
Like brain, spinal cord enclosed in hard
covering IVDD problem in both humans and
canine Anatomical differencescervical same
lumbarhuman bears weight, canine
doesnt Attached rib (thorax) helps stabilize the
IV joint worse at T-L junction (dogs)
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Degenerative Disc Disease Humans
Degeneration of disk occurs with age Dries out,
shrinks (we get shorter as we age)
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IV Disk Disease Anatomy
Normal spinal column and disk Prolapsed disk
1/3 thickness
nucleus fibrosus
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Intervertebral Disk Disease

• Etiology
• IVD dries out with age ? hardened, less compliant
• ?Pressure from jumping
• Occurs most commonly in cervical, caudal
  thoracic, and lumbar vertebrae
• Most common spinal cord disorder in companion
  animals

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Intervertebral Disk Disease

• Hansen TYPE I Nucleus pulposus herniates upward
  narrowest part of annulus fibrosus
• TYPE I Most common in chondrodystrophic (faulty
  development of cartilage) breeds
• Dachshunds, shih tzus, Lhasa apsos, beagles,
  basset hounds (poodles also affected)
• Acute onset
• Can occur at any age, but generally younger dogs

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Intervertebral Disk disease

• Hansen TYPE 2 dorsal protrusion of the annulus
  into the spinal canal
• Common in older dogs and nonchondrodystrophic
  breeds
• Occurs over a longer period of time
• Clinical signs may be less severe
• Generally older dogs

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Intervertebral Disk Disease

• Signs
• Pain
• Paresis/paralysis nerve function is lost in this
  order
• Proprioceptionlargest fibers most susceptible
  to pressure signs are ataxia
• Motor fibersnext smallest fibers signs are
  weakness/paresis
• Cutaneous sensory fiberssmall require a lot of
  pressure to disrupt function decreased
  panniculus reflex
• Deep pain fiberssmallest fibers require the
  most pressure to disrupt loss is associated
  with poor prognosis
• Severity of clinical signs depends on
• Speed at which disk material is deposited
• Degree of compression
• Duration of compression

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IVDD Paralysis of rear legs
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Cervical IVDD
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Loss of Deep Pain
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IVDD Dx Spine X-Rays
Normal horses head consistent IV space
Subluxation L2-3 (old lesion)
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IV Disk Disease Myelogram Definitive diagnosis
Which disk space?
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IV Disk Disease Myelogram
Which disk space?
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Cervical IVDD
Myelogram Disk herniation at C2-3 (narrowed IV
space, narrowed spinal canal)
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IVDD

• Rx TYPE I, acute onset
• Medical Rx is recommended for animals, with deep
  pain intact, with or w/o neuro deficit
• High levels of corticosteroids is CONTROVERSIAL
• Strict confinement2 wk minimum (easy when dog
  hurts not so easy after steroids/other pain
  medications take effect)
• Nursing care
• Soft padded cage
• Urinary cath or express bladder several times/day
• Surgery is recommended for
• repeat offenders
• No voluntary motor function
• loss of deep pain (needs to be done QUICKLY!)
• worsening neuro signs (poor Prognosis)

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Laminectomy
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IVDD Possible sequela
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IVDD
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IVDD - rehabilitation
http//www.youtube.com/watch?v7AkNVDc4ligfeature
related
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IVDD Alternative/Optional Treatment

• Methocarbamol (muscle relaxant)15-20 mg/kg q 8hr
• High-dose Methylprednisolone sodium succinate
  (CONTROVERSIAL!) and should be given within 8
  hours
• Although there is proven benefit in humans,
  results have not been proven in dogs
• Low dose prednisone various regimens
• NSAIDS
• Carprofen, deracoxib, etodolac
• Gastroprotectants
• Acupuncture

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Veterinary Acupuncture

• http//www.youtube.com/watch?vZ-JjZPnk_Mwfeature
  related
• http//www.youtube.com/watch?vvJIJDUQyOmwfeature
  fvw

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IVDD

• Client info
• Do not let susceptible breeds get overweight
• Encourage animals to keep spine parallel to
  ground
• No jumping on/off couch
• No begging on hind legs
• No stair climbing
• Loss of deep pain gt24 h has poor prognosis
• If surgery is done soon enough, there is a good
  Px of recovery
• Almost half of animals treated medically will
  have recurrence
• Extensive home care is required for medical and
  surgical patients
• Severe damage to spinal cord is not reparable

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Atlantoaxial Joint
Atlanto-Axial Joint
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Atlantoaxial Instability (Subluxation)

• Signs
• Toy and miniature breeds (lt1 yr)
• Reluctance to be patted on head
• Neck pain
• May have tetraparesis (weakness in all 4 limbs)
  or tetraplegia (paralysis in all 4 legs)
• Sudden death due to respiratory paralysis
• Diagnosis
• Radiographs lateral x-ray of neck in slight
  ventroflexion
• avoid further spinal cord damage with positioning

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Atlantoaxial Instability (Subluxation)
Normal toy breed dog Toy breed dog with
atlantoaxial subluxation
Narrowed spinal canal
CT scan dens is marked by
X-rays of same dogs note separation of C1 and C2
when dogs neck is flexed in B
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Atlantoaxial Instability (Subluxation)

• Treatment
• Medical
• splint neck in extension with cage confinement x
  6 weeks
• treat like other spinal cord trauma
• Surgical (if unresponsive to medical Rx)
• stabilize/decompress
• attach dorsal process of axis to arch of atlas
• fuse atlas and axis joint with pins and bone
  graft
• hemilaminectomy to relieve spinal cord
  compression
• Client info
• prognosis is fair to good for animals with mild
  signs
• animals should not be used for breeding may be
  hereditary

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Atlantoaxial Instability Surgical Correction
Stabilization using trans-articular screws
Stabilization using screws and bone cement
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References

• Alleice Summers, Common Diseases of Companion
  Animals
• http//cvm.ncsu.edu/vhc/tc/clinical_services/neuro
  /brain_tumor.html
• http//www.canine-epilepsy.net/basics/basics_index
  .html