Buffy, a 10-year-old spayed female Cockapoo, came to Veterinary Referral Hospital of Hickory when her owners noticed she was having moments of ataxia – loss of coordination or unbalanced gait. Her owners reported she had been losing her balance and falling over at home, especially after shaking her body. They noted that after falling, Buffy also had trouble getting back up. She occasionally leans to the left, but has no head tilt or nystagmus (an involuntary and rhythmic oscillation of the eyes). Her appetite was abnormal, and she wasn’t as energetic as usual. She was not vomiting or sneezing, and she had no diarrhea.
A Veterinary Referral Hospital of Hickory emergency veterinarian examined Buffy, and found that she was bright, alert, and responsive. Her pain score was 0, and her temperature and pulse were normal. She had no eye discharge, no nasal discharge, and no oral masses or foreign bodies. She had mild ear discharge. Her heart and lungs sounded normal, her abdomen was soft and non-painful, and there was no muscle or joint pain. Her coat was healthy.
The ER doctor performed a neurological exam and noted that Buffy’s gait was normal and she had no proprioceptive deficits – that is, a neurologic condition in which the legs buckle or feet don’t place properly – and no signs of the reported ataxia. She had no cranial nerve deficits and she was ambulatory on all four legs. Overall, her physical neurological exam was good. The emergency doctor ordered bloodwork.
Buffy’s bloodwork came back normal except for her pO2 (partial pressure of oxygen), which was very high, and her saturated oxygen, which was also high. Her white and red blood cell counts were normal.
The Veterinary Referral Hospital of Hickory emergency veterinarian had discussed several possibilities with Buffy’s owners, including vestibular disease (a sudden, non-progressive imbalance), wobbler syndrome (a neurologic disease that affects the spine in the neck), and CNS disease (an inflammatory disease of the central nervous system). Since her examination alone did not provide a definitive answer, the ER doctor recommended spinal survey radiographs in addition to the baseline labwork.
Buffy’s spinal radiographs did not reveal any signs of disc disease in the back. Our ER doctor recommended outpatient care with conservative medical treatment of Buffy’s symptoms, and a revisit to Veterinary Referral Hospital of Hickory for additional diagnostics if her condition did not improve.
Eight days later
Buffy came back to VRHOH just over a week later, with her owners reporting that she still had episodes of falling over after shaking her body, plus intermittent ataxia. She still had the occasional left head tilt and sometimes leaned or stumbled to the left. Her appetite had improved slightly, but was still not completely normal.
Her owners report that though she had not worsened since her last visit to Veterinary Referral Hospital of Hickory, she also had not improved (except on occasions when she was taken for a walk). She had not been scratching her ears or shaking her head, and while she was still mildly lethargic, she perked up for things she enjoys, such as walks or visitors.
The same emergency veterinarian examined Buffy again, and again, her physical examination was unremarkable. This time, upon a more in-depth physical neurological examination, the doctor observed Buffy’s occasional stumbling and ataxia when Buffy shook her body. However, the rest of her physical neurological exam remained unremarkable. The emergency veterinarian discussed some of the same possibilities, such as vestibular disease and CNS disease, and also discussed the possibility of inner ear disease, musculoskeletal disease, and orthopedic disease. The emergency doctor sent Buffy home with an anti-inflammatory steroid medication and muscle relaxants, with instructions to watch for signs of improvement; if not, the emergency doctor’s recommendation was to follow up with a specialist.
Eleven days later
Buffy returned to VRHOH within two weeks of her last visit. Her appetite improved while on the anti-inflammatory medication, prednisolone, but the muscle relaxant did not improve her tremors. Dr. Scott Helms examined Buffy at this visit, and performed another physical exam, which was unremarkable. Based on his exam, Dr. Helms suspected idiopathic peripheral vestibular disease – vestibular disease caused by a malfunction of components of the inner ear, of an unknown origin.
Idiopathic peripheral vestibular disease usually resolves itself over time, though it may never fully resolve. Dr. Helms recommends glucosamine – a joint supplement – and gabapentin – a pain reliever – to keep Buffy comfortable and pain-free.
Seven days later
A week later, Buffy returned to VRHOH for her recheck. Her owners say her ataxia is worsening, and she now has a left-sided head tilt and circles to the left. She also has positional left-sided ventral strabismus (an abnormal position of the eyes in certain positions, such as when the head is raised or the neck extended). Dr. Helms checked for ear disease on Buffy’s left ear, but sees no evidence of it.
Dr. Helms discussed several options with Buffy’s owners: referral to a neurologist, a CT scan, or a trial of prednisone. Buffy’s owners elect to have a CT scan, and it is scheduled for the next day.
With normal bloodwork the next day, Buffy is cleared for her CT scan. Her scan images show a mass identified on the right side of Buffy’s cerebellum. Dr. Helms’ final diagnosis is paradoxical central vestibular disease secondary to a right-sided cerebellar mass, presumed to be a tumor. Buffy’s owners elect to begin steroid therapy to attempt to reduce peritumoral swelling (swelling around the tumor).
Eight days later
Buffy’s steroid therapy is ineffective, even at higher doses, and her owners eventually follow-up with a neurologist. The bulk of Buffy’s tumor – an atypical meningioma – was removed, and she began a course of radiation therapy to diminish the remaining tumor. As of her last radiation session, Buffy was doing well. She tolerated treatment well and had no side effects.
In the end, Buffy was a minority case with a serious underlying cause of her vestibular disease rather than the exceedingly more common peripheral disease of unknown cause (idiopathic). The diagnosis could have been made earlier, but it isn’t prudent to conduct intensive and expensive advanced diagnostics when there is a likelihood of a simple, resolvable cause of symptoms. Veterinary Referral Hospital of Hickory specialists and veterinarians are fortunate to have extensive resources at their disposal to evaluate and diagnose cases. We are careful, however, to use our intellect and knowledge base first to rule out common and limited causes of symptoms to offer the best treatment plans for our patients. Whether patients need a simple diagnosis and medication for a short-term problem or an extensive workup and surgery for a more complex problem, the veterinarians at Veterinary Referral Hospital of Hickory are well-prepared.