Veterinary Medicine - Neurology Flashcards
Dogs or Cats - Which of the 2 is more likely to suffer from Symptomatic Epilepsy?
Cats
50-60% of Epilepsy cases in cats are symptomatic, as opposed to dogs who in the majority of cases suffer from Idiopathic Epilepsy
Symptomatic Epilepsy - Causes
Congenital (e.g. Hydrocephalus \ Lyssaencephaly \ Storage diseases)
Inflammatory (e.g. MUE \ SRME), Infectious (e.g. Neospora \ Toxoplasmosis \ CDV \ FIP \ Rabies\ FIV \ FeLV \ Ehrlichiosis \ Aspergillosis \ Cryptococcosis \ Protothecosis \ Bacterial)
Metabolic (e.g. Hyperammonemia \ Hypoglycemia \ Hypocalcemia \ Thiamine Deficiency)
Vascular event (e.g. Septic emboli \ Thrombus \ Hemorrhagic stroke)
Trauma
Toxins (e.g. Organic phosphates \ Methylxanthines \ Methyl aldehyde \ Permethrin)
Neoplasia
Idiopathic Epilepsy - What percentage of patients are refractory to treatment
20-30%
What are the 2 main objectives of anti-epileptic treatment in terms of neurophysiology?
- Making the epileptic center fire less frequently (by decreasing Glutamate concentration)
- Making the surrounding brain tissue less excitable (by increasing GABA concentration)
What drug can we give to epileptic dog owners to administer during a generalized tonic-clonic seizure? When should they administer it? Route of administration?
Diazepam (Valium)
After 3 minutes of seizuring
Rectally
What is the Definition of Status Epilepticus?
In 2 cases:
1) Grand mal seizure lasting >5 minutes
2) Two or more seizures in 24 hours without full recovery in between.
What is the definition of Cluster Seizures
Two or more sequential seizures WITH full recovery in between
After a suspected seizure - When is it recommended to perform a neurological exam? (or at the very least a recheck) Why?
48-72h After the event
In severe seizures - There can be residual neurological deficits do to diffuse metabolic changes in the brain, that can cause diffuse \ bilateral symmetric deficits that are possibly temporary
*However - if before or after 72h unilateral \ asymmetric deficits are seen - probability of Symptomatic epilepsy is high (e.g. Neoplasia, Infarct, Infectious diseases etc.)
What is the difference between neurological deficits seen after Symptomatic Seizures as opposed to seizures due to Idiopathic Epilepsy?
Idiopathic - Diffuse \ Bilateral symmetric, Temporary deficits
Symptomatic - Can be anything - Diffuse\Multi-focal\Focal\Symmetric\Asymmetric - But in most cases it will remain until the underlying issue is resolved
Idiopathic Epilepsy - Signalment
Dogs \ Cats - 6 Months - 6 Years old
What are some appropriate diagnostic testing that can be done to try and rule out Symptomatic Epilepsy? (Name some indications for each test)
-Blood pressure (Vascular events)
-CBC
-Panel (Hypoglycemia \ Hypocalcemia \ Urea \ Hyperglobulinemia \ Liver Functions)
-Bile Acids \ Ammonia
-Abdominal US (e.g. Liver shunting, Neoplasia)
-Screening for infectious diseases (e.g. CDV \ Neospora \ Toxoplasmia \ Cryptococcus \ Aspargillosis \ FIV \ FeLV)
-Choline Esterase Levels (Organic phosphates poisoning)
-Coagulation panel\TEM\TEG (Hemorrhagic stroke/Thrombus)
-X-Rays (Metastasis / Granulomas)
-CSF (e.g. Inflammation, Infections)
-MRI \ CT (e.g. Neoplasia, Abscesses, Granulomas, Congenital anomalies, Inflammation, Vascular events)
When is there an indication to start anti-epileptic treatment?
1) More than one seizure a month
2) Status epilepticus
3) Severe \ Violent seizures (even if infrequent\Not status epilepticus
What are the goals that define a successful anti-epileptic treatment
1) Reduction of >50% in frequency of seizures
2) No more than one seizure every 3 months. Tolerable - one seizure every 1-3 Months
What do you do when you want to draw CSF but you also suspect an increase in ICP?
1) MRI \ CT first - Diagnostic cut also to confirm an increase in ICP
2) Decrease ICP (e.g. Mannitol / Hypertonic Saline)
*Drawing CSF from the Sacro-Lumber region instead of the atlantooccipital region can be considered
What are the three important aspects we need to establish before forming a DD List for diseases of the nervous system [Including the Brain, Spinal cord, PNS]
1) Location
2) Onset
3) Progression of neurological signs
C1-C5: Acute neurological presentation - DDs
IVDD (Hansen Type 1 & 3)
Trauma
Atlanto-Axial subluxation
Inflammation/Infection
Discospndylitis
FCE
C1-C5: Chronic neurological presentation - DDs
IVDD (Hansen Type 2)
Discospondylitis
Neoplasia
Inflammation
IVDD Hansen Type 1 - Signalment
Chondrodystrophic breeds (e.g. French bulldog, Dachshund, Pekingese)
Ages: 3-7 years
IVDD Hansen Type 2 - Signalment
Large Breeds, Ages: 5-10 years
IVDD Type 1 - Classic history \ Clinical signs
Ain’t doing well
Not jumping on sofas \ Climb stairs anymore
Abrupt screams of pain
Ventroflexion
Reluctance to move neck
Ataxia / Paraparesis / Paraplegia
IVDD Hansen Type 1 - In cervical disease, usually the main clinical sign is..?
Pain
IVDD Hansen Type 1 - Diagnosis
X-Rays (Narrowing of intervertebral spaces, mineralized intervertebral discs) - NOT DIAGNOSTIC! But helpful in ruling other DDs such as trauma, give clues to IVDD as mentioned above and for future reference).
Myelography \ Myelo-CT \ MRI (Gold standard)
IVDD Hansen Type 1 - Treatment
Depending on clinical signs:
1) Back pain\Loss of CP\Paresis: Cage rest for a month (The anulus undergoes healing).
Future recommendations: Change in life style and less activity\Jumping\climbing stairs\Sofas.
2) Plegia\Loss of deep pain: Surgery as soon as possible.
IVDD Hansen Type 1 - Common locations in the spinal cord
Cervical vertebrae
Thoraco-Lumbar junction (T12-L2)
IVDD Hansen Type 1 - Name of the surgical procedures (2)
Hemilaminectomy (Thoraco-Lumbar)
Ventral slot (Cervical)
Atlanto-Axial Subluxation - Signalment
Congenital - Toy breeds under 1 year (Mostly after 6 months) - e.g. Miniature Poodle \ Pomeranian \ Pekingese \ Yorkshire terrier.
Traumatic - Any age \ breed
Atlanto-Axial Subluxation - Clinical signs
Sudden screams of pain
4 Limb Ataxia \ Occasional falling and lying down
Quadriplegia
Dyspnea (Phrenic N. Involvement)
Atlanto-Axial Subluxation - Diagnosis
Cervical X-ray:
>50% overlap between the Axial spinal process and the Atlas. Can do a slight flexion of the neck to confirm (Must be done very carefully by an experienced vet/neurologist as can compress the spinal cord if done excessively)
Atlanto-Axial Subluxation - Treatment
If too young for surgery - Splint the neck. Otherwise - Surgery
Discospondylitis - Common Causes (Dogs and Cats)
Dogs:
Iatrogenic (Injections)
Immunosuppression (Usually older dogs)
Intact males/females - Brucella Canis
Cats - Bites
Discospondylitis - Signalment
Dogs - Puppies \ Young adults. Large breeds mostly
Cats - Any age/breed
Discospondylitis - Clinical Signs
Lethargy
Depression
Fever
Reluctance to move
Severe back pain
Mostly only light neurological deficits (CPD), Unless chronic and subluxated / 2nd disk protrusion
Discospondylitis - Diagnosis
X-rays - Lysis and proliferation of the Cranial\Caudal borders of the Vertebral bodies (can involve multiple vertebras).
*Lesions only appear on X-rays 10-14 days after clinical signs have started - high rates of false negative during that time! Therefore initially diagnosis is based on history and signs - Send home with antibiotics and if clinical sign resolve - diagnosis is achieved and can perform confirmatory x-rays afterwards
Discospondylitis - Treatment
Antibiotics: 1st Gen. Cephalosporins \ Clindamycin.
After 5-7 days of treatment:
A) Gets better - Take X-rays 2 weeks after to confirm and treat with antibiotics for 8 weeks
B) Doesn’t get better - Switch to Fluoroquinolones
Still no improvement - Possible fungal infection\Brucella Canis\wrong diagnosis - perform additional testing (Aspirate\CT\MRI)
Degenerative Myelopathy - Common Signalment + Presentation
Adult - old dogs (>7-8 Years)
Predisposed breeds: German shepherd \ Pugs. Also: Boxers \ Welsh Corgi \ Ridgeback
Chronic, slowly progressive (Months)
Initially - CPD , Paraparesis, Tail hanging down
As disease progresses - Quardriparesis, Urinary incontinence (UMN), Constipation. 15% of cases - No patella reflex
Degenerative Myelopathy - What is an important clinical sign that is not associated with the disease?
Back pain
Degenerative Myelopathy - What diagnostic tool is contraindicated in Degenerative myelopathy
Myelography
Can cause severe worsening of clinical signs
Degenerative Myelopathy - Diagnosis
Exclusion of other conditions (e.g. Neoplasia, Degenerative changes, IVDD Hansen type 2)
Genetic testing
Degenerative Myelopathy - Treatment
Supportive
T3-L3 - Acute neurological presentation - DDs
IVDD (Hansen Type 1 & 3)
Trauma
FCE
Inflammation\Infection
Discospondylitis
T3-L3 - Chronic neurological presentation - DDs
IVDD (Hansen Type 2)
Discospondylitis
Degenerative myelopathy
Neoplasia
Fibrocartilaginous Emboli - Common Location
T3-L3 (But can happen throughout the spinal cord)
Fibrocartilaginous Emboli - Signalment, History, Clinical presentation
Young, large , active dogs (1-2 years)
Sudden scream of pain preceding clinical signs
CP deficit
Acute asymmetric paraparesis (that can progress but stays asymmetric)
At the time of injury - painful, but usually no pain on exam (due to necrosis of the spinal cord)
Fibrocartilaginous Emboli - Diagnosis
Exclusion of Other DDs (e.g. Trauma / IVDD)
MRI (Gold standard)
Fibrocartilaginous Emboli - Treatment
Steroids (reduce inflammation and edema in the spinal cord
Physical therapy
Aberrant migration of S.Lupi - Clinical presentation
CP deficit
Acute (or sub-acute) asymmetric paraparesis
Biting of lumbo-sacral region
Back pain
Aberrant migration of S.Lupi - Diagnosis
CSF (Predominantly Eosinophils)
PCR on CSF
Aberrant migration of S.Lupi - Treatment
Short course Glucocorticoids (for 2nd inflammation)
Antibiotics (for secondary infections) - Clindamycin
Doramectin - q24h for 3 days, then once a week for 6 weeks
Physical therapy
Cauda Equina Syndrome - Signalment & Clinical Presentation
Old, large breed dog
Down-pointing tail
CP deficit
Paraparesis
Pain in Lumbo-Sacral region
Urinary incontinence
Cauda Equina Syndrome - Common causes
IVDD
Neoplasia
Discospondylitis
Luxation/sub-luxation
Degenerative changes (e.g. stenosis, synovial cysts)
Cauda Equina Syndrome - Diagnosis
CT / MRI
Meningomyelitis - Clinical signs
Fever
Lethargy, Anorexia
Back pain
Neurological deficits: Ranging from CP deficit up to loss of deep pain
Location: Focal\Multi-focal
Meningitis/Meningomyelitis - Possible CBC finding
High WBC
Meningitis/Meningomyelitis - Diagnosis
CSF
Caudal Cervical Spondylomyelopathy - Signalment/Clinical signs
Large adult breed dog
Commonly: Great Dane (2-4y) \ Doberman (6-9y).
Ataxia - Hind Limbs > Front Limbs
Hind Legs - Hypermetria
Front Legs - Hypometria
Caudal Cervical Spondylomyelopathy - Treatment
Surgery
What are the Defining Characteristics of a Meningioma on MRI Imaging (With Contrast)
-Occupying lesion with mass effect
-Large common border with the meninges
-Grows slowly
-Dural tail
-Consistent contrast uptake
What would we expect in terms of Cells/Protein levels from a CSF of an animal with a brain neoplasia
Protein > Cells
What are 2 important post-op drugs that should be given after tumor excision from the brain?
Anti-seizures
GC
Brain Gliomas - Signalment
Brachycephalic breeds
Brain Meningiomas - Signalment
Dolichocephalic breeds
You diagnosed metastasis in the brain - What are some common neoplasia that can cause it?
Prostatic Adenocarcinoma
Mammary Adenocarcinoma
Lymphosarcoma
Hemangiosarcoma
3 DDs for Multifocal lesions in the brain
Metastasis
Micro-abscesses
Inflammation\Infection
Infectious Meningoencephalitis - Common causative agents (Dogs)
Viral (e.g. Distemper, Rabies)
Parasitic (e.g. Toxoplasmosis, Neosporosis)
Fungal (e.g. Cryptococcus, Aspergillosis)
Protothecosis
Bacterial
Infectious Meningoencephalitis - Common causative agents (Cats)
Viral (e.g. FIP, FeLV, FIV)
Fungal (Cryptococcus, Aspergillosis)
Parasitic (e.g. Toxoplasmosis)
Bacterial
Bacterial Meningoencephalitis - Treatment
3rd Gen. Cephalosporins \ Fluoroquinolones
Short course GC
Infectious Meningoencephalitis - Diagnosis
CSF Serology\PCR
Sterile Encephalitis - What is the difference between Meningitis and Meningoencephalitis in terms of clinical signs?
Meningitis will manifest with Fever \ Lethargy \ Neck Pain but with no neurological deficits!
as opposed to Meningoencephalitis which can present with additional more severe neurological signs (e.g. CP deficit, Head tilt, Circling etc.)
Meningoencephalitis of unknown etiology (MUE) - Common breeds and their associated type of MUE
Pug \ Yorkshire \ Maltese \ Chihuahua - Necrotizing Meningoencephalitis (NME)
Granulomatous Meningoencephalitis (GME) - No associated breeds
Yorkshire terriers \ French bulldogs - Necrotizing Leukoencephalitis (NLE)
*Golden Retrievers - Eosinophilic Meningoencephalitis (EME) - Though not considered part of the MUE complex of diseases.
Steroid Responsive Meningitis Arthritis (SRMA) - Common Signalment
Weimaraner \ Beagle \ Bernese \ Boxer. Young - <1.5 years
Meningoencephalitis of unknown etiology (MUE) - Typical Signalment
Young to middle aged
Females more than males
Small breeds more than large breeds (e.g. Maltese \ Pug \ Yorkshire \ Chihuahua )
You draw CSF from a young dog and the predominant cells are Neutrophils - DDs and next step?
Bacterial Encephalitis and SRME\A
Look for presence of bacteria inside\outside of the neutrophils. If no bacteria is identified (And signalment, History and clinical signs correlate) - Start GC \ Immunosuppression.
You draw CSF from a dog and there is a heterogenous population of WBC - Monocytes\Lymphocytes\Maybe Some Neutrophils) - Mononuclear Pleocytosis - DDs and next step
Infectious diseases - (e.g. Aspergillosis \ Cryptococcosis \ Neospora \ Toxoplasma \ CDV)
=>PCR / Serology.
Suspicion of MUE => GC / Immunosuppression
Vestibular Signs - Horner Syndrome - What are the clinical signs? What is the pathology?
Miosis
3rd Eyelid elevation
Smaller palpebral opening
Pathology Involving the sympathetic innervation traversing the tympanic bulla
Vestibular Signs - What combination of neurological deficits would imply peripheral pathology involving CN 8 (vestibulocochlear N.) In an animal showing vestibular signs? Where would you localize the pathology?
1) Facial paralysis (Cranial nerve 7 - Facial nerve)
2) Horner Syndrome (Sympathetic nerve). Pathology involving the middle\inner ear (e.g. Otitis media\interna)
Vestibular Signs - What type of nystagmus is associated exclusively with a central lesion? (i.e. medullary)
Vertical nystagmus
Vestibular Signs - What cerebellar lobes are commonly associated with central vestibular signs?
Caudal Lobe
Flocculonodular Lobe
Peripheral Vestibular Pathology - What are important to look for In the physical examination, additional diagnostics & Blood works in a vestibular patient suspected with peripheral disease
Otoscopic examination (e.g. intact Tympanic Membrane)
Oral cavity examination (e.g. Inflammation \ Abscess \ Teeth problems) - Lesions can involve the ear
CBC + Panel (look for signs for hypothyroidism)
MRI \ CT
CSF
Geriatric / Idiopathic Vestibular Syndrome (“Old Dog Vestibular Syndrome”) - Central / Peripheral Syndrome
Peripheral
Geriatric / Idiopathic Vestibular Syndrome - Approach / Treatment
Tentative diagnosis based on Signalment and clinical signs. If diagnosis is correct - in 72 hours signs will resolve (Head tilt can remain)
Meanwhile - Fluids \ Anti-emetics \ Sedation
Paradoxical Vestibular Pathology - Location of the lesion
Flocculonodular Lobe \ Cerebello-Pontine Angle
Pathological Nystagmus - High frequency usually indicative of..? (Peripheral / Central lesion)
Peripheral
Pathological Nystagmus - low frequency usually indicative of..? (Peripheral / Central lesion)
Central lesion
Positional Nystagmus - Define what it is, and the location of the lesion if present?
Vestibular animal that does not have pathological nystagmus but develops it as soon as we change the animal’s position (i.e. Lateral recumbency)
Central lesion
Animal with Symmetric / Diffuse neurological deficits pointing to the cerebrums. DDs?
Metabolic etiologies:
Hypocalcemia
Hyperammonemia (Hepatic encephalopathy)
Uremia
Hypoglycemia
Low Thiamine (Vitamin B1)
Withdrawal Reflex - Assess which spinal segments?
Forelimb - C6-T2
Hindlimb - L4-S1
Patellar Reflex (Femoral N.) - Assess which spinal segments?
L4-L5 (L6)
Sciatic N. - Assess which spinal segments?
L6-S1
What is the difference between a Paretic/Plegic animal with UMN Lesion as opposed to a LMN lesion in terms of muscle tonicity?
UMN - Hypertonicity
LMN - Hypotonicity
Peripheral Pathologies / Neuromuscular Diseases - DDs
Neurological (e.g. Polyradiculoneuritis), Junctionopathies (e.g. Myasthenia Gravis \ Organic Phosphates (Chronic) / Botulism \ Tetanus)
Muscles: Dermatomyositis \ Polymyositis \ Myopathies \ Storage Diseases
Infectious: Neospora \ Toxoplasmosis \ Hepatozoon Americanum
Endocrine: Hypothyroidism \ Cushing’s disease \ DM \ Addison’s disease
Metabolic: Hypoglycemia \ Hypocalcemia \ Hypokalemia
Polymyositis and Myasthenia Gravis - What are 2 clinical signs that in high probability rule out the diseases
Plegia Decreased \ Missing spinal reflexes
Peripheral neuropathies due to Endocrine disease usually result in at most…? (Which neurological deficit)
Paresis
EMG - When can the test be used in terms of disease time line (Least false negatives)
5-7 Days after onset
LMND - Botulism - What is a diagnostic tool in the clinic that can give a clue to the disease? Why?
X-Rays
In small animals - Botulism is usually the result of eating dead animals => X-Ray of the stomach - May see the Carcass \ Bones
Polyradiculoneuritis - Common EMG finding
Spontaneous muscle electrical activity at Rest
Polyradiculoneuritis - Diagnosis
Rule out other peripheral neuropathies
EMG
Polyradiculoneuritis - Pathology
Sterile autoimmune inflammation of the LMN
Polyradiculoneuritis - Treatment
Supportive (Change recumbency \ watch for Aspiration Pneumonia)
Physical therapy
IVIG (If physical therapy isn’t working)
Polyradiculoneuritis - Prognosis
Most dogs undergo full recovery (usually takes a few weeks, can be months)
Prognosis worsens in cases of aspiration pneumonia
Steroid Responsive Tremor Syndrome - Signalment & Clinical Presentation
Small breed dogs
Constant fine tremors with ataxia and falling
Steroid Responsive Tremor Syndrome - Location of lesion
Diffuse Cerebellar
Steroid Responsive Tremor Syndrome - Diagnosis
Clinical signs
CSF - Lymphocytes predominate
Steroid Responsive Tremor Syndrome - Treatment
Steroids
Cutaneous Trunci deficit can point to damage up to..? (Range)
Up to 4 vertebrae cranially from point of pressure
Monoparesis / Plegia (Involvement of one foot) - Usually the lesion will be…? (Location)
Outside the spinal cord (Peripheral) (Brachial\Lumbosacral plexus, Spinal nerves)
Describe Sympathetic Nerve Pathway
Hypothalamus => Spinal cord => T1-T3 => Brachial Plexus => Cranial Cervical Ganglion => Tympanic bulla => Eye
Autoimmune Neuritis - Can involve only one nerve (T/F)
True
Vestibular Signs - Swaying from side to side is more associated with Peripheral / Cerebellar lesion?
Cerebellar
IVDD Type 2 - Always accompanied with pain on palpation (T/F)
False
Degenerative changes in the spinal column - Give 4 types of pathologies
Ligament thickening
Joint cysts
Facet hypertrophy
Osteophytes
Spinal Arachnoid Diverticulum - Common breeds
Pugs \ French Bulldog \ Rottweiler
Name 5 chronic pathologies of the spinal cord/column that can present without pain
Degenerative Myelopathy
Degenerative changes to the spinal cord
Spinal Arachnoid Diverticulum
IVDD Type 2
FCE
DDs for acute spinal cord pathologies
IVDD Type 1 & 3
Fractures \ Luxation
FCE
Meningitis\Meningomyelitis
Discospondylitis
Animal presents with history of trauma and is paraplegic with no deep pain. DDs?
Fracture \ Luxation
Bleeding
Concussion
Acute disk herniation
Optic Chiasma - Location in the brain
Rostral to the Hypophysis
Tentorium Cerebelli - Definition
Dural reflection separating the Cerebellum and Cortex
What is the name of the structure that separates both of the cortical hemispheres
Falx Cerebri
An injury to CN 6 will cause what clinical sign? Why?
Medial Strabismus
Innervates rectus lateralis m. (and Retractors)
An Injury to CN 3 will cause what kind of Strabismus?
Lateral Strabismus
What test on physical examination can we perform to check if CN 6 is injured?
Corneal reflex
What are the indications for conservative treatment in spinal cord injuries?
Non progressive deficits - at worse paresis
No compression on spinal cord
Accepted by the animal (i.e. Cast)
Fracture is stable
What are the indications for surgical treatment in spinal cord injuries?
Fracture is unstable
Spinal cord compression
Plegic or worse
Progressive
Swallow Reflex - Checks which cranial nerves?
CN 9 - Glossopharyngeal Nerve
CN 10 - Vagus
CN 11 - Accessory
*Note - Mainly checks CN9, but all 3 CN originate from “Nucleus Ambiguus” - in the ventrolateral portion of the caudal Medulla
Hindleg reflexes - Cranial tibial muscle reflex - checks which nerve and which spinal nerves?
Sciatic N. - Specifically L6-S1
Hindleg reflexes - Gastrocnemius muscle reflex - checks which nerve and which spinal nerves?
Sciatic N. (L6-S1)
Increased cross extension reflex - Signifies what type of injury?
UMN Injury
Forelimbs - Cranially to C6 (C1-C5)
Hindlimbs - Cranially to L4 (T3-L3)
Babinski sign - How to perform and what does positive result? What is the type of injury (UMN\LMN)?
Stroke on the palmar\tarsal plain - Carpus\Tarsus to toe or toe to Carpus\Tarsus
Positive result - Extension of toes
Injury - UMN
Syringomyelia - Signalment
Young King Charles Caviler Spaniel (Can be as young as 3 months old)
Syringomyelia - Common clinical signs
Main - Cervical pain! (C1-C5)
Unwillingness to move
Quadroparesis
What are 2 DDs for increased patellar reflex? Explain the least common one
UMN Injury (T3-L-3)
Pseudo hyperreflexia - In cases of injury to the Sciatic nerve - The extensor (Antagonistic) muscles undergo atrophy - Causing less resistance to flexion and increased patellar reflex
What is the connection between plantigrade walk in the hindlimb and Sciatic N. injury?
Loss of innervation to the Gastrocnemius m.
Palpebral \ Lip \ Nasal Sensation - What 3 parts comprise the test?
CN 5
CN 7
Contralateral Cortical Hemisphere
Head Trauma - What are the tenets of conservative treatment?
Ventilation (Keep CO2 down to decrease bloodflow to the brain)
Mannitol \ Hyperosmotic Saline
Keep head at 30 degrees
Anti-seizure (Prophylaxis)
Chocolate Poisoning - 2 Most commonly affected systems and 2 most common clinical signs
Cardiovascular
CNS
Tachycardia \ Arrhythmias
Seizures
Chocolate Poisoning - When trying to add up the amount of toxin the animal ingested - what 2 ingredients should be considered?
Theobromine
Caffeine
Chocolate Poisoning - What is the most dangerous form of chocolate?
Cocoa Powder
PLR - Where do you shine the light in order to check contralateral PLR as well as ipsilateral?
Nasal retina (Medial)
PLR - Where do you shine the light to only check the ipsilateral PLR?
Temporal retina (Lateral)
Lateral Strabismus is often associated with injury to which CN?
Ipsilateral Oculomotor lesion
Cross Extension Reflex - UMN / LMN Lesion?
UMN
MRI of the brain - Ring Enhancement - DDs
Metastasis
Abscess
Glioma
Infarct
Contusion
Demyelinating disease
Radiation necrosis
Idiopathic Trigeminal Neuritis - 3 Clinical signs
Dropped jaw
Facial paralysis
Trigeminal sensory deficits
Describe the nerves, their location and function involved in Micturition
Hypogastric N.
L2-L5
Sympathetic innervation of the bladder detrusor muscle that allows relaxation and filling
Pelvic N.
S1-S3
Parasympathetic innervation of the bladder - Contraction of the Detrusor and relaxation of the Internal Urethral Sphincter - allowing urination
Pudendal N.
S1-S3
Somatic innervation - Contraction of the External Urethral Sphincter - allowing urination.
Myasthenia Gravis - 3 Breeds at risk for acquired MG? (Which is the most common)
Akita (Most common)
Chihuahua
German Shorthaired Pointer
Trismus (Hard to open Mandibles) - Common Causes
Tetanus
Rabies
TMJ Osteoarthritis
Masticatory muscles Myositis
Otitis + Cellulitis
Retrobulbar Abscess
Cerebellar Hypoplasia - Usually caused by…in what animal?
Panleukopenia Virus
Kittens
Pendular Nystagmus - Common breed & Concurrent neurological deficit?
Siamese cats (Also albino cats)
Bilateral blindness in the nasal visual field
A Great Dane presents with limb tremors. They appear only when standing. What is the name of the syndrome and what is the signalment?
Orthostatic Tremor
Large Breeds (e.g. Great Dane \ Irish Wolfhound \ Deerhound)
Steroid Responsive Tremor Syndrome - Signalment and Tremor Characteristics
Dogs Under 15 Kg
Whole Body, Constant, Mostly no other deficits (Rarely Vestibular also)
Describe the way to define a Tremor
1) First - Tremor or Muscle fasciculation
2) Which part of the body is tremoring
3) Is it Intermittent \ Constant \ Intentional
4) Is the tremor positional
5) Are there other neurological deficits
Whole body, constant tremors in a young puppy. Probable cause?
Hypomyelinogenesis
Head-only tremor that can be intermittent. Possible DD
Idiopathic Head Tremor
Most common toxins that can cause Tremors
Organic Phosphates
Pyrethroid
Mycotoxins (Aspergillosis)
What are the 5 possible changes in Wobblers Syndrome (Caudal Cervical Spondylomyelopathy)?
IVDD Type 2
Articular facet hypertrophy
Ligament hypertrophy
Central canal stenosis
Cervical vertebral instability
Plantigrade Posture - causes
Tarsal extensors dysfunction - Gastrocnemius and SDF
Calcaneal tendon rupture
Calcaneal bone fracture
L4-S3 Spinal Lesion
DM \ Hypothyroidism
Hypokalemia Polymyopathy
Neck Flexion - DDs
Spinal lesions: Fracture \ IVDD \ Atlanto-Axial sub-luxation
Metabolic: Hypokalemia \ Hypocalcemia \ Thiamine Deficiency
Endocrine: DM \ Hyperthyroidism \ Hypothyroidism
Myositis
Polyneuropathy
Myasthenia Gravis
Meningoencephalitis of unknown etiology (MUE) - Signalment
Small breeds Females 3-7 Years
Meningoencephalitis of unknown etiology (MUE) - Diagnosis
MRI
CSF - Mononuclear Pleocytosis
Screening for infectious diseases (e.g. Distemper \ Neospora \ Toxoplasma \ Cryptococcus \ Aspergillosis \ Bacterial)
If neoplasia is suspected - US \ X-ray
Histopathology (Gold standard)
SRMA - Useful tool for monitoring treatment?
CRP
SRMA - What concurrent disease can be found in ~50% of patients?
Immune-mediated polyarthritis
Eosinophilic meningoencephalitis (EME) - Common breeds
Golden retriever
Rottweiler
Eosinophilic meningoencephalitis (EME) - Diagnosis (And necessary rule outs)
MRI
CSF - Eosinophils
Rule out Cryptococcus \ Aspergillosis \ Toxoplasma \ Neospora \ S.Lupi \ Worms
Infectious Meningoencephalitis - Bacterial meningitis - What is the most common cause?
Otitis interna
Discospondylitis - Possible causes
Hematogenous Spread - UTI \ Skin infection \ Dental infection \ Endocarditis
Trauma \ Surgery \ Foreign body
Discospondylitis - 2 Main categories of infective agents and name one zoonotic agent
Bacterial \ Fungal
Brucella Canis
Chiari-Like Malformation & Syringomyelia - Signalment
Cavalier King Charles Spaniels, Brussels Gryphon, Small breed dogs
Chiari-Like Malformation & Syringomyelia - Clinical signs
Phantom pruritus of neck area
Neck pain
+-Ataxia
+- Paresis
Vocalization
Chiari-Like Malformation & Syringomyelia - Classic MRI findings
Occipital bone hypoplasia
Protrusion of the cerebellar vermis
Obliteration of dorsal sub-arachnoid space below cerebellum
Medullary kinking
Secondary Syringomyelia
Dilation above mesencephalic aquaduct
Ventriculomegaly
Chiari-Like Malformation & Syringomyelia - Treatment
Surgery - Fat implantation. Best prognosis and can give normal life expectancy along with adjunctive medical treatment
Medical treatment (Alone or with surgery):
Analgesia
NSAID or Steroids to reduce inflammation + Proton pump inhibitors (Decreases CSF production)
Vestibular Disease + Temporal M. Atrophy - Central \ Peripheral? Why?
Central
Mastication muscle atrophy = Trigeminal N. (CN 5) Lesion. CN 5 + CN 8 involvement = Medullary lesion
Peripheral vestibular disease - DDs
Foreign body
Old dog vestibular syndrome
Otitis Media \ Interna
Hypothyroidism
Excessive ear flushing
Metronidazole toxicity
Neoplasia, Polyps
Subarachnoid Diverticulum - Most common breed and name two others
Pugs.
French Bulldog, Rottweiler
Cranial Nerve Evaluation - How to perform?
Observation: Facial Symmetry \ Head Tilt \ Nystagmus \ Muscle Atrophy.
Vision (Cotton Balls) \ Menace \ Palpebral \ Pathological Nystagmus \ Physiological Nystagmus \ Strabismus \ Swallow Reflex \ PLR
Proprioception Evaluation - How to perform?
CP Evaluation
Wheelbarrow
Hopping
Spinal Reflexes Evaluation - How to perform?
Withdrawal
Patellar
Sciatic
Perianal
Cutaneous Trunci
Pain Evaluation - How to Perform?
Deep Pain
Back Palpation
Elevated ICP - 3 Main clinical signs to look for at examination
Mentation Changes
Hypertension
Bradycardia
Tenets of managing/treating head trauma
Elevate head to 30 degrees
Mannitol / Hypertonic Saline
O2 Supplementation
Preventative anti-seizure medication
What is the drug that is contraindicated in all head trauma patients?
Steroids
What are the best routes of administration of Benzodiazepines during a seizure?
Midazolam - Intranasal
Diazepam - Intrarectal
What are the 3 Types of Ataxia?
1) Cerebellar
2) Vestibular (Non-cerebellar)
3) UMN \ Spinal Cord \ Proprioceptive
All four limbs affected + Horner sign. Possible Neurolocation?
T1-T3
Cutaneous Trunci reflex absent on one side in its entirety. Neurolocation? What’s the name of the nerve that is damaged?
C8-T1 of that side
Lateral Thoracic N.
You suspect IVDD type 1. What is the tole of spinal X-rays in the diagnosis?
Rule in/out OTHER pathologies (e.g. Trauma \ Discospondylitis \ Neoplasia)
*Spinal X-rays SHOULD NOT be used as a definitive diagnostic for IVDD - for that use Myelography \ Myelo-CT \ MRI
Cauda Equina Syndrome - Signalment
Medium to large breed dogs.
*German shepherd predisposed to Lumbosacral stenosis
Cauda Equina Syndrome - Neurolocation
L7-S3
Cauda Equina Syndrome - Clinical Signs
L7-S1 Involvement - Pelvic limb lameness \ Muscle atrophy \ Postural and Proprioceptive deficits
S1-S3 Involvement - Fecal and urinary incontinence
Negative perianal reflex
Caudal Nerve involvement - Limp tail
Cauda Equina Syndrome - Diagnosis - Gold standard
MRI - Can visualize soft tissues (The Cauda Equina)
*CT for identifying protruding disks( disk can protrude but can also be an incidental finding and doesn’t necessarily cause clinical signs)
Cauda Equina Syndrome - Indications for surgery
Severe pain
Neurological deficits
No response to medical therapy
Prevention of incontinence if still hasn’t occurred
Cauda Equina Syndrome - Treatment
Conservative treatment:
Cage rest for 4-6 weeks
Analgesia
Physical therapy
Surgery
Brain Stroke - What are the 2 types of stroke?
Ischemic
Hemorrhagic
Brain Stroke - What are the 2 blood supply routes in which strokes most commonly occur?
Territorial (Cerebellar vessels)
Lacunar
Brain Stroke - 3 Breeds that are over-represented
Cavalier King Charles Spaniel, Greyhound, Miniature Schnauzer (Familial Hyperlipidemia)
Brain Stroke - Characteristics (i.e. The definition of a stroke)
Acute
Non Progressive
Focal
Brain Stroke - Causes for Ischemic Stroke
Thrombus
Hyperviscosity Syndrome
Emboli (Parasites \ Septic \ Neoplastic)
Brain Stroke - Causes for Hemorrhagic Stroke
Hypertension
Neoplasia
Vasculitis
Coagulopathies
Brain Stroke - You diagnosed an Ischemic Infarct (on MRI) - What are appropriate further diagnostics?
CBC \ Panel \ T4 \ Cushing Screening \ UA X-Rays \ US
PT\PTT
TEG\TEM
D-Dimer \ FDP
Echocardiography
CSF
Brain Stroke - You diagnosed a hemorrhagic Infarct (on MRI) - What are appropriate further diagnostics?
CBC \ Panel \ UA
BP
PT\PTT
BMBT
X-Rays \ US
Brain Stroke - What is the “Penumbra”?
The area circling the permanently damaged area. This area can heal
Brain Stroke - Treatment (Plus 1 Special Treatment only for Hemorrhagic Infarcts)
Treat underlying cause
Fluids
Anti-seizures: Keppra \ Phenobarbital \ Benzodiazepines
O2
Anti-Emetics (Vestibular disease)
Sedatives
Anticoagulants (e.g. Clopidogrel \ LMWH \ Rivaroxaban)
Brain Stroke - Common Causes (AKA Risk Factors) in Dogs
Ischemic:
Hyperlipidemia (Atherosclerosis)
Hypothyroidism (Atherosclerosis)
Cushing’s disease
PLE \ PLN
Parasitic (Curtebra in cats)
Metastasis \ Neoplasia
Cardiac disease
Hemorrhagic:
CKD \ Hyperthyroidism (Hypertension)
Neoplasia
Thrombocytopathy / Thrombocytopenia
Decrease in clotting factors
Status Epilepticus - Treatment options
Benzodiazepine
Keppra
Phenobarbital
Propofol
General Anesthesia
