Transcerebellar ventriculoperitoneal shunt for management of presumed arachnoid diverticulum in the fourth ventricle of a dog

OBJECTIVE

To describe the approach for placement of a transcerebellar fourth ventriculoperitoneal shunt for management of presumed fourth ventricle arachnoid diverticulum and secondary obstructive hydrocephalus of a dog. To describe the outcome of this procedure.

STUDY DESIGN

Case report.

ANIMALS

Male entire English springer spaniel, 3 years 9 months of age.

METHODS

The dog was initially presented for management of acute, progressive, and multifocal brainstem and forebrain dysfunction. Magnetic resonance imaging revealed internal obstructive hypertensive hydrocephalus. The dog was managed via ventriculoperitoneal shunting from the left lateral ventricle and made an excellent recovery. The dog acutely deteriorated 18 months after initial discharge and follow-up magnetic resonance imaging confirmed the ventricular shunt remained in situ with normal-sized lateral ventricles but revealed a cystlike lesion within the fourth ventricle, presumed to be a fourth ventricle arachnoid diverticulum. The diverticulum was causing mass effect and resultant compression of adjacent neuroparenchyma. A second ventriculoperitoneal shunt was subsequently placed into the fourth ventricle via the caudal cranial fossa and cerebellum. This was attached to a three-way connector, to which the existing shunt (within the left lateral ventricle) was also attached, and then secured to the existing medium-pressure valve.

RESULTS

Postoperatively, the dog immediately developed mild vestibular-cerebellar ataxia, with a marked improvement after 3 months. There were no shunt-associated complications. Long-term follow up at 40 months after the second surgical procedure revealed a normal neurological examination.

CONCLUSION

Transcerebellar ventriculoperitoneal shunt placement for treatment of a presumed fourth ventricle arachnoid diverticulum was performed and was associated with a favorable long-term outcome.

Successful Surgical Resection of an Ependymal Cyst in the Fourth Ventricle of a Dog

Ependymal cysts represent congenital brain malformations rarely described in human medicine, where surgical resection is the treatment of choice. In veterinary medicine, only three cases have been previously reported, with one partially resected with surgery. A 6 yr old entire male American Staffordshire terrier was referred with a 4 mo history of incoordination and collapsing episodes with extensor rigidity. Neurological examination localized the lesion to the left central vestibular system and cerebellum. A brain computed tomography scan showed a hypoattenuating lesion with peripheral contrast enhancement in the fourth ventricle consistent with a cyst and secondary hydrocephalus. Treatment with prednisone was initiated, but despite an initial improvement, neurologic signs recurred and a suboccipital craniectomy to remove the cyst was performed. The cyst was first drained, and the capsule was carefully resected. The histopathological evaluation revealed a simple cubic to cylindrical epithelium with apical cilia and loose surrounding fibrillar tissue consistent with an intraventricular ependymal cyst. Four and a half years after surgery, the dog only shows short episodes of balance loss when turning abruptly but is otherwise neurologically normal. To the authors' knowledge, this is the first reported ependymal cyst in the fourth ventricle of a dog with successful surgical resection.

An extradural cyst in a French Bulldog

CASE HISTORY

A 7-year-old, male neutered French Bulldog was referred to a specialist veterinary hospital for evaluation of progressive paraparesis of 6-months' duration. The owners reported both faecal and urinary incontinence at home.

CLINICAL FINDINGS

The dog presented with ambulatory paraparesis and pelvic limb ataxia that was more pronounced in the right pelvic limb. The pelvic limb withdrawal response and sciatic myotatic response were reduced bilaterally. Postural reaction responses were delayed in both pelvic limbs, and this was more obvious in the right pelvic limb. The anal tone and perineal sensation were normal at the time of examination.An L4-S3 myelopathy was suspected. CT of the spine revealed a compressive, bilobed, extramedullary, cyst-like structure within the vertebral canal, between L7 and S3. Surgical removal of the cyst via a L7-S1 dorsal laminectomy was performed. Histopathological examination and additional immunohistochemistry of the excised structure indicated a probable ependymal cyst with a ciliated lining. The dog recovered well post-operatively, and at follow-up 3 weeks later had some improvement of his neurological signs. The paraparesis and pelvic limb ataxia had improved; however, the remaining neurological examination was similar to the pre-surgical examination.

DIAGNOSIS

Extradural cyst.

CLINICAL RELEVANCE

Spinal cysts can contribute to clinical signs that resemble other common chronic spinal cord diseases, such as intervertebral disc disease. Therefore, this disease should be considered as a differential when dealing with cases of progressive paraparesis and pelvic limb ataxia. This case report may potentially provide opportunities in the future for further understanding of the pathogenesis, behaviour, outcomes and subclassification of spinal cysts in dogs.

Atypically located arachnoid cyst in a five-year-old cat

Arachnoid cysts are cystic lesions that occur in spinal or intracranial locations in the leptomeningeal space. Four intracranial cases have been described in cats, three of which were diagnosed by imaging techniques alone. We now report the clinical, gross and histopathological findings in a 5-year-old, male-neutered European Shorthair cat that presented with chronic, asymmetrical encephalopathy. Using magnetic resonance imaging, a focal, fluid-filled cavity that did not show contrast enhancement was identified in the left temporal and piriform lobes. Necropsy confirmed the presence of a cystic, meningeal cavity filled with clear, serous fluid. Histologically, the cyst had an irregular, hypereosinophilic surface and single psammoma bodies with moderate perivascular oedema in the adjacent neuroparenchyma. Immunohistochemical evidence of meningeal tissue surrounding the cyst confirmed the diagnosis of an arachnoid cyst, which should be considered as a differential diagnosis of intracranial, fluid-filled cavities.

Symptomatic lateral ventricular cystic lesion in a young cat

Case summary

A 1.5-year-old male neutered Persian cat was referred for acute deterioration of chronic left head tilt and ataxia. A lateral intraventricular cystic lesion, closely associated with the left choroid plexus, was identified on MRI. The intralesional signal intensity and cytological analysis of the fluid revealed a liquid similar to cerebrospinal fluid. After trepanation, an endoscopic-assisted fenestration and aspiration of the cyst were performed to temporally relieve the high intracranial pressure while waiting for surgical cystoperitoneal shunt placement. Three weeks after surgery, clinical relapse and recurrence of the lesion were noted on the pre-cystoperitoneal shunting MRI. During anaesthesia, the cat arrested. Cardiac resuscitation was successfully performed and cystoperitoneal shunting was postponed. Global brain ischaemia was then suspected, based on major forebrain clinical signs and MRI abnormalities. During a 6-month recovery period, a further three fine-needle CT-guided aspirations of the lesion were required, owing to clinical recurrence and increased cyst size. Cystoperitoneal shunting was eventually performed, allowing persistent reduction of the lesion and long-term improvement of the cat’s neurological status.

Relevance and novel information

This is the first report of a symptomatic lateral intraventricular cystic lesion in a cat. A left lateral intraventricular choroid plexus cyst was suspected based on the MRI features. Our case suggests that endoscopic fenestration and CT-guided aspiration are not adequate treatments for long-term management. Cystoperitoneal shunting may be a safe procedure, allowing significant and stable reduction of the cystic lesion, associated with improvement in the cat’s neurological status by preventing high intracranial pressure.

A Recurrent Suprapituitary Ependymal Cyst Managed by Endoscopy-Assisted Transsphenoidal Surgery in a Canine: A Case Report

A 9-years-old spayed female mixed-breed dog was referred for the evaluation of intermittent head tremors, obtundation, long-standing blindness, and a tendency to seek confined spaces. The dog lost its vision 6 months before the current presentation. A menace response was absent on ophthalmological examination. Neurological examination did not show any abnormalities. A cyst measuring 16 × 18 × 14 mm was observed above the pituitary gland on magnetic resonance imaging. It extended toward the frontal area and compressed the optic chiasm and hypothalamic regions. A minimum preoperative database, including the findings of other required blood tests, was prepared. No abnormal laboratory findings were observed. Endoscopy-assisted transsphenoidal hypophysectomy was performed to remove the pituitary gland, drain the cyst, and partially excise the cyst wall. Normal pituitary gland tissue was observed on histopathology, and the mass was found to have a neuroendocrine or ependymal origin on cytology. Strict post-operative laboratory tests were performed at 1-h intervals for 24 h. An empty sella turcica region, and a collapsed and empty cyst wall was observed on follow-up magnetic resonance imaging. After 3 days of observation, the dog was discharged with a prescription of substitution therapy. However, the dog presented with the same signs and symptoms 73 days after the surgery. Cyst recurrence was apparent on magnetic resonance imaging. The owner requested euthanasia, and an ependymal cyst was observed on necropsy. To the best of our knowledge, we present the first case of an intra- and suprasellar ependymal cyst, and its surgical management in a canine. The findings from this case suggest that endoscopic transsphenoidal drainage and hypophysectomy could be a good surgical approach in cases where involvement of the pituitary gland is confirmed or strongly suspected on the basis of cytological and imaging findings.

Intracranial ectopic choroid plexus cyst in a dog

A 4-year-old male Toy Poodle was presented with a history of status epilepticus. On presentation, neurological examination revealed a delay in postural reactions in the right pelvic limb. Magnetic resonance imaging showed a fluid-containing cystic lesion that compressed the mesencephalon, hippocampus, and amygdala. The cyst was surgically removed via left rostrotentorial craniotomy. The final diagnosis was an intracranial ectopic choroid plexus cyst. The patient has remained free of seizures for 18 months after surgery. This is the first case report of an intracranial ectopic choroid plexus cyst that was surgically removed in a dog.

Neuroendodermal cyst in the fourth ventricle of a dog

CASE REPORT

We describe the MRI appearance and surgical outcome of a rare neuroendodermal cyst in the fourth ventricle of a German Shorthaired Pointer. The dog presented with uncoordinated gait and occasional falling that increased when she became excited. The MRI appearance is shown and the surgical treatment described. Recurrence occurred on two occasions and the dog was euthanased.

CONCLUSION

Recurrence of these cysts is highly likely unless there is complete surgical resection.

Magnetic resonance imaging diagnosis of brain tumors in dogs

A great deal of information is now available regarding the range of magnetic resonance imaging (MRI) features of many primary and secondary brain tumors from dogs. In this review, these canine neoplasms are grouped into meningeal masses, ventricular masses, intra-axial enhancing lesions, intra-axial mildly to non-enhancing lesions, and multifocal lesions. For each of these patterns, the major and sporadic neoplastic differential diagnoses are provided, and guidance on how to rank differential diagnoses for each individual patient is presented. The implication of MRI features such as contrast-enhancement, signal intensities and location is discussed. However, the information garnered from MRI must be correlated with all available clinical information and with epidemiological data before creating a differential diagnosis.

Intracranial arachnoid cysts in a chimpanzee (Pan troglodytes)

An intracranial arachnoid cyst was detected in a 32-year-old, 44.6-kg, female chimpanzee at the Primate Research Institute, Kyoto University. Magnetic resonance imaging (MRI) and computed tomography (CT) were performed and the cognitive studies in which she participated were reviewed. MRI revealed that the cyst was present in the chimpanzee's right occipital convexity, and was located in close proximity to the posterior horn of the right lateral ventricle without ventriculomegaly. CT confirmed the presence of the cyst and no apparent signs indicating previous skull fractures were found. The thickness of the mandible was asymmetrical, whereas the temporomandibular joints and dentition were symmetrical. She showed no abnormalities in various cognitive studies since she was 3 years old, except a different behavioural pattern during a recent study, indicating a possible visual field defect. Detailed cognitive studies, long-term observation of her physical condition and follow-up MRI will be continued.

Magnetic resonance imaging of intracranial malformations in dogs and cats

Intracranial malformations may occur because of an inherent developmental defect or secondary to in utero injury to the brain with subsequent hypoplasia and atrophy. They can cause neurologic deficits in growing animals, although some anomalies may not produce clinical signs until adulthood. Malformations of the brain include hydrocephalus, hydranencephaly/porencephaly, holoprosencephaly, corpus callosum agenesis/dysgenesis, lissencephaly, polymicrogyria, meningoencephalocele, intracranial cysts, cerebellar malformations, and hamartomas. These conditions are defined and reviewed with an emphasis on their features in magnetic resonance images.

Ependymal cyst in the cerebrum of an African green monkey (Chlorocebus aethiops)

A focal lesion was detected by magnetic resonance imaging in the right caudal occipital lobe of the cerebrum in an African green monkey (Chlorocebus aethiops). Neurological signs were not observed in this animal. At necropsy examination, an 8mm wedge-shaped intracranial cavity was found, which apparently did not communicate with the ventricles. Microscopically, the inner surface of the cavity was lined by ciliated cuboidal epithelium with positive immunoreactivity for S100 protein, glial fibrillary acidic protein and cytokeratin. Based on the gross, microscopical and immunohistochemical findings the lesion was classified as an ependymal cyst. To the best of our knowledge, this is the first report of an ependymal cyst in an African green monkey.

Quadrigeminal arachnoid cysts in a kitten and a dog

Two quadrigeminal arachnoid cysts with different pathogenesis are described in 2 different species. A 10-week-old male Persian kitten with a progressively decreasing level of consciousness died spontaneously. At necropsy, mild internal hydrocephalus, caudal cerebellar coning, and cerebellar herniation through the foramen magnum were associated with a congenital quadrigeminal arachnoid cyst compressing the rostral cerebellum and shifting the entire cerebellum caudally. In contrast, a possibly acquired quadrigeminal cyst was observed in a 2-year-old male neutered Yorkshire Terrier in association with necrotizing encephalitis. Quadrigeminal arachnoid cysts have been rarely reported in dogs and humans.