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Localization of Brain Lesions

WESTERN VETERINARY CONFERENCE 2003
Richard A. LeCouteur University of California Davis, CA, USA

OBJECTIVES
To be able to recognize and localize brain lesions.

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KEY POINTS
Although it is possible to localize a problem to the brain and sometimes to the approximate location within the brain, it must be remembered that clinical signs may be the same regardless of the underlying cause. Brain tumors, infections, congenital disorders, trauma, vascular disorders, degeneration, immunologic and metabolic disorders, toxicities, and idiopathic disorders may result in similar clinical signs. For this reason it is essential to follow a logical diagnostic plan for a cat or dog with signs of brain dysfunction.

OVERVIEW
Following a complete history and physical and neurologic examination, a minimum database for an animal with signs of brain dysfunction should be obtained. This should include a hemogram, serum chemistry panel, and urinalysis. Survey thoracic radiographs and abdominal ultrasound help to rule out problems elsewhere. The major objective in doing these tests is to exclude disease outside the brain as a cause of the signs of cerebral dysfunction. Plain skull radiographs are useful for detecting problems of the skull or nasal cavity that may have extended to the brain. Occasionally, lysis or hyperostosis of the skull may accompany a primary brain tumor (e.g., meningioma of cats) or there may be mineralization of a neoplasm. Skull radiographs are of little value in detecting dysfunction within the brain.

Cerebrospinal Fluid
Analysis of cerebrospinal fluid (CSF) is recommended as an aid in the diagnosis of a brain disorders. The results of CSF analysis may help to identify inflammatory causes of cerebral dysfunction, and in some cases may support diagnosis of a brain tumor. CSF bathes the entire CNS, both internally (the ventricles and central canal) and externally (the subarachnoid space). CSF composition may be affected by many nervous system diseases and the ease with which this fluid may be collected has made it a useful diagnostic tool in the diagnosis of CNS disease. Unfortunately, for cells to be shed into the CSF a disease must involve the ventricular system or the subarachnoid space. Disorders involving deeper brain structures (e.g., neoplasms) may not shed cells into the CSF. Frequently these diseases disrupt the blood-brain barrier allowing protein to leak into the CSF and resulting in an increased protein level. CSF must be evaluated keeping in mind history and clinical signs. Neoplasms and some other noninflammatory diseases may result in inflammatory changes in CSF composition. CSF composition may also change as a disease becomes more chronic. Also, following various therapies CSF may no longer accurately reflect an etiology. Care should be used in the collection of CSF, because frequently an increased intracranial pressure (ICP) may be present in association with a brain tumor, and pressure alterations associated with CSF removal may cause brain herniation. Because CSF pressure measurements are of limited usefulness, it is often desirable to utilize techniques such as hyperventilation to decrease intracranial pressure prior to CSF collection. CSF may be collected at either the cerebellomedullary cistern or by lumbar puncture. In general the cerebellomedullary cistern is easier to perform, allows collection of a larger volume and generally collection from
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this area results in less blood contamination. All patients undergoing CSF collection should be anesthetized appropriately. If it is suspected that intracranial pressure is elevated the patient should be hyperventilated for several minutes prior to collection as well as during and after collection in order to decrease arterial CO2 and intracranial pressure. Complications of CSF collection include needle injury to the brain and herniation of the brain, usually due to high intracranial pressure. Both these complication may be fatal if appropriate steps to reduce intracranial pressure (hyperventilation and mannitol administration) are not instituted immediately.

CSF Collection
For CSF collection from the cerebellomedullary cistern, a 20- or 22-gauge 1.5 inch (3.5 cm) spinal needle and a sterile container in which to collect fluid are needed. The hair over the area should be clipped and the skin prepared for a sterile procedure. The patient is placed in lateral recumbency with the head parallel to the table and an assistant must hold the head flexed at 90 to the long axis of the body. A line drawn down the middle of the patient's face and nose should be parallel to the table. These patients should be intubated to prevent airway obstruction. The landmarks for cisternal CSF collection are the wings of C1 and the occipital protuberance. The needle should be inserted where the line from the occipital protuberance (the midline) intersects a line drawn between the two wings of C1. The needle bevel should face cranially and the needle should be advanced slowly keeping it perpendicular to the long axis of the spine. A sudden loss of resistance may be felt as it enters the subarachnoid space and at that time the stylet should be removed in order for CSF to flow. Care must always be taken to prevent accidental needle movement and the needle should be held firmly with the thumb & forefinger each time the stylet is removed or replaced. In very small animals, the fluid volume available may be very small and may take 30-45 seconds to appear in the hub of the needle. If no fluid appears the stylet may be replaced and the needle advanced further. If bone is encountered then the needle tip should be redirected. Failure to find the space is usually due to poor patient positioning, (most often insufficient flexing of the neck or the patient's nose sloping downwards towards the table) or not being on the midline with needle placement. If the cerebellomedullary cistern cannot be found the needle should be removed and the entire procedure repeated. If CSF flow is very slow, carefully occluding the jugular veins will increase CSF pressure and flow. Apnea or changes in respiratory rate not associated with anesthetic depth usually indicate brain herniation or damage. The needle should be immediately withdrawn, anesthesia discontinued and the patient hyperventilated until consciousness and normal respiration return. If the patient does not respond within 5 minutes to these maneuvers then mannitol should be administered. Once CSF begins to flow it should be allowed to drip freely into the container and at least one milliliter collected. If fluid needs to be stored for any length of time prior to cell analysis then it should be stored in a plastic container and refrigerated to stop cellular degeneration.

CSF Analysis
Always note from where the CSF was collected. CSF from the cisternal space has a lower protein than fluid from the lumbar space. Analysis should include gross visual examination, cytologic analysis, protein measurement and possibly fluid culture. Normal CSF should appear clear and colorless. Turbidity may indicate increased white cell numbers and/or protein elevation. A pink color to the fluid may be due to blood contamination. Persistence of this color change after centrifugation of a small amount of sample may indicate the presence of free hemoglobin, suggesting previous subarachnoid hemorrhage, rather than sample contamination. Xanthochromia develops if more than 48 hours have elapsed following hemorrhage. Cytological preparation should be completed as soon as possible (within 30 minutes of collection), since CSF cells undergo degeneration rapidly. WBCs degrade faster than RBCs in the CSF, making interpretation difficult. Refrigeration does help to slow WBC lysis. The cytologic evaluation should begin with a total cell count on the unconcentrated fluid. A slide should then be prepared of concentrated fluid for evaluation of cell morphology and differential cell counts. The two most common slide preparation techniques are cytocentrifugation and sedimentation. The sedimentation technique is easy and reliable and may preserve cell architecture better than centrifugation methods. Normal CSF should contain less than 5 WBC/ul. Cell numbers may increase most commonly with inflammatory disease but also with tumors, necrosis, trauma, and vascular injury. The type and number of cells may reflect the cause of the inflammation. CSF is most accurate in acute, untreated illnesses. Correcting the number of WBCs in

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the CSF for blood contamination is possible only with very mild contamination. The WBC numbers in the CSF increase approximately 1 WBC/ul for each 500 to 700 RBCs/ul. A predominance of polymorphonuclear leukocytes in CSF may indicate a suppurative meningitis probably due to bacterial infection or to severe viral encephalitis. The presence of multiple cell types in CSF, including macrophages, lymphocytes, neutrophils and sometimes plasma cells is generally the result of a granulomatous inflammation, such as occurs with fungal, protozoal, and some idiopathic diseases. Mixed cell populations may also be seen with inadequately treated chronic bacterial infections and in response to foreign bodies. A nonsuppurative inflammation is diagnosed if the increased cell numbers are primarily mononuclear cells, especially lymphocytes. It is most characteristic of viral and rickettsial infections, although it can also be seen with neoplasms. CSF should be submitted for both aerobic and anaerobic bacterial culture and antibiotic sensitivity testing whenever abnormalities consistent with meningitis are found. Negative cultures are common even when bacterial or fungal organisms can be seen. Culturing the sedimented or centrifuged CSF may increase the likelihood of a positive culture. Causative organisms may also be isolated from the blood of animals with systemic infections. It is recommended that a large volume of CSF, preferably 2 or 3 ml, be collected for bacterial and/or fungal culture. Serology may also be useful in diagnosis of CNS fungal infections. In normal cerebellomedullary CSF, protein is less than 25 mg/dl and less than 35 mg/dl with lumbar puncture. Since storage of CSF does not affect protein it can be sent to an outside laboratory for protein evaluation. CSF protein is elevated with many diseases including encephalitis, meningitis, neoplasms, trauma and infarcts. Over 75% of CSF protein should be albumin. With noninflammatory disruption of the blood-brain-barrier, (e.g., neoplasm and infarcts), most CSF protein will be albumin, whereas with increased intrathecal production (e.g., encephalitis) it is predominantly globulin. Where both albumin and globulin are elevated an inflammatory process affecting both the meninges and the CNS (e.g., FIP) should be suspected. Although increased CSF protein content and a normal to increased CSF white blood cell count have been considered "typical" of a brain neoplasms, in one study, only 39.6% of dogs with a primary brain tumor exhibited "typical" CSF alterations. CSF analysis was normal in 10% of the dogs in this study, while the remaining 50.4% of dogs had a variety of nonspecific CSF changes. The CSF from dogs with a meningioma often may have an elevated white blood cell count (> 50/ul), with more than 50% of these cells being polymorphonuclear leukocytes. Neoplastic cells may be present in CSF, particularly when sedimentation techniques are used for analysis. The use of CSF protein electrophoresis, and IgG index of CSF, may aid in the determination of the presence of a brain neoplasm. Little information is available regarding CSF alterations seen in association with feline brain tumors; however, changes are similar to those described for dogs.

Imaging
Skull radiographs are useful in patients with suspected bony or cartilaginous changes (e.g., head trauma, bony tumors), but in general plain skull films are of limited value in patients with brain disease. Angiography and venography were used in the past to try to diagnose brain disorders. These techniques have severe limitations and in most instances fail to define the exact extent of a neoplasm and its precise relationship to surrounding structures. These techniques have now been replaced with computed tomography (CT) and magnetic resonance imaging (MRI).

CT and MRI
CT and MRI allow imaging of brain tissue rather than just the surrounding bony skull. Both can distinguish lesions which have only slightly different densities than the surrounding tissues and this can be further enhanced by contrast agents allowing the identification of masses and other abnormal tissues within the brain. Images obtained by means of MRI may be superior to those of CT especially in certain areas such as the brain stem, although CT is usually better for bony lesions (e.g., middle ear studies). While the major tumor types are reported to have characteristic CT or MRI appearances, non-neoplastic lesions may mimic the CT or MRI appearance of a neoplasm, and occasionally a metastasis may resemble a primary brain tumor on CT or MRI images. Patients for either CT or MRI must be anesthetized, intubated, and hyperventilated whenever an increase in ICP is even suspected. Proper patient positioning is extremely important. The animals should be placed in sternal recumbency with the head extended. The entire calvaria should be examined in the non-contrast series of images. This should be followed by a post contrast series of images.

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Brain Biopsy
At the present time, biopsy is the sole method available for the diagnosis of brain lesions (including tumor type) in cats or dogs. Biopsy methods include ultrasound-guided biopsy, and CT-guided biopsy. Rapid cytological evaluation of a brain lesion from a biopsy sample can provide crucial information on operative management, medical management, chemotherapy, or radiation therapy. Smear preparations are generally wet fixed in 95% alcohol and stained with hematoxylin and eosin although toluidine blue, giemsa, or Papanicolaou's stain may also be used. In a recent study in which the results from the smear technique were compared with those from sections of paraffin embedded tissue, the overall diagnostic was about 80%. The main advantages of this method of intraoperative diagnosis are speed, ease of preparation, technical simplicity, need for minimal equipment, high degree of cytological resolution compared to frozen preparations, low cost and small sample size required. A limitation of this system is that it is difficult to prepare adequate smear preparations in certain tough and coherent tumors (e.g., schwannomas, fibrillary astrocytomas, and some meningiomas). Smear preparations provide excellent cytologic detail, however these differ from the conventional histologic appearance of HE stained paraffin-embedded tissue. Experience is required in the correct interpretation of smear preparations.

SUMMARY
Patient signalment, history and physical and neurological examination findings will help to localize a lesion to the brain and possibly a particular area of the brain. Further diagnostic tests are required to localize the affected area within the brain, and to obtain an accurate diagnosis. These tests include CSF analysis, CT or MR imaging, and brain biopsy. References
1. LeCouteur RA: Tumors of the nervous system. In Withrow SJ, MacEwen EG (ed): Small Animal Clinical Oncology, 3rd ed. Philadelphia, WB Saunders, 2001, p. 500 2. Vernau KM, Higgins RJ, Bollen AW, et al: Primary canine and feline nervous system tumors: Intraoperative Diagnosis using the smear technique. Vet Pathol 38: 47-57, 2001. 3. Koblik PD, RA LeCouteur, RJ Higgins, AW Bollen, KM Vernau, GD Kortz and JE Ilkiw: CT-guided brain biopsy using a modified Pelorus Mark III stereotactic system: Experience with 50 dogs. Veterinary Radiology and Ultrasound 40:434-440, 1999. 4. LeCouteur RA:Cerebral meningiomas: Diagnostic and therapeutic considerations. In August JR (ed): Consultations in Feline Internal Medicine, Volume 4, WB Saunders Company, Philadelphia, p 385 .

SPEAKER INFORMATION
(click the speaker's name to view other papers and abstracts submitted by this speaker) Richard A. LeCouteur, BVSc, Ph.D Professor, Surgical and Radiological Sciences (Neurology) University of California-Davis Davis, CA
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