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VETERINARY eMAGAZINE BEAT ISSUE 25 JULY 2025 LEARNING TO LISTEN TO OUR PATIENTS DOGS AND CATS
NEUROLOCALIZATION
IN
highlights inside MIND MASSAGE
TECH TIPS
IMAGING THE DYSPNEIC CAT: A CASE SERIES
CANINE INSULINOMA: RECOGNITION, DIAGNOSIS, & TREATMENT
QUARTERLY BEAT / JULY 2024 QUARTERLY BEAT / APRIL 2025
NEUROLOCALIZATION IN DOGS AND CATS 04
TO OUR PATIENTS 08
CAT: A CASE SERIES 12
LEARNING TO LISTEN
IMAGING THE DYSPNEIC
BACK ON TRACK 16
& TREATMENT 20
CANINE INSULINOMA: RECOGNITION, DIAGNOSIS,
WORKPLACE CULTURE DERAILED! HOW TO GET YOUR PRACTICE
MIND MASSAGE 24
TECH TIPS 29
UPCOMING WEBINARS 30
ISSUE 25 – JULY 2025 beat TABLE OF CONTENTS
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NEUROLOCALIZATION
DOGS AND CATS
IN
Wondering how to trace back your patient’s abnormal gait to where the root problem is? We’ve got you covered! In this VETgirl article, Dr. Missy Carpentier, DACVIM (Neurology) provides a comprehensive review of small animal neurolocalization. Read on to refresh your knowledge of how to read the map of central nervous system signs in cats and dogs!
Missy Carpentier, DVM, DACVIM (Neurology) Minnesota Veterinary Neurology, Columbus, MN The main goal of the neurologic examination is to identify if the patient is truly neurologic, and if so, further identify the specific area of the nervous system that is affected, known as neurolocalization. Neurolocalizing your patient is the only way that you can make an appropriate list of differentials and come up with the best recommendations for your patient. I am not going to go through the step-by-step neurologic examination – you can open any textbook and find this information – but I am going to review the main points of the neurologic examination and discuss how you use this information to neurolocalize your patient. IS YOUR PATIENT NEUROLOGIC? The first goal of the neurologic examination is to identify if your patient’s signs are neurologic in origin – this can sometimes be the hardest part! Below are the bullet points for a good neurologic examination. To me, the most important part of the neurologic examination is the hands-off evaluation. Don’t worry if you don’t know what muscle belly you are supposed to be hitting and what the reflex is called - you can neurolocalize most patients based on their signalment, history, and gait evaluation. This doesn’t mean that you shouldn’t be performing a hands-on neurologic examination to the best of your abilities but think of the hands-on part of the exam as further solidifying what part of the nervous system is affected.
HANDS-OFF NEUROLOGIC ASSESSMENT SIGNALMENT Many neurologic disorders have an age and breed predilection that is helpful when forming your list of differentials. HISTORY/PRESENTING COMPLAINT The first question that I have my technicians ask when they go into the room is what brought the owners in to be evaluated. We encourage the owners to give as much descriptive information as they can about their concerns. If they start to use medical terminology and they are not in the medical field, we will ask them to clarify what they mean (i.e., if they come in saying their dog had a tonic clonic seizure with loss of consciousness and autonomic dysfunction, ask for an actual description to be sure they didn’t just pull this information from Google and that truly is what occurred). Allowing the owners to describe abnormal events in detail also allows us to pick up additional information about the event or clinical signs that the owner may not know are important to the history. You should be able to gather the following information from the owners:
NEUROLOCALIZATION REGIONS 1. Brain
• Onset • Duration • Progression • +/- Lateralization • Presence of hyperesthesia • Presence or absence of improvement with medications
• You can get more specific but just figuring out if the brain is involved or not is a great place to start. Below you will find information regarding cerebellar signs that can allow you to be more precise.
2. C1-C5 myelopathy 3. C6-T2 myelopathy 4. T3-L3 myelopathy 5. L4-S3 myelopathy 6. Diffuse lower motor neuron 7. Multifocal
Other important information to obtain from the owners includes how long they have had the pet, vaccine status, travel history, use of preventative medications, access to toxins, any history of trauma, if any other animals or littermates are affected, diet, current medications, and any pertinent prior medical history.
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HANDS-ON NEUROLOGIC ASSESSMENT Based on the information you have gathered above, you likely have a good idea of where you would neurolocalize your patient. The hands-on evaluation helps you to confirm your suspicion/solidifies you are down the right track. CRANIAL NERVE EVALUATION First up is the cranial nerve evaluation. Below is a chart that goes through the cranial nerve reflexes, responses, and other evaluations of the head, as well as the cranial nerves that are involved in these tests.
As my technicians are going through the above history with me, I am observing the patient. How is their mentation and attitude? Do they have a low head carriage, do they look painful, are they kyphotic, is there pronounced muscle atrophy, do they have a head tilt or turn? This not only provides me with more information, but it also allows me to modify my evaluation if needed. If I have a patient with a low head carriage and is clearly exhibiting signs of cervical hyperesthesia, there is no need to assess the dog for neck pain – we don’t need to make them hurt any more than they already do. And on this subject, you should NEVER do range-of-motion of a dog’s cervical spine. Lateral palpation is all you need if you are assessing for neck pain. You never know when an atlantoaxial luxation is lurking, and you don’t want to find out during your neurologic examination. GAIT EVALUATION The more cases you see the more you will be able to identify “classic” gaits. Below are descriptions of some of the classic gaits. Remember, a normal gait doesn’t rule out neurologic disease. Also, these gaits are in the context that these patients are ambulatory, but a lot of these dogs will present non- ambulatory. If the patient is non-ambulatory, you should still be performing a gait evaluation and classifying the motor function of the patients (i.e., paretic or -plegic). Forebrain: Pacing, wide circles with lateralization if there is a focal forebrain lesion (always circling in one direction TOWARDS the side of the lesion), head pressing, proprioceptive ataxia or proprioceptive deficits that are CONTRALATERAL to the side of the lesion. Cerebellar: Hypermetria, wide based stance, fine oscillating head tremors, truncal sway, menace deficit with normal vision. Vestibular: Head tilt, rolling or falling to one side, nystagmus, strabismus, if central vestibular other cranial nerve deficits or proprioceptive +/- proprioceptive ataxia and paresis (+ if central). Bilateral Peripheral Vestibular: Wide based head excursions with a low body carriage (decreased extensor tone). C1-C5 Myelopathy: Tetraparesis and proprioceptive ataxia with a FLOATING thoracic limb gait and a spastic pelvic limb gait. C6-T2 Myelopathy: A two-engine gait, which is characterized by a tetraparesis with a SHORT, CHOPPY thoracic limb gait and a spastic pelvic limb gait. Proprioceptive ataxia also present. T3-L3 Myelopathy: Paraparesis and proprioceptive ataxia with a spastic pelvic limb gait. • Some of these cases may present with a Shiff-Sherrington posture. If they present with a Shiff-Sherrington posture, then they are either going to be non-ambulatory paraparetic or paraplegic. They will have increased extensor tone of the thoracic limbs, but they have normal movement and proprioception of the thoracic limbs when you support them in a normal standing position. It is important to know that this can occur, because these patients can be confused with cervical myelopathies. L4-S3 Myelopathy: Paraparesis and proprioceptive ataxia with a floppy pelvic limb gait. Lower Motor Neuron: Walking on eggshells, short-strided gait, holding the limbs directly beneath the body (think of a circus dog standing on a ball).
Menace Response
Optic (2), Facial (7)
Pupillary Light Reflex
Optic (2), Oculomotor (3)
Palpebral Reflex
Trigeminal (5), Facial (7)
Nasal Sensation
Trigeminal (5), Forebrain
Physiological Nystagmus aka Vestibulo-ocular Reflex
Vestibulocochlear (8), Oculomotor (3), Trochlear (4), Abducens (6)
Gag Reflex
Glossopharyngeal (9), Vagus (10)
Medial – Abducens (6), Ventrolateral, not positional – Oculomotor (3) Dorsolateral – Trochlear (4)
Strabismus
Facial Symmetry – Position of the Ears, Lip Commissure, and Palpebral Fissure
Facial (7)
Masticatory Muscles
Trigeminal (5)
Tongue Symmetry and Movement
Hypoglossal (12)
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HANDS ON EVALUATION OF THE LIMBS I normally start with the pelvic limbs and move to the thoracic limbs – do what works best for you. I like to start in the back because I start with evaluating for good femoral pulses, especially if they are presenting for intermittent pelvic limb weakness. When evaluating the limbs you are trying to decide if you have an upper motor neuron or a lower motor neuron limb. To figure this out, you are focusing on evaluation of conscious proprioception/CP’s and the NEURO RAT > R = REFLEXES A = ATROPHY T = TONE Remember, you have already assessed evidence of paresis or plegia during the gait evaluation, so you already have that information. Below is a chart of what you should be minimally assessing with the limbs.
Spinal Hyperesthesia: Save this for last and only assess if it isn’t obvious where the patient is painful. There are many patients that come in and you can clearly see where they hurt, in those cases spinal palpation is not performed. If I am not certain, then I will evaluate for spinal hyperesthesia with gentle spinal palpation. Again, never perform range of motion of the cervical spine. Pain Sensation: This is also a component of the neurologic examination that should be saved for last and only should be performed in plegic animals. I cannot stress this enough – you should only be assessing for pain sensation in a limb if the animal is plegic. If the animal is ambulatory, don’t do it. If the animal is non-ambulatory paraparetic (i.e., you can see good movement of the pelvic limbs but the patient isn’t strong enough to ambulate alone), don’t do it. There is no reason to evaluate a patient for pain sensation in a limb if there is movement of the limb. If they can move the limb, they can feel it. The one exception to this rule is the patient that is chewing their foot off due to a sensory neuropathy – but this is rare. When you are assessing pain sensation you need to be sure that the patient consciously acknowledges that you are pinching their toes. A conscious response means either the patient vocalizes, turns their head or tries to bite you. A withdrawal of the limb is just a reflex and does not indicate pain sensation. Most paraplegic, deep pain negative dogs that come in will have intact withdrawal reflexes, so don’t let it fool you. There must be a conscious acknowledgement, not just pulling back of the limb. If after all your hard work, you still can’t fit your patient into one of the nice neurolocalization regions in the chart above, don’t worry! It is likely, because your patient is multifocal and therefore, they shouldn’t fit nicely into one of the boxes above. A multifocal neurolocalization is a neurolocalization region! END RESULT Now, your patient is successfully neurolocalized and you can open any neurology textbook to start making your list of differentials to make your best recommendations for diagnostics and treatment options.
Withdrawl Reflex
Patellar Reflex
CP's
Atrophy
Tone
Hyper- Reflexive, Normal, Decreased/ Absent Hyper- Reflexive, Normal, Decreased/ Absent
Normal, Mild Atrophy, Pronounced Atrophy Normal, Mild Atrophy, Pronounced Atrophy
Increased, Normal, Decreased, Absent Increased, Normal, Decreased, Absent
Intact/ Delayed/ Absent
Thoracic Limbs
Hyper- Reflexive, Normal, Decreased/ Absent
Intact/ Delayed/ Absent
Pelvic Limbs
Once you evaluate the above for each limb, you then can identify each limb as either: UPPER MOTOR NEURON = Normal to increased segmental reflexes, mild atrophy, normal to increased tone.
VS
LOWER MOTOR NEURON = Decreased to absent segmental reflexes, moderate to severe atrophy, decreased to absent tone. Based on all of the above information that you have gathered, you can then neurolocalize your patient more confidently to one of the following areas.
Lower Motor Neuron
BRAIN C1-C5 C6-T2 T3-L3 L4-S3
Thoracic Limbs
LMN
LMN
UMN UMN
Normal
Normal
Pelvic Limbs
LMN LMN
UMN UMN UMN UMN
Still not convinced of your neurolocalization? Good news, there are a few more steps you can take to continue to narrow it down!
Tail Tone and Movement: Can be abnormal (decreased) with L4-S3 lesions.
Anal Tone: Can be abnormal with L4-S3 lesions.
Cutaneous Trunci Reflex: This reflex is normally present between T2 through L4/5 and can be most helpful with C6-T2 and T3-L3 myelopathies. It can be lost just caudal to a lesion anywhere along the T2 through L4/5 path. Start testing caudally and work your way forward, once you get the reflex there is no reason to continue evaluating it cranially.
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LEARNING TO LISTEN TO OUR PATIENTS
Debbie Martin, KPA CTP, LVT, VTS (Behavior) TEAM Education in Animal Behavior, LLC, Austin, TX In order to be able to grasp what dogs and cats might be trying to communicate to us, there are 3 required areas of knowledge including: 1. How the sensory perception of dogs and cats varies from ours 2. How dogs and cats communicate 3. And how pleasant and unpleasant associations with environments or situations are formed By understanding these 3 aspects, you will be able to put yourself in your patient’s paws and learn how you can adapt the veterinary environment and your interactions to make for a better experience. SENSORY PERCEPTION Stimuli in the veterinary hospital can create fear, anxiety, and stress in our canine and feline patients. Understanding how our patients perceive the veterinary hospital allows us to not only empathize but also develop solutions to make their experiences more pleasant. To understand a dog or cat’s perception of our hospital, we need to understand their senses. In general, dogs and cats tend to be more sensitive to environmental stimuli than we are. Let’s compare how dogs' and cats’ sensory perception varies from human perception. VISION Compared to humans, dogs and cats have poor visual acuity, a wider field of vision, and a smaller area of binocular vision. Cats see about 20/100-200, have a field of vision of 200° and a binocular vision overlap of 90-100°. 1 The visual acuity of the dog is about 20/75 with a field of vision of 245° binocular overlap of only 30-60° pending facial morphology. 2 In comparison, a human generally sees 20/20, has a field of vision of 180° with a binocular field of vision overlap of 140°. Although dogs and cats do not have very good visual acuity, they are very good at motion detection. Compared to humans, both cats and dogs can see better in dim light because of the increased number of rods in the retina and the tapetum lucidum, a reflective layer located behind the retina. Color vision is less developed in dogs and cats. Cats most likely have dichromatic vision with sensitivity to greenish-yellow and blue. Dogs are considered red-green color blind.
According to Heather E. Lewis, AIA, “The ability to see the UVB spectrum is interesting because it means that some materials appear to fluoresce to dogs [and cats], including organic material like urine that contains phosphorous as well as bright white, man-made materials such as paper, plastic and white fabrics, Lewis says. Because these white items are more visually jarring to dogs [and cats], their use should be avoided.” Because of the dog’s and cat’s sensitivity to motion, wider field of view, and poor visual acuity, it is beneficial to minimize fast movements as they can be startling. Utilize color schemes in the hospital to promote relaxation in people. Calm pet guardians result in calmer pets. Consider the use of pastels, dimmable lighting, and natural light. Minimize exposure to potentially frightening visual stimuli for patients and clients. This might include providing visual blocks, so cats do not see (hear or smell) dogs. HEARING Cats and dogs hear a wider range of frequencies than humans. The range of frequency for the cat is 20 Hz up to 85,000-100,000 Hz with the useful range probably up to 60,000 Hz. 1, 4 The range for dogs is 15 Hz up to 65,000 Hz with hearing best at around 4,000 Hz. 2 The range for humans is 20 Hz up to 19,000. 2 Because dogs and cats have moveable pinnae, they are better able to locate the source of sounds. Things do not sound louder to them, but they hear a broader range of sounds than we do. Consequently, they have more to tune out than we do. Take a walk through your hospital while recording sounds then play it back to help you identify potentially jarring or unnecessary noises that could be contributing to patients’ auditory overload. In this VETgirl Webinar “Learning to Listen to Our Patients” Debbie Martin, KPA CTP, LVT, VTS (Behavior) transforms your approach to veterinary care through learning to understand sensory perception, communication, and associations in dogs and cats. If you’re ready to see the clinic through your patients’ eyes (and ears, noses, and paws!), keep reading to discover practical ways to create more positive, fear- free visits. Missed the webinar? Catch the replay HERE or scroll down for the highlights!
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SMELL Dogs and cats have more epithelium dedicated to smell than humans; dogs 20-200 sq. cm, cats 20 sq. cm, and humans 2-4 sq. cm. 2 Smells are an important form of communication for dogs and cats. Cats might be better able to distinguish odors than humans and dogs. Mammalian noses have 3 different scent receptors. One of them, V1R, is believed to be responsible for differentiating one smell from another. Dogs have nine variants of the V1R protein, humans have two, and cats have 30! The vomeronasal organ is located in the roof of mouth. In dogs it does not open into the nasal cavity as it does in cats. The vomeronasal organ is important for detecting pheromones and for social communication. 2 It is linked to the limbic system of the brain and thought to be associated with emotions and feelings. Take into consideration the odors and chemical messages (pheromones) in the veterinary hospital. Cleaning products can overwhelm the olfactory sensory receptors resulting in a temporary inability to detect other odors and pheromones in the animal’s environment. Because dogs and cats use odor and pheromone communication to determine the safety of their environment, this loss of sensory perception can be very disturbing. Capitalize on providing pleasant olfactory stimuli and minimize unpleasant ones. This can include using dilute aromatherapy and calming pheromones. TASTE The dog’s perception of taste is similar to humans. They are sensitive to sweets and prefer novel/fatty foods. Palatability is affected by texture, smell, temperature, and flavor. The typical adult cat responds to salty, sour, and bitter tastes. Cats appear to lack functioning receptors for sweet stimuli. 4 However, sweet tastes can mask or neutralize bitter tastes, so sweet flavoring is often used when compounding bitter-tasting medications. Cats are obligate carnivores, so the need for sugary plant-based carbohydrates is not necessary from an evolutionary perspective. Some cats will be interested in sugary foods, but this may be due to the fat content or texture of the food (whipping cream seems to be a favorite for many cats!). 2 Dogs have approximately 1700 taste buds, cats have 480, and humans 9000. 2 Cats will use smell first then taste their food. 5 TOUCH Touch is important for maintaining social relationships. Touch receptors are located at the base of every hair and the vibrissa are especially sensitive. Skin receptors sense proprioception, pain, temperature, chemical stimulation, and pressure. Touch can be calming, arousing, or aversive, depending on the type of touch, the circumstances, and the individual. A few studies have looked at the domestic cat’s preferences for petting. A 2002 study of 9 cats indicated the temporal region (between the eyes and ears) was preferred. Intermediate preference was the perioral (including the chin and lips), and the least preferred area was the caudal (tail) region. 6 These results were comparable to another study performed in 2000 with 90 cats and owner-described petting preferences. This study found the head area was preferred, and only 8% of cats were described as preferring to be pet on the stomach or tail. 7 Dogs can be conditioned to appreciate and enjoy touch. The reverse (touch being regarded by the dog as aversive) is also true and is seen regularly at the veterinary clinic. It shouldn’t be assumed that touch of any particular
type is reinforcing (pleasurable) to any individual dog. In addition, while it may seem counterintuitive, some dogs appear in puppyhood to develop preferences and aversions to touch without any overt trauma noted. If a patient presents with an intolerance of touch, pain or discomfort should always be considered a factor until proven otherwise. 2 In general, petting that involves slow, long, smooth stroking in the direction of the fur promotes relaxation, whereas patting or quick rubbing back and forth is more likely to increase activity/agitation. COMMUNICATION Being able to recognize signs of a relaxed or stressed patient is critical to creating a pleasant environment. Dogs and cats communicate primarily through visual (body language), auditory (vocal), and olfactory (pheromone and scent) communication. VOCALIZATION Often high-pitched sounds are considered distance-decreasing, meaning coming closer. Examples of distance-decreasing sounds in cats and/or dogs are meowing, purring, whining, whimpering, or high-pitched barks. Low-pitch sounds are generally considered distance-increasing, meaning go away. Examples of distance increasing sounds in the cat and/or dog include the hiss, yowl, shriek, and deep or guttural growl and/or bark. OLFACTORY Olfactory communication is extremely important to the cat. Each cat has his/her own signature scent. When one cat in the house visits the veterinary hospital, they will return home smelling different. This can result in the resident cat being unable to recognize their housemate. Dogs and cats release pheromones that can be detected by other members of their species. These pheromones can communicate pleasant and unpleasant information. A stressed cat may leave chemical messages behind that will act to create fear and anxiety in other feline patients throughout the day. The challenge with pheromone communication and smells we humans cannot detect is that since we cannot perceive them, we might overlook their significance to our patient’s well-being. BODY LANGUAGE Being able to interpret body language in dogs and cats involves not only analyzing the entire pet (facial expression, tail carriage, and body posture) but also assessing the context of the interaction. Looking at a snapshot in time only tells part of the story. We need the details about the context to hypothesize the emotional status or communication the pet is trying to express. Even then, we might be inaccurate.
HIGHLIGHTS
WEBINAR
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HUMAN COMMUNICATION WITH DOGS AND CATS Threatening gestures include prolonged eye contact, approaching directly, and distance-increasing vocalizations (deep, guttural sounds). To provide our patients with a considerate approach, we should avoid direct eye contact and a direct approach, turn sideways to look smaller and less threatening, move smoothly and calmly, talk slowly and softly, allow the pet to approach you, offer treats if medically appropriate to do so, avoid aversive scents and use calming ones instead. Rather than reaching toward the pet to offer a treat, try tossing the treats to allow the pet to keep some distance from you initially. This can help prevent putting the pet in a motivational conflict (he wants the treat but is afraid of you at the same time). ASSOCIATIONS Associations are being made all the time. Because we tend to be systematic in our approach to veterinary medicine, animals quickly learn the order of things to come. For example, when placed on a table and the tail is touched, the thermometer will follow. When the technician gets the nail trimmers out of the drawer, nail trimming is about to occur. We can create pleasant associations rather than neutral or negative ones with stimuli in the hospital by pairing pleasant stimuli with a neutral or possibly unpleasant one. For example, nail trimmers can become associated with getting canned dog/cat food. Consequently, the dog or cat may experience happy anticipation when they see the trimmers. A proactive approach to creating pleasant associations with veterinary care is imperative. Changing the pet’s mind after an unpleasant association has been made is much more difficult. Strive to be proactive instead of reactive.
SENSORY PERCEPTION CHART Make a list of stimuli that the pet or client will see, hear, smell, taste, or feel in your hospital. Visually transport yourself from the parking lot to the housing/kennel area. Group the stimuli in categories of potentially pleasant and potentially unpleasant. Take into consideration that for the veterinary setting, promoting calm and relaxed behavior is more conducive to providing veterinary care than promoting active and excitable behavior. Consider how you might be able to minimize potentially unpleasant or over-exciting sights, sounds, smells, taste, and touch and increase pleasant or relaxing ones within the veterinary hospital. Recognize that stimuli that might be pleasant for one patient potentially could be unpleasant for another.
Sights
Sounds
Smells
Taste
Touch
• Pleasant
• Pleasant
• Pleasant
• Pleasant
• Pleasant
• Unpleasant
• Unpleasant
• Unpleasant
• Unpleasant
• Unpleasant
CONCLUSION: Our patients are often more sensitive to environmental stimuli than we are. Consider how you will provide pleasant sensory input and avoid unpleasant ones. Listen to what your patients are telling you and adapt your approach. Set up the environment and our patients for success to create pleasant associations. Through early recognition of behavioral signs of fear, anxiety, and/or stress and intervention on our end, we can prevent the escalation of fear in our patients. Constantly evaluate and re-evaluate and modify as needed. Consequently, we can facilitate pleasant associations with the veterinary hospital and the procedures we want to perform and create a safer and more enjoyable work atmosphere. Your patients and clients will thank you!
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REFERENCES
1. Bradshaw JWS. The Behavior of the Domestic Cat, CABI Publishing, Wallingford, 1992. 2. Martin, D., Shaw, J. Canine and Feline Behavior for Veterinary Technicians and Nurses, John Wiley& Sons, Inc., 2023. 3. Lewis H. Online article published September 24, 2015. Accessed on May 19, 2016. http://veterinaryhospitaldesign.dvm360.com/fear-free- what-you-see-not-what-cat-or-dog-gets 4. Li, CAtXia Li; Weihua Li, Weihua; Wang, H; Bayley, D; Cao, J; Reed, D; Bachmanov, A; Huang, L; Legrand-Defretin, V; Beauchamp, GK; Brand, JG, Cats Lack a Sweet Taste Receptor. J Nut 2006;136(7):1932S–1934S, https://doi.org/10.1093/jn/136.7.1932S. 5. Hullar, I., Fekete, S., Andrasofszky, E. et al. Factors influencing the food preference of cats. J Anim Physio Anim Nut 2001;85 (7-8):205-211. 6. Soennichsen, S; Chamove, AS. Responses of cats to petting by humans. Anthrozoös 2002;15:258-265. 7. Bernstein, P.L.. People petting cats: a complex interaction. Abstracts of the Animal Behaviour Society, Annual Conference, Atlanta, GA, USA, 2000.
OTHER RESOURCES
HIGHLIGHTS
WEBINAR
• Debbie Martin, LVT, VTS (Behavior), Elite FFCP-V • www.TEAManimalbehavior.com
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IMAGING THE DYSPNEIC CAT: A CASE SERIES
Marc Seitz, DVM, DACVR, DABVP (Canine and Feline Practice)
In this VETgirl Webinar “Imaging the Dyspneic Cat: A Case Series,” Dr. Marc Seitz, DVM, DACVR, DABVP (Canine and Feline Practice) breaks down the approach one of the most stressful ER presentations: the acutely dyspneic cat. From when to pause for stabilization to how to get the most out of your thoracic rads and POCUS findings, Dr. Marc Seitz, walks you through the key imaging clues that help differentiate heart failure, pleural effusion, airway disease, and neoplasia. If you’ve ever questioned whether it’s safe to shoot rads, when to tap the chest, or what to make of all those lung rockets, read on! Missed the webinar? Catch the replay HERE or scroll down for the highlights! depth is inappropriate. Alveolar-interstitial disease caused by edema or cellular infiltrates will change the repetition artifact (A-lines) of normal lung tissue to a ring-down artifact (termed B-lines). In private practice, the colloquial term “lung rockets” has also been used for ring-down artifact occurring with alveolar-interstitial disease. This term should not be confused with a similar space-themed term, “comet-tail artifact,” which occurs when the ultrasound strikes a highly reflective structure such as a needle or catheter. Unfortunately, the presence of ring-down artifact is incredibly non- specific and occurs with any disease capable of producing an unstructured interstitial or alveolar pulmonary pattern. Examples include, but are not limited to, cardiogenic pulmonary edema, non-cardiogenic pulmonary edema, infectious etiologies, neoplasia, hemorrhage, acute lung injury, and atelectasis. When combined with the history, signalment, and physical exam findings, results from a POCUS exam can help localize the cause of dyspnea as well as guide stabilization therapies and further diagnostics. Thoracic POCUS ultrasound findings can also be used to complement radiographic findings. Specific examples include confirming the presence of pleural effusion, guiding diagnostic or therapeutic thoracocentesis, and differentiating cardiogenic pulmonary edema secondary to left sided heart failure from airway disease like asthma. Although thoracic POCUS findings are rapid and quite useful, they are never a replacement for thoracic radiographs as they only evaluate the pleural space, heart, and surface of the lungs. 1 Large lesions or regions of abnormal lung can easily be missed by ultrasound due
Associate Clinical Professor of Diagnostic Imaging College of Veterinary Medicine, Department of Clinical Sciences Mississippi State University, Mississippi State, MS, USA INTRODUCTION Cats are stable until they aren’t. Dyspnea of any cause is a common reason cats present acutely unstable. Imaging is a vital part of diagnosing the underlying cause of dyspnea. However, triaging and stabilizing patients is imperative prior to pursuing imaging studies as stress and non-sternal recumbency can alter ventilation, disrupting the delicate balance that comes with compensation for hypoxemia. This is especially true for pleural space disease. All patients benefit from remaining in sternal recumbency and some form of oxygen therapy. Many patients benefit from a mild sedative (e.g., butorphanol) or an anxiolytic drug. Other stabilization therapies should be tailored to triage exam findings. For example, bronchodilators can be given to patients with suspected asthma. A diuretic like furosemide can be given to patients with suspected heart failure. If pleural effusion is present, thoracocentesis should be performed prior to radiographs as it will improve evaluation of the pulmonary parenchyma. Thoracic point-of-care ultrasound (POCUS) is one imaging technique that can be safely performed after the initial triage exam and while patient stabilization is being performed. Thoracic POCUS is easily performed with the patient standing or in sternal recumbency. A detailed description of various techniques and interpretation is beyond the scope of this article and well-reviewed elsewhere (references below). However, POCUS is invaluable at rapidly diagnosing pleural effusion, pericardial effusion, and alveolar-interstitial disease. Pleural and pericardial effusion are both usually anechoic. The presence of echogenic debris within effusion increases suspicion that the fluid is exudative or hemorrhagic. However, a lack of echogenic fluid does not rule out these conditions. Pericardial effusion becomes more difficult to diagnose when pleural effusion is also present due to decreased visualization of the pericardial sac from edge shadowing and anisotropy. Additionally, severe cardiac chamber enlargement can sometimes artifactually mimic pericardial effusion, especially if machine
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to the negative effects of repetition artifact that results from gas within the pulmonary parenchyma. Additionally, thoracic radiographs provide a global view of the thorax, evaluating structures that may influence interpretation of cardiopulmonary or pleural space pathology. As a result, thoracic radiographs are essential and should be acquired when safe to do so. A complete thoracic radiographic study involves acquiring three projections: right lateral, left lateral, and either ventrodorsal (VD) or dorsoventral (DV) projections. A DV projection is likely safer in most patients as it maximizes ventilation. The only downside is that if pleural effusion is present, it is more likely to decrease visualization of the cardiac silhouette on a DV projection as compared to VD. The author prefers to start with the DV (or VD) projection for all thoracic studies as it will decrease the odds of atelectasis (resulting from lateral recumbency) causing increased opacity throughout the pulmonary parenchyma that could be confused with true disease. Finally, it is prudent to keep in mind that each lateral projection only evaluates the pulmonary parenchyma and pleural space of the opposite side because of recumbent atelectasis. For example, when looking at a right lateral radiograph, only the left cranial and left caudal lung lobes are evaluated. Beyond imaging, other routine diagnostics helpful during the initial work up of dyspneic cats include a complete blood count, a chemistry profile, urinalysis, retrovirus testing, and heartworm antigen/ antibody testing. More advanced testing includes echocardiography, diagnostic thoracic ultrasound, and computed tomography with contrast. THE NORMAL FELINE THORAX The feline cardiac silhouette is smaller appearing within the thoracic cavity as compared to the dog, with less interpatient variation in size and shape. Objectively, the cardiac silhouette spans 2-3 ribs spaces on the lateral projection and < 50% of the thoracic cavity width on the VD/DV projection. In most cats, the vertebral heart score (VHS) measured in lateral recumbency should be < 8.1. However, the sensitivity and specificity of the VHS in predicting cardiac enlargement is highly dependent on the cut-off value used with a trade-off favoring either one or the other. 2,3 Unfortunately, different studies have yielded very different cut-offs when determining 100% sensitivity (best for screening) versus 100% specificity (best for discriminating). Additionally, the VHS is no better than subjective evaluation of cardiac size, making the routine use of objective cardiac measures of questionable value at this time. The VHS and other measurements may be better for monitoring changes over time on serial radiographic studies for the individual patient. In geriatric cats, the cardiac silhouette often rotates cranioventrally, causing it to occupy more intercostal spaces without actually increasing in size. The feline pulmonary parenchyma is more lucent and “less busy” relative to the dog due to decreased visibility of pulmonary markings. Similar to the dog, a thin body condition will make the lungs appear more lucent, whereas obesity will cause an artificial increase in soft tissue opacity throughout the lungs, giving the false appearance of an unstructured interstitial pulmonary pattern. Cats do not commonly develop age-related pulmonary fibrosis, so the presence of a bronchial pattern should raise suspicion for airway disease. Finally, the pleural space is not normally visible unless it pathologically contains gas or fluid. Excessive fat within the mediastinum can also widen pleural fissures as well as make the cardiac silhouette appear enlarged.
The radiographic findings of specific etiologies will be discussed below. However, it is important to keep in mind that most imaging findings in isolation (e.g., unstructured interstitial pulmonary pattern on radiographs or ring-down artifact/B-lines on ultrasound) are incredibly non-specific with multiple differentials possible. As is this case for any diagnostic test, the diagnosis comes from the combination of historical clues, physical exam findings, other diagnostic test results, and most importantly, the veterinarian’s clinical acumen. It is well established that the accuracy of any imaging modality increases with ancillary information and experience level of the interpreter. HEART FAILURE Left sided heart failure is one of the most common causes of dyspnea in the cat. Acquired cardiomyopathies (e.g., hypertrophic, thyrotoxic, restrictive, non-specific, and dilated) are the most common cause of left sided congestive heart failure in cats. Heart failure is a clinical diagnosis that comes from physical exam and radiographic findings. Although echocardiography is useful to determine the underlying etiology of heart failure, it is often not necessary for diagnosing failure or initially treating the dyspneic patient. The presence of hypothermia on triage exam in a dyspneic cat should greatly raise the index of suspicion for heart failure and/or aortic thromboembolism. A recent study 4 demonstrated that the combined findings of hypothermia, tachycardia, tachypnea, and a gallop rhythm are strongly suggestive of heart failure and warrant diuretic therapy until further testing can be performed. The hallmark radiographic findings of feline left sided heart failure include a patchy (or less commonly diffuse) unstructured interstitial or alveolar pulmonary pattern and enlarged pulmonary lobar veins. Unfortunately, cats love to be very different than dogs in many ways. First, cardiomegaly may be only mild in the face of fulminant heart failure. When present, cardiomegaly is often generalized without appreciable chamber enlargement. A valentine-shaped cardiac silhouette is commonly seen on DV or VD radiographs and is most often caused by left atrial enlargement. 5 Second, the presence of enlarged pulmonary lobar veins is inconsistent in cats and further masked with a single dose of a diuretic. Third, pleural effusion commonly occurs with left sided heart failure in cats as compared to right sided failure in dogs. Finally, cardiogenic pulmonary edema will sometimes increase pulmonary opacity only around the bronchi (i.e., peribronchial cuffing) in cats, mimicking the bronchial pulmonary pattern that occurs with inflammatory airway disease. Without cardiac or pulmonary lobar venous enlargement, the findings of a pulmonary pattern with or without pleural effusion are very nonspecific and caused by other etiologies such as neoplasia and infectious disease. In these cases, a diuretic trial can be performed by administering an appropriate dose of a diuretic and repeating radiographs 6-24 hours later. Radiographic improvement of the pulmonary pattern in a short period of time following diuretic administration is strongly supportive of left sided heart failure. A clinical response to furosemide is not pathognomonic for heart failure as patients with airway disease will respond to the drug’s bronchodilatory effects.
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AIRWAY DISEASE Inflammatory airway diseases are also frequently seen in dyspneic cats. Common causes of airway disease in the cat include asthma, heartworm disease, chronic bronchitis, and other infectious disease caused by parasitism, fungal etiologies, and bacteria. All are indistinguishable on radiographs with the end result being airway inflammation and thickening. While airway disease can still be present in the face of normal radiographs, the vast majority of cats exhibit a bronchial pulmonary pattern. 6 “Bronchial” should not be confused with the term “bronchiolar,” the latter of which refers to small airways. Thickened bronchi may be sharply marginated or ill-defined. Many cats also exhibit an unstructured interstitial pulmonary pattern, which may indicate extension of inflammation into the surrounding interstitium, concurrent infection, and/or pulmonary fibrosis. More recently, extension of airway disease from the larger bronchi to the smaller bronchioles (< 2 mm in diameter) has been described and classified 7 with yet to be determined clinical significance regarding treatment. Additionally, primary bronchiolar disease without larger airway involvement may also occur. Radiographs are unable to evaluate for bronchiolar disease. While there are limited reports on the use of CT in diagnosing lower airway involvement, bronchiolar disease is best confirmed with histopathology. Sequalae associated with feline asthma are somewhat different than those seen in dogs with chronic bronchitis. As the disease progresses, airway narrowing secondary to spasms, inflammation, or fibrosis can lead to air trapping that causes hyperinflation of the affected lobe(s). The increased lung volume causes the lung fields to appear bigger and more lucent. In more severe cases, the diaphragm will displace caudally and appear flattened on lateral projections or tented on the ventrodorsal projection. The author has witnessed on more than one occasion severe pulmonary hyperinflation confused for pneumothorax due to the decreased visualization of pulmonary markings. Occasionally, mucus plugs are sometimes seen in the lumen of large bronchi as ill-defined or sharply marginated soft tissue opaque structures. When bronchioles fill with mucus, pus, or fluid, multi-focal nodules with or without linear branching may be seen, a pattern termed “tree-in-bud.” Whether present in large or smaller airways, mucus plugs may be mistaken for pulmonary nodules or fungal/ parasitic granulomas. Another complication of lower airway disease more commonly seen in cats is lobar collapse secondary to airway obstruction from mucus or exudative material. Although any lung lobe can be affected, the right middle is most commonly reported. Atelectasis will cause a severe alveolar pulmonary pattern in the affected lobe, characterized by increased opacity, air bronchograms, border effacement of surrounding soft tissue structures, and a lobar sign. In certain cases, the collapsed lobe may contract and appear missing or difficult to visualize. Reinflation often occurs with treatment of the underlying disease. Although less common, secondary airway infection can occur in asthmatic cats as it does in dogs with chronic bronchitis. Bronchiectasis is less common but reported. Finally, a small percentage of cats may fracture the mid-portion of their most caudal five ribs secondary to severe dyspnea or coughing. PLEURAL EFFUSION Due to its myriad of causes, pleural effusion is a common cause of dyspnea in young, middle-aged, and older cats. Congestive heart failure (discussed above) and neoplasia (discussed below) are the most common causes of pleural effusion in the cat. Other causes include pyothorax from penetrating
trauma like bite wounds, feline infectious peritonitis (FIP), other infectious etiologies, idiopathic chylothorax, and hemorrhage. Pleural effusion can cause dyspnea alone via hypoventilation or along with concurrent pulmonary disease which compounds hypoxemia. Radiographic signs of pleural effusion include widened, opaque soft tissue interlobar fissures, retraction of the lung lobes, rounding of the lung margins and costophrenic sulci, and effacement of the margins of other soft tissue structures such as the cardiac silhouette and diaphragm. Most causes of pleural effusion present bilateral due to the incomplete mediastinum in cats. However, unilateral pleural effusion may occur with exudative etiologies that plug mediastinum fenestrations, such as pyothorax and FIP. Small volume pleural effusion is easily confirmed via thoracic POCUS. When possible, fluid should always be sampled to help prioritize differentials. DIFFUSE NEOPLASIA Diffuse neoplasia is an uncommon cause of dyspnea in cats but is very tricky as it can mimic other more common diseases. For both primary and metastatic neoplasia, respiratory signs primarily occur when the disease process is diffuse and/or causing concurrent pleural effusion. Carcinomas are the most common primary lung tumor and typed according to their location as bronchial, alveolar, or bronchoalveolar. While carcinomas most often form a single solitary mass that sometimes contains cavitations, they also can present as multifocal nodules, complete lung lobe consolidation, or a diffuse bronchial pulmonary pattern. The latter two radiographic presentations are deceptive as they can easily be confused with lung lobe torsion/abscessation or inflammatory airway disease, respectively. Feline pulmonary carcinomas are highly metastatic and may cause concurrent pleural effusion and lymphadenopathy. Lymphoma can occur in the lungs as either multicentric disease or primary pulmonary disease. Consistent with the saying “lymphoma does what lymphoma wants,” it can manifest as any pulmonary pattern: a single solitary mass, multifocal nodules, bronchial, alveolar, unstructured interstitial, or a combination thereof. Most deceptive are unstructured interstitial/alveolar or bronchial patterns as they can mimic pulmonary edema/infectious etiologies or inflammatory airway disease, respectively. Lymphoma also commonly causes pleural effusion, lymphadenopathy, and/or mediastinal masses. Hepatosplenomegaly may also be seen in the viewable cranial abdomen.
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REFERENCES
1. Cole L, Pivetta M, Humm K. Diagnostic accuracy of a lung ultrasound protocol (VetBLUE) for detection of pleural fluid, pneumothorax and lung pathology in dogs and cats. J Small Anim Pract. 2021;62(3):178-186. 2. Guglielmini C, Toaldo MB, Poser H, et al. Diagnostic accuracy of the vertebral heart score and other radiographic indices in the detection of cardiac enlargement in cats with different cardiac disorders. J Fel Med Surg . 2014;16:812-25. 3. Sleeper MM, Roland R, Drobatz KJ, et al. Use of the vertebral heart scale for differentiation of cardiac and noncardiac causes of respiratory distress in cats: 67 cases (2002-2003). J Am Vet Med Assoc. 2013;242(3):366-371. 4. Dickson D, Little CJL, Harris J, et al. Rapid assessment with physical examination in dyspnoeic cats: the RAPID cat study. J Small Anim Pract. 2018;59:75-84. 5. Oura TJ, Young AN, Keene BW, et al. A valentine-shaped cardiac silhouette in feline thoracic radiographs is primarily due to left atrial enlargement. Vet Radiol Ultrasound. 2015;56(3):245-250. 6. Gadbois J, d’Anjou MA, Dunn M, et al. Radiographic abnormalities in cats with feline bronchial disease and intra- and interobserver variability in radiographic interpretation: 40 cases (1999-2006). J Am Vet Med Assoc. 2009;234(3):367-375. 7. Reinero CR, Masseau I, Grobman M, et al. Perspectives in veterinary medicine: Description and classification of bronchiolar disorders in cats. J Vet Intern Med. 2019;33:1201-1221.
ADDITIONAL READINGS
• Bahr, R. Chapter 35: Canine and Feline Cardiovascular System. In: Thrall DE (eds). Textbook of Veterinary Diagnostic Radiology. 7 th eds. St Louis, MO: Elsevier, 2018, pp 684 – 709. • Balleger EA, Forrest LJ, Stepein RL. Radiographic appearance of bronchoalveolar carcinoma in nine cats. Vet Radiol Ultrasound. 2002;43(3):267-271. • Boysen SR. Chapter 189: AFAST and TFAST in the intensive care unit. In: Silverstein, DC and Hopper, K. Small Animal Critical Care Medicine, 2 nd ed. 2015:988-994. • Geyer NE, Reichle JK, Valdes-Martinez A, et al. Radiographic appearance of confirmed pulmonary lymphoma in cats and dogs. Vet Radiol Ultrasound. 2010;51(4):386-390. • Hahn H, Specchi S, Masseau I, et al. The computed tomographic “tree-in-bud” pattern: Characterization and comparison with radiographic and clinical findings in 36 cats. Vet Radiol Ultrasound. 2018;59(1):32-42. • Lisciandro GR, Gambino JM (eds). Diagnostic imaging: point-of-care ultrasound. Vet Clin North Am Small Anim Pract. 2021;51(6). • Louvet A, Bourgeois JM. Lung ring-down artifact as a sign of pulmonary alveolar-interstitial disease. J Vet Radiol Ultrasound. 2008;49(4):374-377. • Thrall, DE. Chapter 36: Canine and Feline Lung. In: Thrall DE (eds). Textbook of Veterinary Diagnostic Radiology. 7 th eds. St Louis, MO: Elsevier, 2018, pp 710 - 734.
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