Veterinary Neurocritical Care

We are delighted to invite colleagues to contribute to this Special Issue focusing on recent progress and diagnostic innovations in veterinary neuropathology that will be published in Animals in honour of Professor Pumarola on his retirement.

We invite you to submit original research articles and reviews. Case series or case reports on unique clinical presentations or novel diagnostic techniques are also welcome. Don't miss out on this opportunity!!

https://www.mdpi.com/journal/animals/special_issues/Veterinary_Neuropathology

SMALL ANIMAL NEUROLOGY INTERNSHIP
If you seek specialization in Veterinary Neurology, do not miss out on this great opportunity to join our team of 2 experienced Neurology Diplomates, a third-year ECVN resident and a great neurology nurse. Please check the link below for further details and application, and feel free to share with whoever might be interested!

https://www.hamiltonspecialists.vet/about-us/careers/clinical-roles/internship-–-small-animal-neurology

Internship – Small Animal Neurology Find out more about the career opportunities we offer at our specialist veterinary referral hospital in High Wycombe.

Do not miss this incredible opportunity and join the 2022 British Veterinary Neurology Society Symposium to learn the latest advances in the diagnostics and therapeutics of epilepsy in human and veterinary medicine!

Program of the Symposium My site

new job!! (& new posts to come!)

Roberto Jose-Lopez, European and RCVS specialist in veterinary neurology, has extensive experience in referral practice, both in Spain and the UK. In 2015 he joined the neurology team at the University of Glasgow, becoming head of department before moving to Hamilton Specialist Referrals.

WHAT IS THE IMPACT OF HYPERTONIC SALINE 7.2% AND MANNITOL 20% ON ELECTROLYTE AND ACID-BASE IN DOGS WITH INCREASED INTRACRANIAL PRESSURE (ICP)?

A common and recurrent question in neurocritical care is what is the best fluid to treat an increase on intracranial pressure. Many times we do not take into account the impact on electrolyte and acid-base that our decision will have on the patient. This is quite important to be balanced in our decision making process since acidemia, alkalemia and hyper or hypoosmolality can have a direct impact on intracranial pressure and patient’s outcome. In the paper we bring this month, the authors aimed to describe the duration and magnitude of changes in electrolyte and acid-base variables after hyperosmolar treatment in 28 dogs with increased ICP and baseline normal acid-base status. This was a prospective, randomized, non-blinded experimental cohort study where dogs with different intracranial pathologies were included. After evaluation by a board certified neurologist the dogs were assigned to receive either a bolus of 4 ml/kg of hypertonic saline 7.2% (HS) or 1g/kg of 20% mannitol IV over 15 min. Electrolyte and acid-base variables were measured before administration (T0) and at 5, 60 and 120 minutes after (T5, T60, T120). The results from this study found that after HS administration, sodium and chloride increased at T5, T60, T120 compared to T0 but at T60 and T120 these values have also started to decline and were lower than at T5. Potassium was transiently lower at T5 compared to T0. Mannitol administration resulted in a transient decrease in sodium, chloride and plasma ionized calcium at T0 and T5 which was not maintained at T60,120. Changes in acid-base variables were minor and considered not relevant from the clinical perspective. From a clinical point of view the changes described in this study make us think and be aware that patients with sodium and chloride derangements and increased intracranial pressure should be managed cautiously and the clinical impact of hyper or hyponatremia should be considered before treatment. Hope you enjoy the reading!
https://pubmed.ncbi.nlm.nih.gov/33236379/
Luis Bosch
Roberto José López

Couldn’t have said it any better. Real sad day in the history of Veterinary Neurology. It was a honor to meet him in person and attend to some of his lectures. RIP Dr Alexander de Lahunta

RIP Dr de Lahunta
Sadly a legend has left us. Dr Alexander (Sandy) de Lahunta, known to a lot of us as Dr D, was an inspiration for anyone who had the chance to meet him in his or her career. A true gentleman, amazing clinician and one of the most charismatic and entertaining neurology speaker you would ever meet. Dr D the neurology community will miss you lot! Thank you for your outstanding contribution to our profession, for your kindness and for inspiring so many of us who had the chance one day to work with you.
Laurent Garosi
Simon Platt

Hello everyone! If you are looking into new horizons in your professional career check this out.

https://hcv.uab.cat/ca/formacio/residencies/residencia-urgencias-medicina-intensiva/

Residència en Urgències i Medicina Intensiva Hospital Clínic Veterinari UAB L’objectiu de la convocatòria és seleccionar un/a veterinari/a per a la realització d’una residència en l’especialitat d’Urgències i Medicina Intensiva per a l’obtenció del títol de Diplomat pel European College of Emergency and Critical Care: Dipl. ECVECC. Aquesta residència es de...

getting ready for next week 😊

ARE SYNTHETIC COLLOIDS USEFUL AS A CONSTANT RATE INFUSION?
Patients with decreased intravascular colloid osmotic pressure (COP) are a real challenge for veterinary criticalists due to the risks of hypovolemia, peripheral edema and effusion. For this reason patients with hypoalbuminemia and those where clinicians wanted to maximized blood perfusion ( i.e spinal and head trauma) have been treated for many years with a constant rate infusion (CRI) of synthetic colloids.
However, few years ago the classic model of the Frank-Starling forces and the potential usefulness of synthetic colloids as a CRI were challenged by the recognition of the endothelial glycocalyx. At the same time, human studies reported many adverse effects related to their use and clinical guidelines such the Surviving Sepsis Campaign took off their recommendations the use of synthetic colloids. This translated into veterinary medicine, and one study (Hayes et al. 2016, JVECC) also pointed out towards their complications and potential increase in mortality. Other studies published over the lasts years in dogs and cat have not been able to show such a correlation and the debate of their usefulness is still going on. The study we bring you today focused on hypoalbuminemic dogs and how a CRI of hydroxyetylstarch (HES) at either 1 or 2 ml/kg/h would impact their COP. This study was performed with a sample of 30 hypoalbuminemic dogs with different diseases and all of them were randomly assigned to receive an infusion at either 1 or 2 ml/kg/h without the administration of a previous synthetic colloid bolus. The authors of this study concluded that the administration of HES did not have an impact on COP when these are administered at the doses previously reported. However several limitations in this study need to be highlighted such as the lack of a control study group and the small sample size. Hope you enjoy the reading!
https://pubmed.ncbi.nlm.nih.gov/32910831/
Luis Bosch
Roberto José López

ARE SYNTHETIC COLLOIDS USEFUL AS A CONSTANT RATE INFUSION?
Patients with decreased intravascular colloid osmotic pressure (COP) are a real challenge for veterinary criticalists due to the risks of hypovolemia, peripheral edema and effusion. For this reason patients with hypoalbuminemia and those where clinicians wanted to maximized blood perfusion ( i.e spinal trauma and head trauma) have been treated for many years with a constant rate infusion (CRI) of synthetic colloids. However, few years ago the classic model of the Frank-Starling forces and the potential usefulness of synthetic colloids as a CRI were challenged by the recognition of the endothelial glycocalyx. At the same time, human studies reported many adverse effects related to their use and clinical guidelines such the Surviving Sepsis Campaign took off their recommendations the use of synthetic colloids. This translated into veterinary medicine, and one study (Hayes et al. 2016, JVECC) also pointed out towards their complications and potential increase in mortality. Other studies published over the lasts years in dogs and cat have not been able to show such a correlation and the debate of their usefulness is still going on. The study we bring you today focused on hypoalbuminemic dogs and how a CRI of hydroxyetylstarch (HES) at either 1 or 2 ml/kg/h would impact their COP. This study was performed with a sample of 30 hypoalbuminemic dogs with different diseases and all of them were randomly assigned to receive an infusion at either 1 or 2 ml/kg/h without the administration of a previous synthetic colloid bolus. The authors of this study concluded that the administration of HES did not have an impact on COP when these are administered at the doses previously reported. However several limitations in this study need to be highlighted such as the lack of a control study group and the small sample size. Hope you enjoy the reading! https://pubmed.ncbi.nlm.nih.gov/32910831/
Luis Bosch
Roberto José López

8yo Collie cross was running in the woods at night & was found tetraplegic by his owners after they heard a yelp. CT & MRI studies showed the below findings. Would you stabilize?
See what your thoughts are, we will share the answer next week. Until then, enjoy!
Luis Bosch
Roberto José-López

we’ll be discussing brain tumours and traumatic brain and spinal cord injuries soon in this amazing course, do not miss it!!

Uno de nuestros profesores estrella en las emergencias neurologicas del Posgrado de Neurologia!

Iniciamos este 19 de Abril 2021
Medios de contacto:
Mail: [email protected]
WhatsApp: +54 11-6857-2673
Contacto directo: https://wa.me/5491168572673

Coming soon!! great course for Spanish speakers who wish to further their knowledge in veterinary neurology, check it out!

BATTLE OF EVIDENCE: IS PROPHYLACTIC TREATMENT WITH LEVETIRACETAM A USEFUL STRATEGY TO DECREASE POST-OPERATIVE SEIZURES IN DOGS UNDERGOING SURGICAL CORRECTION OF EXTRAHEPATIC PORTOSYSTEMIC SHUNT?

The veterinary literature has traditionally agreed on the difficulty to treat dogs and cats that develop seizures after surgical correction of extrahepatic portosystemic shunts (EHPS). This complication has been usually associated to a fatal prognosis (Mathews K. et al, JAHHA 1988 and Tindall et al. JSAP 2000). Several case reports have described different strategies to manage it (Heidenreich et al.,JVECC, 2016 and Gommeren et al. JVECC 2010). In 2011 a paper published by Fryer et al. at JVIM opened the door to using levetiracetam (LEV) prior to EHPS ligation to prevent post-operative or post-attenuation seizures. In this retrospective study, 42 dogs receiving LEV at least 24h prior to surgery (median dose 20mg/kg TID) were compared to 84 dogs that did not receive anticonvulsant therapy. Neurological signs prior to surgery were not significantly different between groups. Post-attenuation seizures (PAS) occurred only in four dogs (3%) which had not received LEV prior to surgery and that did not survive. Therefore, this study concluded that pre-treatment with LEV might be a useful strategy to decrease PAS in dogs. However, this strategy has been questioned in recent years by many authors. In 2019, Mullins et al. published a multicenter retrospective study in Veterinary Surgery including 10 institutions. A total of 940 dogs were studied and divided into three groups: dogs with no preventive antiseizure treatment, dogs that received LEV > 15mg/kg/TID for more than 24h prior to surgery and dogs that received LEV < 15mg/kg/TID for less than 24h prior to surgery. In this cohort, 75 dogs (7.9%) developed PAS. LEV treatment prior to surgery at either dose did not show a protective effect for the development of PAS. Thus, this study concluded that pre-emptive LEV prior to surgical EHPS ligation offers no protection for PAS. This conclusion is also supported by other similar and recent studies (Brunson W. et al Can Vet J 2016, and Strickland R. et al Vet Surg 2018). What are your thoughts? From the evidence we have, it does not seem like LEV prior to EHPS ligation surgery is of much help. Perhaps a prospective double-blinded randomized clinical trial might help to finally answer this question. Hope you enjoy the reading!
https://pubmed.ncbi.nlm.nih.gov/30706530/
https://pubmed.ncbi.nlm.nih.gov/22092631/
Luis Bosch
Roberto José-López

Next March 10th at 2 PM will be speaking (in spanish) for Vets and Clinics- Affinity on how to handle and stabilize a common and stressful emergency: the flat cat. Do not miss this opportunity to ask those questions you always wondered! See you soon!
Luis Bosch
https://www.linkedin.com/posts/vets-and-clinics_somosvets-activity-6772888076814577664-0q56/

Vets & Clinics on LinkedIn: 36.ES. ¿CÓMO MANEJAR AL GATO EN SHOCK? (Dr. Luis Bosch) 36.ES. ¿CÓMO MANEJAR AL GATO EN SHOCK? (Dr. Luis Bosch) La especie felina presenta características diferentes a la canina en prácticamente todos los aspectos...

Following up on our previous post today, here is a fantastic diagram explaining the pathophysiology of intracranial hypovolemia! For more info, please check the open access case report below.
https://doi.org/10.1111/vsu.13586
Enjoy!
Luis Bosch
Roberto José-López

BATTLE OF EVIDENCE: IS CT SCAN USEFUL TO DETERMINE SHORT-TERM PROGNOSIS IN DOGS WITH TBI?
Quite often we have to face difficult clinical decisions in dogs with traumatic brain injury (TBI). In addition to the TBI, other body systems can be injured, and our assessment and the clinical decision-making process can be challenging. As clinicians, we all wonder about the prognosis of these patients and how our decisions can impact the outcome. Two recent studies have been published looking at early CT and its clinical utility to predict short-term prognosis in TBI. Interestingly these two papers found contradictory results and we found this quite interesting to discuss. In the study by Rapoport K. et al in The Vet Journal, 35 dogs with TBI and a median Modified Glasgow Coma Scale score of 14 (range 6-17) were CT scanned over the initial 72h. CT scan results were used to develop a novel score: The Koret CT Score (KCTS) ranged from 0 to 7 and was correlated with the clinical outcome. KCTS showed a significant negative association with the short and long-term survival, with higher scores associated to worse outcome. Dogs with a score of 3 or less had a positive predictive value of 100% for survival. According to these results, an early head CT in dogs with TBI seems quite helpful to determine the short-term prognosis of dogs with TBI. On the other hand, the study by Wyatt S. et al in Vet Radiol Ultrasound enrolled 40 dogs with TBI and median Modified Glasgow Coma Scale score of 16 (range 7-18) that were CT scanned over the initial 72h. This study scored CT findings using a Modified Advanced Imaging System that was published for dogs with TBI using MRI in 2014. Although in this study CT Scan showed to be a valuable tool to detect structural abnormalities after TBI, it failed to prove a correlation between abnormalities and prognosis. Among all, both studies had similar numbers on short-term survival, 77% versus 75%. So, the question that prompts after reading these two papers is: What would your approach be? Perhaps, consider every case individually and try not to make a rule for everyone? Enjoy the reading!
https://pubmed.ncbi.nlm.nih.gov/33241888/
https://pubmed.ncbi.nlm.nih.gov/33323172/
Luis Bosch
Roberto José-López

BRITISH VETERINARY NEUROLOGY SOCIETY (BVNS) ANNUAL SYMPOSIUM
Great online congress coming up on the 17th of April we will be contributing to its organization! This year the focus of the meeting will be on neurometabolic and movement disorders with the contribution of renowned human medicine and veterinary experts on this interesting and developing field. Do not let this opportunity pass and join us at the meeting!
Hope to see you there!
http://bvns.org.uk/index.php/program-of-the-symposium
Luis and Roberto

Program of the Symposium My site

Check this postgraduate course in veterinary neurology we will be lecturing at on traumatic brain and spinal cord injury as well as brain neoplasia. Lots of other topics will be covered by great speakers, pass it on!
Roberto & Luis

ATLANTO-OCCIPITAL FOREIGN BODY IN A DOG - A TRUE VETERINARY NEUROCRITICAL CARE STORY
We are back! And we thought we would start this year’s posts with this interesting case from my (Roberto) time as a resident back at the Universitat Autònoma de Barcelona.
This 6-month-old maltese dog presented as an emergency due to an acute onset of severe vestibular ataxia, right head tilt and right eye ventrolateral strabismus shortly after hoovering something during his walk. Plain laterolateral and ventrodorsal radiographic views demonstrated a radio-opaque foreign body (FB), most likely consistent with a wire or a needle, migrating to the atlanto-occipital (AO) junction and likely going through the spinal cord (images). The dog underwent respiratory arrest at premedication for anesthesia for emergency removal of the foreign body. He responded to cardiopulmonary resuscitation and was subsequently anesthetized and ventilated so my mentor (Sònia Añor) and I could remove the FB by means of a ventral approach to the AO junction. He recovered uneventfully from surgery and anesthesia and his neurological signs resolved within a couple of days!
Aside from the curiosity, we thought it would be interesting for you to know that clinical signs of vestibular system dysfunction can occur with lesions to the first three cervical spinal cord segments, interrupting the spinovestibular tracts. Respiratory arrest in this case might have resulted from secondary injury (e.g., edema, inflammation) to the respiratory centers in the adjacent medulla oblongata. Finally, and also importantly, as we identified a suspected metallic FB in plain radiographs, we avoided MRI as this could have made it migrate further and cause more damage. So, if slightly suspicious of a FB in the CNS, remember to do radiographs or CT first!
Hope you find it interesting!
Luis Bosch
Roberto José-López

THERAPEUTIC PLASMA EXCHANGE TO TREAT MYASTENIA GRAVIS

We recently posted a new approach to diagnose myasthenia gravis. This week we bring you an alternative way to treat those fulminant cases that might not be responding to the traditional therapeutic approach. This technique has been used in human medicine for years. Therapeutic plasma exchange (TPE) is a new modality of treatment that is becoming more available in veterinary medicine over the last years. There are 2 different forms of TPE, including centrifugal and membrane based. In the case series we bring you today, membrane-based TPE was used to separate plasma from the cellular components of blood in three cases. Plasma was then replaced with a combination of crystalloids, colloids, and plasma. Two out three cases showed reduction in antibody titers and clinical improvement after treatment. TPE seemed to be safe and well tolerated. Although we still have a long way to go in this matter, the cases presented here open a new therapeutic approach for complicated and critically ill patients not responding to conventional medical management. Hope you enjoy the reading!

https://pubmed.ncbi.nlm.nih.gov/33217167/
Luis Bosch
Roberto José-López

Emergency stabilization is always required for critically ill patients. Our first steps have a profound impact on outcome and we should all be aware on what to do and what to avoid during those stressful first minutes. Please join me next Thursday at 8 pm (Spanish time) for this streaming webinar in Spanish sponsored by Hills-AVEPA-FIAVAC, where I will be reviewing the key aspects of emergency stabilization in dogs and cats. Hope to see you there!
Use this link: bit.ly/3aMTt4H
Luis Bosch