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Tauro A, Di Dona F, Zoelch N, Stent A. Fluctuation of Clinical Signs With Near-Syncopal Episodes in a Dog With Gliomatosis Cerebri: A Diagnostic Challenge. Top Companion Anim Med 2021; 43:100508. [PMID: 33434679 DOI: 10.1016/j.tcam.2021.100508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 12/21/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Abstract
A 2-year-old Bull Mastiff cross Boxer neutered male dog was evaluated because of 2-month history of non-progressive right head tilt and mild vestibular ataxia. MRI of the brain revealed a faint T2W, FLAIR, DWI and ADC heterogenous hyperintense and T1W isointense intra-axial lesion with indistinct margins at the level of the pons and medulla oblongata. The lesion did not show any susceptibility artefact on T2* GRE images or contrast enhancement and CSF analysis was normal. Analysis of the spectra from MRS of the thalamus not promptly available at the time of the MRI study revealed a decreased level of NAA, as seen in people with gliomatosis cerebri. The dog represented 3 weeks later and, on this occasion, displayed left-sided head tilt, left-sided postural reaction deficits and near-syncopal episodes associated with state of confusion. Repeated MRI revealed a larger non-enhancing intra-axial lesion with a more hyperintense signal than previously described. CSF was normal and PCR of CSF for infectious diseases was negative. Thoracic and abdominal computed tomography did not reveal any primary or metastatic process. Immunosuppressive treatment was attempted and the dog remained stable over 5 days, then developed generalized tonic-clonic seizures which led to status epilepticus and death. Histopathology supported the diagnosis of gliomatosis cerebri. Gliomatosis cerebri remains difficult to diagnose ante-mortem, due to the broad age of onset and the variable duration and wide range of clinical signs. The mismatch between MRI findings and clinical presentation, the fluctuating clinical signs with near-syncopal episodes associated with a state of confusion, the presence of an infiltrative brain disease as depicted on MR imaging and a normal CSF analysis, should prompt the clinician to consider possible diagnosis of a widespread infiltrative neoplasm. Although, MRS may help narrow the differential diagnosis in favor of a neoplastic lesion, the overall prognosis remains poor.
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Affiliation(s)
- Anna Tauro
- Chestergates Veterinary Specialists, Chester, Cheshire, UK.
| | | | - Niklaus Zoelch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Switzerland
| | - Andrew Stent
- University of Melbourne, Werribee Victoria, Australia
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Olszewska A, Schmidt MJ, Failing K, Nicpoń J, Podgórski P, Wrzosek MA. Interictal Single-Voxel Proton Magnetic Resonance Spectroscopy of the Temporal Lobe in Dogs With Idiopathic Epilepsy. Front Vet Sci 2020; 7:644. [PMID: 33195502 PMCID: PMC7541947 DOI: 10.3389/fvets.2020.00644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Proton magnetic resonance spectroscopy (H1-MRS) could provide insight into the metabolic pathophysiology of the temporal lobe of canine brain after seizure. Currently, there is no evidence-based data available on MRS of temporal lobe in dogs with idiopathic epilepsy (IE). The aim of this prospective, cross-sectional study was to evaluate the interictal metabolic activity of the temporal lobe in IE dogs compared to a control group with the use of H1-MRS. Ten healthy dogs and 27 client-owned dogs with IE underwent 1.5-Tesla magnetic resonance imaging (MRI) and single-voxel H1-MRS. The MRS studies were acquired as spin echoes with a repetition time (TR) of 2,000 ms and an echo time (TE) of 144 ms. A cubic voxel (10 ×10 ×10 mm) was positioned bilaterally into the region of the left and right temporal lobe, including a middle part of the hippocampus and the amygdala. The N-acetylaspartate (NAA)-to-creatine (NAA/Cr), NAA-to-choline (NAA/Cho), choline-to-creatine (Cho/Cr), and choline-to-NAA (Cho/NAA) ratios were determined in both hemispheres and compared to controls. No significant differences in all metabolite ratios between epileptic dogs and the control group could be found. A time-dependent decrease in the NAA/Cho ratio as well as an increase in the Cho/NAA ratio was found with proximity in time to the last seizure. We found no correlation between metabolite ratios and age or sex in this animal group. Time span from the last seizure to the acquisition of MRS significantly correlated with NAA/Cho and Cho/NAA ratio. We conclude that without a time relation, metabolite ratios in dogs with IE do not differ from those of the control group.
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Affiliation(s)
- Agnieszka Olszewska
- Department of Veterinary Clinical Science, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Martin Jürgen Schmidt
- Department of Veterinary Clinical Science, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Klaus Failing
- Unit for Biomathematics and Data Processing, Faculty of Veterinary Medicine, Justus Liebig-University Giessen, Giessen, Germany
| | - Józef Nicpoń
- Department of Internal Diseases With a Clinic for Horses, Dogs and Cats, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland.,Center of Experimental Diagnostics and Innovative Biomedical Technologies, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Przemysław Podgórski
- Department of General Radiology and Interventional Radiology and Neuroradiology, Wrocław Medical University, Wrocław, Poland
| | - Marcin Adam Wrzosek
- Department of Internal Diseases With a Clinic for Horses, Dogs and Cats, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
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Lee AM, Beasley MJ, Barrett ED, James JR, Gambino JM. Single-voxel and multi-voxel spectroscopy yield comparable results in the normal juvenile canine brain when using 3 Tesla magnetic resonance imaging. Vet Radiol Ultrasound 2018; 59:577-586. [PMID: 29886575 DOI: 10.1111/vru.12634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 11/29/2022] Open
Abstract
Conventional magnetic resonance imaging (MRI) characteristics of canine brain diseases are often nonspecific. Single- and multi-voxel spectroscopy techniques allow quantification of chemical biomarkers for tissues of interest and may help to improve diagnostic specificity. However, published information is currently lacking for the in vivo performance of these two techniques in dogs. The aim of this prospective, methods comparison study was to compare the performance of single- and multi-voxel spectroscopy in the brains of eight healthy, juvenile dogs using 3 Tesla MRI. Ipsilateral regions of single- and multi-voxel spectroscopy were performed in symmetric regions of interest of each brain in the parietal (n = 3), thalamic (n = 2), and piriform lobes (n = 3). In vivo single-voxel spectroscopy and multi-voxel spectroscopy metabolite ratios from the same size and multi-voxel spectroscopy ratios from different sized regions of interest were compared. No significant difference was seen between single-voxel spectroscopy and multi-voxel spectroscopy metabolite ratios for any lobe when regions of interest were similar in size and shape. Significant lobar single-voxel spectroscopy and multi-voxel spectroscopy differences were seen between the parietal lobe and thalamus (P = 0.047) for the choline to N-acetyl aspartase ratios when large multi-voxel spectroscopy regions of interest were compared to very small multi-voxel spectroscopy regions of interest within the same lobe; and for the N-acetyl aspartase to creatine ratios in all lobes when single-voxel spectroscopy was compared to combined (pooled) multi-voxel spectroscopy datasets. Findings from this preliminary study indicated that single- and multi-voxel spectroscopy techniques using 3T MRI yield comparable results for similar sized regions of interest in the normal canine brain. Findings also supported using the contralateral side as an internal control for dogs with brain lesions.
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Affiliation(s)
- Alison M Lee
- Department of Clinical Sciences, Mississippi State University College of Veterinary Medicine, Mississippi State, MS, 39762
| | - Michaela J Beasley
- Department of Clinical Sciences, Mississippi State University College of Veterinary Medicine, Mississippi State, MS, 39762
| | - Emerald D Barrett
- Department of Clinical Sciences, Mississippi State University College of Veterinary Medicine, Mississippi State, MS, 39762
| | - Judy R James
- Medical Physics Division, Department of Radiology, Mayo Clinic College of Medicine, Phoenix, AZ, 85054
| | - Jennifer M Gambino
- Department of Clinical Sciences, Mississippi State University College of Veterinary Medicine, Mississippi State, MS, 39762
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Söbbeler FJ, Carrera I, Pasloske K, Ranasinghe MG, Kircher P, Kästner SBR. Effects of isoflurane, sevoflurane, propofol and alfaxalone on brain metabolism in dogs assessed by proton magnetic resonance spectroscopy ( 1H MRS). BMC Vet Res 2018; 14:69. [PMID: 29506576 PMCID: PMC5839062 DOI: 10.1186/s12917-018-1396-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 02/27/2018] [Indexed: 01/18/2023] Open
Abstract
Background The purpose of this study was to determine the effects of isoflurane, sevoflurane, propofol and alfaxalone on the canine brain metabolite bioprofile, measured with single voxel short echo time proton magnetic resonance spectroscopy at 3 Tesla. Ten adult healthy Beagle dogs were assigned to receive isoflurane, sevoflurane, propofol and alfaxalone at 3 different dose rates each in a randomized cross-over study design. Doses for isoflurane, sevoflurane, propofol and alfaxalone were FE’Iso 1.7 vol%, 2.1 vol%, 2.8 vol%, FE’Sevo 2.8 vol%, 3.5 vol% and 4.7 vol%, 30, 45 and 60 mg kg− 1 h− 1 and 10, 15 and 20 mg kg− 1 h− 1 respectively. A single voxel Point Resolved Spectroscopy Sequence was performed on a 3 T MRI scanner in three brain regions (basal ganglia, parietal and occipital lobes). Spectral data were analyzed with LCModel. Concentration of total N-acetylaspartate (tNAA), choline, creatine, inositol and glutamine and glutamate complex (Glx) relative to water content was obtained. Plasma concentration of lactate, glucose, triglycerides, propofol and alfaxalone were determined. Statistics were performed using repeated measures ANOVA or Wilcoxon Sign Rank test with alpha = 5%. Results Plasma glucose increased with isoflurane, sevoflurane and alfaxalone but decreased with propofol. Plasma lactate increased with all anesthetics (isoflurane > sevoflurane > propofol > alfaxalone). Cerebral lactate could not be detected. Only minor changes in cerebral metabolite concentrations of tNAA, choline, inositol, creatine and Glx occurred with anesthetic dose changes. Conclusion The metabolomic profile detected with proton magnetic resonance spectroscopy at 3 Tesla of canine brain showed only minor differences between doses and anesthetics related to tNAA, choline, creatine, inositol and Glx.
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Affiliation(s)
- Franz Josef Söbbeler
- Small Animal Clinic (Söbbeler, Kästner), University of Veterinary Medicine Hanover Foundation, Bünteweg 9, 30559, Hannover, Germany.
| | - Inés Carrera
- Clinic of Diagnostic Imaging (Carrera, Kircher), Vetsuisse Faculty, University of Zurich, Winterthurestrasse 258c, 8057, Zurich, Switzerland
| | - Kirby Pasloske
- Jurox Pty Ltd. (Pasloske, Ranasinghe), 85 Gardiner St, Rutherford, NSW, 2320, Australia
| | | | - Patrick Kircher
- Clinic of Diagnostic Imaging (Carrera, Kircher), Vetsuisse Faculty, University of Zurich, Winterthurestrasse 258c, 8057, Zurich, Switzerland
| | - Sabine Beate Rita Kästner
- Small Animal Clinic (Söbbeler, Kästner), University of Veterinary Medicine Hanover Foundation, Bünteweg 9, 30559, Hannover, Germany
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Choi S, Song Y, Lee K, Lee Y, Choi H. Multi-voxel magnetic resonance spectroscopy of cerebral metabolites in healthy dogs at 1.5 Tesla. J Vet Sci 2017; 17:217-24. [PMID: 26645339 PMCID: PMC4921670 DOI: 10.4142/jvs.2016.17.2.217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/08/2015] [Accepted: 10/07/2015] [Indexed: 11/20/2022] Open
Abstract
This study was conducted to measure the difference in levels of cerebral metabolites in the right and left hemispheres, gray (GM) and white matter (WM), imaging planes, and anatomical regions of healthy dogs to establish normal variations. Eight male Beagle dogs (1 to 4 years of age; mean age, 2 years) with no evidence of neurologic disease were studied. Using the multi-voxel technique on a 1.5 Tesla magnetic resonance imaging scanner, metabolite values (N-acetyl aspartate [NAA], choline [Cho], creatine [Cr]) were obtained from the frontoparietal WM, parietal GM, temporal GM, occipital GM, thalamus, cerebellum, mid-brain, and pons. There was no significant difference in levels of these metabolites between the right and left in any locations or between the GM and WM in the cerebral hemispheres. However, there were significant differences in metabolite ratios within imaging planes. The NAA/Cr was lower in the cerebellum than other regions and the thalamus had a higher Cho/Cr and lower NAA/Cho ratio than in other regions. The spectral and metabolic values will provide a useful internal reference for clinical practice and research involving multi-voxel magnetic resonance spectroscopy. Measurement of metabolite values in the transverse plane is recommended for comparing levels of regional metabolites.
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Affiliation(s)
| | - Yumi Song
- Ian Animal Diagnostic Center, Seoul 06014, Korea
| | - Kija Lee
- College of Veterinary Medicine, Kyungpook National University, Daegu 41566, Korea
| | - Youngwon Lee
- College of Veterinary Medicine and Research Institute of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Hojung Choi
- College of Veterinary Medicine and Research Institute of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea
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Sievert C, Richter H, Beckmann K, Kircher PR, Carrera I. COMPARISON BETWEEN PROTON MAGNETIC RESONANCE SPECTROSCOPY FINDINGS IN DOGS WITH TICK-BORNE ENCEPHALITIS AND CLINICALLY NORMAL DOGS. Vet Radiol Ultrasound 2016; 58:53-61. [PMID: 27714889 DOI: 10.1111/vru.12427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 12/30/2022] Open
Abstract
In vivo diagnosis of tick-borne encephalitis is difficult due to high seroprevalence and rapid viral clearance, limiting detection of antibodies in blood and cerebrospinal fluid. Magnetic resonance imaging (MRI) characteristics of tick-borne encephalitis have been reported, however MRI studies can also be negative despite the presence of neurologic signs. Magnetic resonance spectroscopy (1 H MRS) is an imaging method that provides additional information about the metabolic characteristics of brain tissues. The purpose of this retrospective cross-sectional study was to describe brain metabolites using short echo time single-voxel 1 H MRS in dogs with confirmed tick-borne encephalitis and compare them with healthy dogs. Inclusion criteria for the affected dogs were neurological symptoms suggestive of tick-borne encephalitis, previous endemic stay and tick-bite, diagnostic quality brain MRI and 1 H MRS studies, and positive antibody titers or confirmation of tick-borne encephalitis with necropsy. Control dogs were 10, clinically normal beagles that had been used in a previous study. A total of six affected dogs met inclusion criteria. All dogs affected with tick-borne encephalitis had 1 H MRS metabolite concentration alterations versus control dogs. These changes included mild to moderate decreases in N-acetyl aspartate and creatine peaks, and mild increases in glutamate/glutamine peaks. No lactate or lipid signal was detected in any dog. Myoinositol and choline signals did not differ between affected and control dogs. In conclusion, findings supported the use of 1 H MRS as an adjunctive imaging method for dogs with suspected tick-borne encephalitis and inconclusive conventional MRI findings.
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Affiliation(s)
- Christine Sievert
- Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057, Zurich, Switzerland
| | - Henning Richter
- Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057, Zurich, Switzerland
| | - Katrin Beckmann
- Department of Neurology, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057, Zurich, Switzerland
| | - Patrick R Kircher
- Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057, Zurich, Switzerland
| | - Ines Carrera
- Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Winterthurerstrasse 258c, 8057, Zurich, Switzerland
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Diagnostic techniques to detect the epileptogenic zone: Pathophysiological and presurgical analysis of epilepsy in dogs and cats. Vet J 2016; 215:64-75. [DOI: 10.1016/j.tvjl.2016.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/24/2016] [Accepted: 03/05/2016] [Indexed: 12/17/2022]
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Carrera I, Richter H, Beckmann K, Meier D, Dennler M, Kircher PR. Evaluation of intracranial neoplasia and noninfectious meningoencephalitis in dogs by use of short echo time, single voxel proton magnetic resonance spectroscopy at 3.0 Tesla. Am J Vet Res 2016; 77:452-62. [DOI: 10.2460/ajvr.77.5.452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Carrera I, Richter H, Meier D, Kircher PR, Dennler M. Regional metabolite concentrations in the brain of healthy dogs measured by use of short echo time, single voxel proton magnetic resonance spectroscopy at 3.0 Tesla. Am J Vet Res 2015; 76:129-41. [PMID: 25629910 DOI: 10.2460/ajvr.76.2.129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate regional differences of relative metabolite concentrations in the brain of healthy dogs with short echo time, single voxel proton magnetic resonance spectroscopy ((1)H MRS) at 3.0 T. ANIMALS 10 Beagles. PROCEDURES Short echo time, single voxel (1)H MRS was performed at the level of the right and left basal ganglia, right and left thalamus, right and left parietal lobes, occipital lobe, and cerebellum. Data were analyzed with an automated fitting method (linear combination model). Metabolite concentrations relative to water content were obtained, including N-acetyl aspartate, total choline, creatine, myoinositol, the sum of glutamine and glutamate (glutamine-glutamate complex), and glutathione. Metabolite ratios with creatine as the reference metabolite were calculated. Concentration differences between right and left hemispheres and sexes were evaluated with a Wilcoxon signed rank test and among various regions of the brain with an independent t test and 1-way ANOVA. RESULTS No significant differences were detected between sexes and right and left hemispheres. All metabolites, except the glutamine-glutamate complex and glutathione, had regional concentrations that differed significantly. The creatine concentration was highest in the basal ganglia and cerebellum and lowest in the parietal lobes. The N-acetyl aspartate concentration was highest in the parietal lobes and lowest in the cerebellum. Total choline concentration was highest in the basal ganglia and lowest in the occipital lobe. CONCLUSIONS AND CLINICAL RELEVANCE Metabolite concentrations differed among brain parenchymal regions in healthy dogs. This study may provide reference values for clinical and research studies involving (1)H MRS performed at 3.0 T.
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Affiliation(s)
- Inés Carrera
- Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland., Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
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Beckmann K, Carrera I, Steffen F, Golini L, Kircher PR, Schneider U, Bley C. A newly designed radiation therapy protocol in combination with prednisolone as treatment for meningoencephalitis of unknown origin in dogs: a prospective pilot study introducing magnetic resonance spectroscopy as monitor tool. Acta Vet Scand 2015; 57:4. [PMID: 25637270 PMCID: PMC4316757 DOI: 10.1186/s13028-015-0093-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 01/09/2015] [Indexed: 11/29/2022] Open
Abstract
Background A plethora of treatment options have been described for canine meningoencephalitis of unknown origin (MUO), yet a gold standard has not been established. The aim of this prospective pilot study was to document the effect of a newly designed 30 Gray (Gy) radiation therapy (RT) protocol plus corticosteroids as treatment for focal and multifocal MUO, to monitor clinical and imaging changes during the course of the disease with conventional magnetic resonance imaging (MRI) and proton MR Spectroscopy (H-1 MRS) and to detect the occurrence of radiation related side effects. Results Six dogs (3 with focal and 3 with multifocal lesions) were included in the study. The RT protocol used consisted of 30 Gy in 10 fractions. The neurological status of all six dogs improved during RT, with 3 of 6 cases returning to a normal condition. One dog was euthanized early during follow-up (<3 weeks after end of RT). Three month follow up MRI was normal in one dog and improved in 3 dogs and H-1 MRS normalized in 4. In the dog without improvement of the MRI lesions, the N-acetyl aspartate continued to decrease, while choline and creatine concentrations remained stable during that time. This dog was euthanized 18 month after the end of RT due to relapse. One dog was lost to follow up 12 month after completion of RT. The other 3 dogs are still alive at the time of writing. Conclusions RT with 30 Gy in 10 fractions can provide an additional option for anti-inflammatory treatment of focal and multifocal MUO. The protocol used for treatment monitoring was feasible while no side effects of RT could be observed during the follow up period. Moreover, H-1 MRS could represent a new and non-invasive tool to control the progression of the disease during the treatment course.
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Stadler KL, Ober CP, Feeney DA, Jessen CR. Multivoxel proton magnetic resonance spectroscopy of inflammatory and neoplastic lesions of the canine brain at 3.0 T. Am J Vet Res 2014; 75:982-9. [DOI: 10.2460/ajvr.75.11.982] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Carrera I, Kircher PR, Meier D, Richter H, Beckman K, Dennler M. In vivo proton magnetic resonance spectroscopy for the evaluation of hepatic encephalopathy in dogs. Am J Vet Res 2014; 75:818-27. [DOI: 10.2460/ajvr.75.9.818] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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