RM Clemmons, DVM, PhD, CVA, CVFT Gainesville, FL HOW I TREAT SELECTIVE NEUROLOGIC DISEASE: HYRODCEPHALUS, CNS NEOPLASIA & DEGENERATIVE MYELOPATHY RM Clemmons, DVM, PhD, CVA, CVFT Gainesville, FL

Hydrocephalus

Disorders Affecting Brain Anomalous Hydrocephalus COMS Intracranial arachnoid cyst Dandy-Walker Syndrome

HYDROCEPHALUS Congenital De Novo Outflow obstruction Brain disappears Copyright 1999 University of Florida

HYDROCEPHALUS DV LAT Copyright 1999 University of Florida

HYDROCEPHALUS T2-horizontal T1-coronal Copyright 1999 University of Florida

HYDROCEPHALUS T1-sagittal (lateral) T1-sagittal (midline) Copyright 1999 University of Florida

HYDROCEPHALUS Medical Management VentriculoPerotoneal Shunt Antioxidants and Steroids VentriculoPerotoneal Shunt Helpful when progressive changes in neurologic status TCVM treatment Copyright 1999 University of Florida

Ventriculoperitoneal Shunt Cranial end of shunt is placed through bur hole Copyright 1999 University of Florida

Ventriculoperitoneal Shunt Tunnel is made to bring shunt tubing to the abdomen Copyright 1999 University of Florida

Ventriculoperitoneal Shunt Abdominal end is pushed into abdomen using Kelly hemostats Extra is left for growth or movement Copyright 1999 University of Florida

TCVM Hydrocephalus Kidney jing deficiency Fails to support the development of marrow Does not nourish the child (liver) Does not control the grandchild (heart) Insults the grandparent (spleen)

Hydrocephalus Patterns Kidney & Spleen Qi Deficiency Younger animals with congenital hydrocephalus Kidney & Liver Yin/Blood Deficiency Older animals with Canine Cognitive Disease Liver Qi Stagnation Secondary to CNS inflammatory disease or cancer

Jocko

Jocko Problem List TCVM Diagnosis Treatment Shen Disturbance Hydrocephalus Confirmed ultrasound Hepatoencephalopathy Confirmed BW Overall poor development TCVM Tongue thin-red Pulses Deep, weak fast particularly on right side Diagnosis Jing Deficiency Yin deficient Treatment Hydrocephalus formula Liu Wei Di Huang Epimedium powder

Peanut’s Hydrocephalus Formula Bai Zhi Angelica Dispel Wind-Cold, relieve pain Bai Zhu Atractylodes Strengthen Spleen Qi Ban Xia Pinellia Transform Damp and stops vomiting Bo He Mentha Dispel Wind-Heat Cang Zhu Atractylodes Dry up Dampness, strengthen Spleen Qi Chan Tui Cicada Dispel Wind, move Qi to the head Dang Shen Codonopsis Tonify Qi Deng Xin Cao Juncus Clear Heat, Drain Damp-Heat Fu Ling Poria Benefit the urination Huang Qi Astragalus Tonify Spleen Qi and dissipate swelling Jie Geng Platycodon Open to the Upper Jiao, transform phlegm Jin Yin Hua Lonicera Clear Heat, detoxify Ju Hua Chrysanthemum Clear Heat, detoxify Shan Yao Dioscorea Tonify Spleen Qi Sheng Ma Cimcifuga Clear Wind-Heat, move Qi to the head Ze Xie Alisma Benefit the urination Zhi Ban Xia Pinellia Transform Damp and stops vomiting Zhu Ling Polyporous Benefit the urination

Epimedium Powder Epimedium Yin Yang Huo Tonify Kid Yang/Jing, Promote Sexual Desire Cuscuta Tu Si Zi Tonify Kid Yang, Jing & Yin Cistache Rou Cong Rong Tonify Kid Yang & Yin Paeonia Bai Shao Yao Nourish Liver Yin & Blood Polygonum He Shou Wu Nourish Blood & Jing, Benefit Hair Actinolite Yang Qi Shi Tonify Kid Yang Cynomorium Suo Yang Tonify Kid Yang Psoralea Bu Gu Zhi Tonify Kid Yang & Strengthen Bones Dipsacus Xu Duan Tonify Kid Yang & Promote Fracture Healing Lycium Gou Qi Zi Nourish Liver Yin, Benefit Eyes Condonopsis Dang Shen Tonify Qi Astragalus Huang Qi Tonify Qi Rehmannia Shu Di Huang Nourish Kid Yin & Jing Angelica Dang Gui Nourish Blood Ophiopogon Mai Men Dong Moisten & Nourish Yin Scrophularia Xuan Shen Cool Blood & Clear Heat Citrus Chen Pi Move Qi & Relieve Pain

5 year old Siberian Husky Copyright 1999 University of Florida

De Novo Hydrocephalus Copyright 1999 University of Florida

Pierre 15 yr old M poodle Owner went on vacation Boarded at facility Upon return ataxia that progressed to coma in 8 hours

Pierre

Husky & Pierre Problem List TCVM Diagnosis Treatment Shen Disturbance Hydrocephalus Confirmed MRI/CT scan TCVM Tongue thin-red Pulses Deep, weak fast particularly on right side Diagnosis Liver & Kidney yin deficiency Treatment ½ Dose Hydrocephalus formula Liu Wei Di Huang ½ Dose Epimedium powder

CNS Neoplasia Today’s Frontier

CNS Neoplasia- -Dogs Common Types Meningioma Astocytoma Oligodendroglioma Choroid plexus papilloma Lymphoma Neuroectodermal tumors Metastatic tumor

CNS Neoplasia- -Dogs Dog has 1-18 months average survival time 1-3 with nothing 6-9 with surgery 12-18 with radiation treatment All tumors are invasive (malignant)

CNS Neoplasia- -Cats Most common is meningioma Usually extra-axial and benign Seen in aged cats Present with depression and dementia

Elvis

Elvis MRI revealed mass in the cerebral cortex

Elvis

Treatment Prednisolone (0.25-0.5 mg/kg q12h) Chemotherapy Treats secondary effects Cover with gastroprotectants Chemotherapy Radiation therapy

Chemotherapy Lomustine Procarbazine 60 mg/M2 given Monitor CBC weekly If WBC and platelets okay in 5 weeks, then give 80 mg/M2 Repeat every 5-8 weeks Procarbazine 2-4 mg/kg/day for 1 week, then 4-6 mg/kg/day Monitor CBC Continue as long as WBC levels are > 4000/µl & platelet count is > 100,000/µl

Chemotherapy 5-hydroxyurea Melatonin Meningiomas 50 mg/M2 given Monitor CBC weekly Repeat every 3-4 weeks Melatonin Gliomas 0.1-0.2 mg/kg once a day in the evening Reduces growth of many tumors by 50%

Treatment Diet Supplements Herbal medications Low carbohydrate Antioxidants & membrane stabilizers Herbal medications Western- -Canine Cancer formula Traditional Chinese medicine- -Stasis in the Mansion of the Mind

Blood Stagnation Hz: Tongue Pulse Rx Principle AP TCM Herbal Acute Seizures Head Injury Tongue red & greasy Pulse Fast, wiry & slippery Rx Principle expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood AP CV-15, ST-40, PC-5, HT-7, LI-11, LIV-3, An Shen, Da Feng Men TCM Herbal Ding Xian Wan TCVM Cancer Treatment

Stasis in Mansion of Mind Angelica Bai Zhi Warm the Channel, relieve pain Pinellia Ban Xia Transform phlegm Ligusticum Chuan Xiong Move Blood Salvia Dan Shen Move Blood Lumbricus Di Long Clear Wind, invigorate Channel Ligusticum Gao Ben Relieve pain Pueraria Ge Gen Bring Qi upward Carthamus Hong Hua Break down Blood Stasis Bombyx Jiang Can Transform phlegm, resolve nodule Scorpion Quan Xie Break down Blood Stasis Cimicifuga Sheng Ma Ascend Qi Fritillary Zhe Bei Mu Transform phlegm, resolve nodules Scolopendra Wu Gong Detoxify, resolve nodules

Max’s Formula Bai Zhi Angelica Clear Wind-Cold and relieve pain Da Huang Rheum Clear stagnation/stasis and clear Heat Jie Geng Platycodon Open the Upper Jiao and transform phlegm Mu Li(Shu) Ostrea Soften hardness and clear mass Tian Hua Fen Trichosanthes Clear Heat and promote body fluids Xia Ku Cao Prunella Clear Liver Heat and resolve nodules Xuan Shen Scrophularia Clear Heat and cool Blood Zhe Bei Mu Fritillaria Soften hardness and clear nodules

Wie Qi Booster Bai Hua She She Cao Oldenlandia Inhibit cell mutation and tumor growth Ban Zhi Lian Scutellaria Inhibit cell mutation, inhibit tumor growth Chen Pi Citrus Move Qi and transform phlegm Dang Gui Angelica Tonifies Blood Dang Shen Codonopsis Tonify Qi and boost Wei Qi Huang Qi Astragalus Tonifies Qi in whole body and Wei Qi Wu Yao Lindera Move Qi and clear stagnation Xuan Shen Scrophularia Cool Blood and nourish Yi

Stasis Breaker Bai Hua She She Cao Oldenlandia Inhibit cell mutation and tumor growth Ban Zhi Lian Scutellaria Clear Heat-toxin, inhibit cell mutation, inhibit tumor growth E Zhu Zedoaria Purge the interior, break Blood stasis and clear mass Mu Li(Shu) Ostrea Soften hardness and clear mass San Leng Sparganium Purge the interior, break stasis and clear mass Zhe Bei Mu Fritillaria Soften harness and clear nodules

Reba 5 year old, German Shorthair Pointer History of seizures starting 1 month prior Responsive to phenobarbital Tongue: purple Pulse: fast & wiry

Reba Neurologic Exam Localization Mild dementia CP deficits in both hind legs Babinski’s sign on left side of the body Localization Cerebrum affecting both side (>right)

Reba- -1st CT scan

Reba Di Tan Tang Stasis in Mansion of Mind Wei Qi Booster Western herbs

Jerry 10 year old, Mx Progressive loss of coordination and head tilt Personality change Tongue: purple Pulse: fast & wiry

Jerry Neurologic Exam Localization Left head tilt Positional, vertical nystagmus Mild CP deficits in rear L>R Xextensor R -> L in rear Localization L Cerebellar pontine angle with cerebral signs

Jerry TCM Dx: TCM Rx: Liver Blood Stagnation Stasis in Mansion of Mind Wie Chi Booster

Jerry- -MRI scan

Radiosurgery (3D radiation therapy) McKnight Brain Institute at UF High, single dose radiotherapy 5 arcs of radiation provide sphere of death Based upon the focal size and tissue treated

Radiosurgery- -Treatment Treatment is applied with LINAC unit at UFBI Cost of radiosurgery procedure is around $3000.00 plus workup & conventional surgery

Radiosurgery Success Overall ED50 is around 13 months Some patients survive much longer Prognosis for meningiomas is better than others

Cancer Recommendations Low-Carbohydrate food (home prepared is best or use Pedigree Weight Loss Formula) Canine basic antioxidant formula (Westlab Pharmacy 1-800-4WESTLA) Canine arthritis formula (Westlab) Canine cancer formula (Westlab)- -use at 2 times prevention dose COX-2 inhibitor (daily- -particularly for carcinomas) Melatonin at night (0.1-0.2 mg/kg)

TCVM Brain Cancer Max Formula Stasis in Mansion of Mind Wei Qi Booster Western herbs or Transports to Head and and

Cervical Neoplasia Acute or chronic progressive quadriparesis Usually has neck pain Often in older animals

Cervical Neoplasia

Cervical Neoplasia

German Shepherd Degenerative Myelopathy (GSDM) A Perspective on History

GSDM A chronic, progressive neurodegenerative disease Initial signs are due to TL spinal cord disease Represents an autoimmune disorder

Signalment Breeds Age Sex Onset Clinical Course German Shepherd dogs Belgium Shepherds Old English Sheepdogs Rhodesian Ridgebacks Weimaraner Probably Great Pyrenes Age > 5 years old (usually 8-9) Sex Equal Onset 1 month to 1 year Clinical Course Paralysis within 3 to 6 month without treatment

Signs of GSDM

Histopathology Axon and myelin loss Astrocyte proliferation Swollen axons Patchy demyelination Astrocyte proliferation Increase in vasculature

Diagnosis Physical and Neurologic Examination Electrodiagnostic Examination Neuroimaging CSF tap & analysis

Treatment Exercise 20-30 minutes twice a week 1 hour once a week sustained aerobic exercise is needed  CNS O2 delivery

Treatment Dietary Considerations Tofu Fresh vegetables carrots greens peppers broccoli Ginger, garlic & mustard

Treatment Supplements Antioxidants Membrane stabilizers Tonics Anti-inflammatory

Treatment Medication Aminocaproic acid (500 mg TID) n-Acetylcysteine (25 mg/kg TID QD for 2 weeks, then TID QOD)

Greta Signalment 8 yr F/S GSD Weakness Posterior Paresis S

Greta S History Seemed to be slower over last 6 months Trouble getting up Vet checked for HD Minimal response to NSAIDs Worse over last 30 days S

Greta

Greta O Neurologic Examination Head- -NAF CN- -NAF Mild Neck Pain (C6) Forelegs- -NAF (slight dysmetria) Rear Legs- Slight hyperflexia L>R CP deficits Bilaterally Babinski L Hypermetria Mild Back Pain (TL) O

Greta O T3-L3 Spinal Cord Localization of Lesion D A M N I T V IVDD, GSDM T3-L3 Spinal Cord Spinal Tumor Myelitis GME O

Greta P Problem List Differential Dx Diagnostic Approach Treatment ? Diagnostic Approach Treatment GSDM IVDD Infect/Inflamm Neoplasia Posterior Paresis Foreleg Hypermetria Neck & Back Pain P

Greta- -Diagnostic Approach MDB CBC Chemistry Profile UA Chest & Abdominal Radiographs Abdominal Ultrasound Neurologic Tests EMG CSF Analysis Cisternal Lumbar MRI (Whole Spine) Client Education P

Greta- -Client Education May expect gradual return to function expecting 80% of recovery in 3 months May continue to progress over 12-18 months Need to monitor spleen and blood work every 6 months Reassess as needed, changing medications when appropriate P

Greta- -TCVM exam Tongue Pulse Sensitivity TCVM Diagnosis Pale Wet Weak bilaterally Sensitivity GB 21 BL 18 BL 23 TCVM Diagnosis Combined Qi/Yin Deficiency with Stagnation

Greta- -TCVM Therapy Herbal AP Hu Qian Tang Di Huang Yin Zi Cervical points BL10 GB 21 Lumbar points GV 14 Bai Hui (EA & Moxa) BL40 BL62 Other points ST 36 SP 6 LI 10 LIV 3 Herbal Hu Qian Tang Walking Tiger Formula Jing Tang Di Huang Yin Zi Rehmannia Formula for Paralysis

Hu Qian Wan Bai Shao Yao Paeonia Nourish Blood Chen Pi Citrus Move Qi and Relieve Pain Gan Jiang Zingiberis Strengthen Stomach and Promote Appetite Gui Ban Chinemys Nigricans, Plastrum Nourish Yin, anchors Yang, tonify Blood, Nourish Heart Huang Bai Phellodendron Clear Heat, Nourish Yin Niu Xi Achyranthes Strengthens the Kidney and benefit the knees Shu Di Huang Rehmannia Nourish Yin, Blood and Jing Suo Yang Cynomorium Tonify Kidney Yang, Nourish Blood, Tonify Essence, Strengthen Sinews Zhi Mu Anemarrhena Nourish Yin, Clear Heat

Di Huang Yin Zi Ba Ji Tian Morinda Tonify kidney, strengthen yang Fan Shi Hu Descurainiae Herba Nourish Yin, clear deficient heat, nourish stomach Yin Fu Ling Poria Drain Damp, Strengthen Spleen Fu Zi Aconite Warm Spleen Mai Men Dong Ophiopogon Nourish Yin Rou Cong Rong Cistanche Salsa Caulis Tonify kidney, strengthen yang Rou Gui Cinnamomum Tonify Kidney Yang Shan Zhu Yu Cornus Nourish Yin Shi Chang Pu Acorus Open orifices, vaporize phlegm, quiet spirit,harmonize middle burner Shu Di Huang Rehmannia Nourish Blood and Yin Wu Wei Zi Schisandra Consolidate and Nourish Lung Yin Yuan Zhi Polygala Calm spirit, quiet heart, clears orifices