CASE STUDY: Max

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Max is a 19 year-old, male castrated mixed breed that presented to BVNS for circling and a head tilt. He was diagnosed with two meningiomas and ten months later he is thriving at home.

Presenting Complaint

One month lethargy, 4 days of stiffness after walks, not jumping into the car and suddenly circling to the right, head tilt right.

Examination Abnormalities and Localization

Max had a right head tilt, fast phase nystagmus to the left, and would lean and fall to the right but also make large circles to the right. His right eye was droopy, the third eyelid was prolapsed and he did not menace well on the right. A central vestibular problem was likely due to the poor menace with a normal palpebral response. However, a poor menace response and large radius circling can indicate forebrain dysfunction. Therefore disease in more than one area was also considered.

Diagnostics

MRI of the brain showed a large, right-sided mass at the level of the pons and a second mass in the left olfactory lobe.

The characteristics were the most compatible with TWO meningiomas. However, lymphoma or a fungal infection called Cryptococcus were also considered. A CSF analysis was inconsistent with lymphoma and Cryptococcus antigen testing was negative, therefore Max was diagnosed with TWO meningiomas.

Treatment

Palliative or symptomatic treatment with prednisone allowed Max to do so well that definitive treatment was considered. BVNS worked with Dr. Rick Joseph and Dr. Sarah Charney at the Animal Specialty Center in Yonkers, New York to obtain cyber knife radiation treatment for Max. This technologically-advanced form of radiation therapy can direct the radiation such that larger doses of radiation can be given per treatment, reducing the number of anesthetic episodes from 15 to 3.

Outcome

Max is currently about six months out from his radiation and is doing well. We received this update from his family recently: “Max is still doing fantastic! ...chasing bikers, joggers, deer and puppy wrestling. His hearing is good, sight seems very good too. He sleeps very well and is alert and active when he’s awake. He’s walking 1-2 miles/day, and back to playing with stuffed animals and throwing them around, and playing with squeaky toys (He can hear them again!).” 

While Max was in Yonkers he met another dog who was twenty-four years old and was going in his for second round of radiation therapy four years after his first treatment of a meningioma, and was otherwise happy and healthy. 

We are thrilled with Max’s progress and look forward to hearing more positive updates from his family in the future.

Take Home Points

1 - Patients with head tilt + poor menace and a normal blink reflex have disease within the brain and therefore do not have Old Dog Peripheral Vestibular Disease. Furthermore, when the signs just do not seem to fit, often more than one lesion is present or at a minimum the disease is within the brain rather than Old Dog Peripheral Vestibular Disease.

2 - Meningiomas are the most common type of primary brain tumor in cats, dogs, and humans. Surgery and/or full course radiation have been the mainstay of treatment. Technological advances and research are providing excellent long term outcomes with a high quality of life in many patients.

3 - BVNS strives to offer as many treatment options as possible and partners with many different experts nationwide. Current treatment options and average survival times are as follows:
a. Steroid alone – 3 months
b. Steroid + Hydroxyurea – 6 months
c. Conventional surgery – 10 months
d. Full course radiation or cyberknife – 12-14 months, may be longer with cyber knife
e. Surgery + Autologous Vaccine - pilot date shows 75% of dogs alive 600 days post-treatment
 
4 - BVNS is working with Dr. John Ohlfest at University of Minnesota Brain Tumor  Lab where the patient’s meningioma is developed into an intradermal vaccine that is then administered along with a topical immunostimulant every 2 weeks for 12 weeks. The patients we have treated had complete excisions of their tumors prior to vaccine and are doing exceedingly well.


To discuss this case or to ask a question related to this case please email Dr. Young.

Case referred to BVNS by Dr. Renee Welch at the Anderson's Corner Animal Hospital.

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