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PPCO Twist System PEER REVIEWED The NEUROLOGICNEUROLOGIC EXAMINATIONEXAMINATION in Companion Animals In the January/February issue of Part 2: Interpreting Today’s Veterinary Practice, Part 1 of this article discussed performing Abnormal Findings a neurologic examination; Part 2 will address interpretation of Helena Rylander, DVM, Diplomate ACVIM (Neurology) abnormal findings. complete neurologic examination should be THE BRAIN done in all animals presenting with suspected Lesions in the brain can be localized to the: Aneurologic disease. Abnormalities found during t Cerebrum and thalamus (ie, prosencephalon) the neurologic examination can reflect the location of t Brainstem the lesion, but not the cause, requiring further tests, t Cerebellum. such as blood analysis, electrodiagnostic tests, and In order to localize the lesion to a specific part of advanced imaging, to determine a diagnosis. the brain, an understanding of the anatomy and func- The neurologic examination evaluates different parts tion of the brain is necessary (see Brain Anatomy & of the nervous system; the findings from the examina- Related Functions). tion help localize the lesion to the: t Brain Ataxia t Spinal cord A patient with ataxia may have a lesion in the proprio- t Peripheral nervous system ceptive pathways (peripheral nerves, spinal cord, or t Cauda equina. cerebrum), vestibular system, or cerebellum. Ataxia A fundic examination is recommended, especially in can be described as an uncoordinated gait, with cross- patients with brain disorders. Repeat neurologic exami- ing of the limbs and, sometimes, listing or falling to 1 nations are helpful to discover subtle abnormalities and or both sides. Ataxia can be further characterized as: assess progression of disease. U Proprioceptive: Mild, usually bilateral ataxia U Vestibular: Moderate, asymmetric ataxia U Cerebellar: Symmetric, truncal ataxia. Read The Neurologic Examination Circling in Companion Animals—Part 1: The direction of circling is usually toward the side Performing the Examination (January/February with the lesion. The circles tend to be larger with le- 2013) at todaysveterinarypractice.com. sions in the prosencephalon than with lesions in the vestibular system. 40 Today’s Veterinary Practice March/April 2013 THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS, PART 2 | Cranial Nerve Abnormalities Cranial nerve abnormalities are BRAIN ANATOMY & RELATED FUNCTIONS signs of either a peripheral neu- Cerebrum & Thalamus ropathy or brainstem lesion. The cerebrum initiates movements; the thalamus executes movements. Brainstem lesions can be local- r A common finding in cats with a large meningioma compressing the ized to the part of the brain- cerebrum is difficulty initiating movements and continuous, aimless stem where the cranial nerve walking in large circles. nucleus is located. Peripheral r A patient with a thalamic lesion may have a compulsive behavior: if neuropathy may affect only 1 restrained, the patient may struggle, vocalize, and try to keep walking. nerve (eg, idiopathic facial pa- ralysis) or be part of a polyneu- Brainstem ropathy. The brainstem connects the cerebrum with the spinal cord and body. All information to and from the body (which is examined by postural reaction Decerebellate Posture assessment) passes through the brainstem and thalamus to leave or reach This rare posture is seen with a the cerebrum. severe lesion in the cerebellum. The brainstem includes the midbrain (mesencephalon), pons, and medulla Findings include: oblongata. Localizing to one specific part of the brainstem is often not pos- U A mentally alert patient sible; however, cranial nerve deficits may help pinpoint the lesion. U Opisthotonus (dorsiflexion of The brainstem contains the cranial nerve cell bodies (except CN I and II). the head and neck) r The midbrain contains the reflex center for vision and hearing (colliculi) U Increased extensor tone in and the nuclei of CN III and IV. the thoracic limbs due to r The pons lies between the midbrain and medulla oblongata and contains loss of inhibition from the the nucleus of CN V. In addition, some of the vestibular nuclei are partially cerebellum to the extensor in the pons. muscles r The medulla oblongata, the most caudal part of the brainstem, contains U Pelvic limbs with reduced the respiratory and blood pressure regulation centers, nuclei of CN VI to muscle tone that are usually XII, and the vestibular nuclei (4 vestibular nuclei on each side). flexed. Cerebellum Decerebrate Posture The cerebellum adjusts and moderates all movements initiated by the This rare posture is seen with cerebrum and executed by the thalamus. Clinical signs that may indicate a a severe lesion in the midbrain cerebellar lesion include: or pons. r Cerebellar ataxia U The mentation in these r Variable and intermittent loss of the menace response patients is severely affected r Ipsilateral postural reaction deficits and/or hypermetria (stupor or coma). r Intention tremor. U Opisthotonus may be present if the animal has a cerebel- lar lesion in addition to the brainstem lesion. U Increased extensor tone in all limbs is a result of loss of inhibitory function from the pontomedullary reticular formation (RF or RAS), which affects extensor tone of the limbs. Hemineglect (Hemiinatten- tion) Hemineglect is a reduced re- action to a stimulus (body or head) contralateral to a lesion in the cerebrum. To test for hemineglect observe the pa- tient’s reaction (turning the Lisa Wirth, VMD head around, whining, trying Cross-section of cerebrum and thalamus and lateral aspect of brainstem to bite) while pinching the side March/April 2013 Today’s Veterinary Practice 41 | THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS, PART 2 of the trunk with hemostats. Compare reac- tions when pinching the other side. Mental Status Figure 1. Myotat- A change in mental status is caused by a lesion ic and withdraw- in the prosencephalon or brainstem (the re- al reflex pathways; ticular activating system is diffusely spread in thoracic and pel- the brainstem and responsible for our aware- vic limbs ness and arousability). U Owner’s knowledge of his or her pet’s Figure 2. C1 to C5 myelopathy: personality plus observations at home are 1 essential to assess the patient’s mental sta- Postural reactions tus, especially when there are subtle menta- are delayed or ab- tion changes. sent in all limbs U Repeat examinations and observation of the (red lines); spinal reflexes are nor- animal over a longer time period and in dif- mal or increased ferent surroundings are also helpful. (green lines) Figure 3. T3 to L3 HORNER’S SYNDROME & myelopathy: Pos- tural reactions and ANISCORIA spinal reflexes in Horner’s syndrome is caused by a 2 thoracic limbs are lack of sympathetic innervation to the normal; postur- eye. In patients with other neurologic al reactions are dysfunction, it is most commonly delayed or ab- seen with peripheral vestibular sent (red lines) dysfunction, C6 to T2 myelopathy, or but spinal reflex- brachial plexus injury (ie, outside the es are normal or spinal canal). Clinical signs include: increased (green • Miosis (constricted pupil) lines) in pelvic • Enophthalmia (sunken eye) limbs • Ptosis (drooping eyelid) Figure 4. C6 to T2 • Protrusion of the third eyelid. 3 myelopathy: Pos- tural reactions are Anisocoria refers to pupils of delayed or absent unequal size. in all limbs; spi- • Loss of sympathetic tone (ie, nal reflexes are re- Horner’s syndrome) results in one duced or absent in pupil failing to dilate (remaining thoracic limbs (red constricted) in darkness. lines) and normal • A parasympathetic lesion (ie, or increased in deficit of the oculomotor nerve pelvic limbs (green CNIII) results in one pupil failing to lines) constrict (remaining dilated) when 4 exposed to light. Figure 5. L4 to S3 myelopathy: • Brain edema and brain herniation Postural reac- may cause compression of the CNIII tions and spinal nucleus in the midbrain, resulting reflexes in thorac- in anisocoria, pinpoint pupils that ic limbs are nor- do not dilate in the dark or respond mal (green lines); to light, or fixed and dilated pupils. postural reactions In these patients mental status is are delayed or ab- also altered (stuporous or coma- sent and spinal re- tose). This is a serious finding that flexes are reduced requires immediate attention and or absent in pelvic treatment. 5 limbs (red lines) 42 Today’s Veterinary Practice March/April 2013 THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS, PART 2 | Paresis POSTURAL REACTION ASSESSMENT A patient with a cerebral lesion usually has mild, All postural reaction tests assess the sensory path- almost unnoticeable paresis. Patients with brain- way from the paw to the brain stem and contralateral stem lesions have more pronounced paresis and cerebrum (through the limb and spinal cord) and the ataxia ipsilateral to the lesion. motor pathway that returns the same way to the paw (Figures A and B). Seizures Conscious recognition is required from the cere- If there is a history of seizures, the lesion can be brum in order for the patient to replace the paw cor- localized to the prosencephalon, even if the neu- rectly; a slow or absent response indicates a problem rologic examination is normal. somewhere along the pathway. The pathways to and from the cerebellum contribute to the response and, THE SPINAL CORD in patients with cerebellar lesions, cause altered pos- Patients with spinal cord lesions have normal tural reactions. mental status and cranial nerves. Spinal cord le- Other findings help pinpoint the lesion to a spe- sions can be localized based on: cific area. t Gait abnormalities • In patients with brain disorders, postural reaction t Postural reaction deficits deficits are ipsilateral (both thoracic and pelvic t Spinal reflex abnormalities. limbs) to a lesion in the brainstem and contra- The spinal cord is divided into 4 functional lateral to a lesion in the cerebrum and thalamus (Figure C). regions: (1) C1 to C5, (2) C6 to T2, (3) T3 to L3, • A patient with a cervical myelopathy (C1–C5 or and (4) L4 to S3.
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